2017 Sec 1 Green Book

tracheostomies due to airway obstruction, rather than prolonged mechanical ventilation support. 2,8–10 Forty- one percent of patients in our study were premature, which is consistent with other international case studies. 11 All patients with chronic tracheostomies at our institution are scheduled for yearly endoscopic evalua- tion with rigid bronchoscopy. Twenty-three percent of bronchoscopies were preceded by symptoms that were reported at the preoperative evaluation. The most com- mon symptom was presence of tracheal secretions, inter- mittent difficulties with ventilation, voice complaints, tracheitis, dysphagia, or erythema surrounding the stoma. Of those patients with complaints prior to sur- veillance DLB, 54% required operative intervention com- pared to 58% of the entire cohort. This suggests that preoperative symptoms are not predictive for need for operative intervention. Over half of these children in this study, 58%, required operative intervention with debridement of granulation tissue, airway dilation, or tracheostomy tube exchange. This suggests that children are frequently asymptomatic from suprastomal granula- tion tissue, airway stenosis, or inappropriate tracheot- omy tube size. By addressing potential airway complications in advance, we hope to reduce the morbidity and mortality related to pediatric tracheostomies. According to a sur- vey of the American Society of Pediatric Otolaryngology, a large portion (41%) of physicians only perform endos- copy on patients with difficulties ventilating. 6 Our study suggests this practice may overlook patients with asymptomatic suprastomal granulomas that may benefit from operative intervention to optimize the airway and prevent more dangerous complications in the future. The complication rate in tracheostomies ranges from 13% to 88%, and late complications are more common than perioperative complications related to tracheos- tomy. 1–3 Late complications include accidental decannu- lation, tube occlusion, suprastomal granulation, and tracheitis, which may be increased in patients with a history of prematurity and low body weight at the time of tracheotomy. 9,12,13 Yearly surveillance DLB is not without risks, as the anesthetic risk and economic burden cannot be over- looked. The variability in current care practices accord- ing to institutional practices or geographic influence may affect reimbursement and variable quality in patient care. 7 This study demonstrates an opportunity to develop care practice guidelines for long-term surveil- lance of children with chronic tracheostomies to optimize patient care and reduce healthcare costs. The American Thoracic Society (ATS) published consensus clinical practice guidelines for management of pediatric tracheostomies, and recommended routine rigid or flexible bronchoscopy every 6 to 12 months and fur- ther research to validate this recommendation. 4 In our study, the presence of preoperative symptoms, age at tracheostomy, prematurity, and presence of preoperative symptoms did not predict need for intervention. Based on this finding, the standard of care at our institution is to perform yearly surveillance DLB on all asymptomatic

TABLE II. Surveillance DLB Preoperative Findings.

No. of Patients (%)

Surveillance DLB, n 5 1,094 Mean no. of DLBs per patient, median (range) No. of DLBs requiring intervention

2.2, 2 (1–14)

639/1094 (58%) 253/1094 (23%) 137/639 (54%)

No. of DLBs with preoperative symptoms No. of DLBs with preoperative symptoms that required intervention No. of patients requiring multiple DLBs

156/489 (32%)

Preoperative symptoms, n 5 253 Tracheal secretions Bleeding from tracheostomy

197 (78%)

20 (8%) 17 (7%) 2 (1%) 2 (1%) 3 (1%) 3 (1%) 2 (1%) 3 (1%)

Difficulties with ventilation

Voice complaints

Aspiration of secretions

Air leak surrounding tracheostomy tube

Tracheitis Dysphagia

Erythema surrounding tracheostomy stoma

DLB 5 direct laryngoscopy and bronchoscopy.

patients had an increase in tracheostomy tube size, 51% of patients underwent decrease in tracheostomy tube size, and 2% of patients had tracheostomy tube exchange for a different style of tube in the same diameter. If a patient underwent tracheal dilation, balloon dilation was the most common technique used (50%), followed by use of microlaryngoscopy and carbon dioxide (CO 2 ) laser (23%), and serial dilation using rigid bronchoscopes (20%). The remaining tracheal dilations were performed using a combination of stellate CO 2 laser incisions with balloon or rigid dilation (7%). For those patients who presented with symptoms prior to DLB, 54% of those DLB required an intervention. This was not statistically significant compared to patients who were asymptomatic (77% of all patients) prior to surveillance DLB ( P > .05). In addition, age at tracheostomy, duration of tracheos- tomy, interval time to DLB, prematurity, and indication for tracheostomy did not predict need for intervention ( P > .05). There were no perioperative complications. One hundred sixty-seven patients (34%) were eventually dec- annulated, and 43 patients (9%) underwent laryngotra- cheal reconstruction. DISCUSSION There is no current consensus on endoscopic sur- veillance of children with chronic tracheostomies. At our institution, asymptomatic children with chronic trache- otomies undergo yearly surveillance DLB. The most common indication for tracheostomy was upper airway obstruction due to congenital anomaly and airway obstruction, including craniofacial dysmorphism, sub- glottic stenosis, vocal fold paralysis, and laryngomalacia. These findings are consistent with current literature that demonstrates a trend in indications for pediatric

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Richter et al.: DLB in Children With Tracheostomies

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