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© Borgis - New Medicine 2/2020, s. 39-44 | DOI: 10.25121/NewMed.2020.24.2.39
Małgorzata Chromniak, Maria Koziołek, Katarzyna Pawlik, *Monika Jabłońska-Jesionowska, Lidia Zawadzka-Głos
Analysis of tracheotomy indications in children treated in the Department of Pediatric Otolaryngology of Medical University of Warsaw between 2015-2020
Analiza wskazań do tracheotomii u dzieci leczonych w Klinice Otolaryngologii Dziecięcej Warszawskiego Uniwersytetu Medycznego w latach 2015-2020
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Wstęp. Tracheostomia to otwór w tchawicy umożliwiający oddychanie z pominięciem krtani, gardła i jamy ustnej, mający na celu przywrócenie i utrzymanie drożności dróg oddechowych. Wskazania do jej przeprowadzenia zmieniały się na przestrzeni lat. Zarówno wybór pacjentów do tej procedury, jak również moment, w którym należy ją wykonać, wymagają multidyscyplinarnego podejścia i nadal nie są jednoznacznie określone. Potrzebne są wystandaryzowane procedury, które ułatwią podjęcie decyzji. Konieczne są analizy, które umożliwią stworzenie ogólnodostępnych wytycznych.
Cel pracy. Analiza wskazań do tracheotomii u dzieci wykonanych w latach 2015-2020 w Klinice Otolaryngologii Dziecięcej Warszawskiego Uniwersytetu Medycznego.
Materiał i metody. Przeanalizowano wszystkie przypadki dzieci, u których w okresie 5 lat (2015-początek 2020) wykonano tracheotomię w Klinice Otolaryngologii Dziecięcej. Po elektronicznym i manualnym przeszukaniu medycznych baz danych wyodrębniono kilka grup wskazań do tracheotomii. Następnie zestawiono kolejne dane dzieci (wiek w momencie wykonania zabiegu, choroby towarzyszące, obciążenia) i stworzono charakterystykę naszych pacjentów, co umożliwiło porównanie z wynikami uzyskanymi w latach poprzednich.
Wyniki. Tracheotomię wykonano u 64 dzieci. Mediana wieku pacjentów wyniosła 0,5 roku, a średnia wieku 4,26 roku. Pacjentów podzielono na 8 grup w zależności od wskazań do zabiegu: wady wrodzone, urazy, porażenie fałdów głosowych, powikłania okołoporodowe, choroby autoimmunologiczne, infekcje, zwężenie pointubacyjne. Najczęściej wykonano tracheotomię u dzieci ze złożonymi wadami wrodzonymi.
Wnioski. 1. Wskazania do tracheotomii u dzieci zmieniają się na przestrzeni lat. 2. Rośnie liczba tracheotomii wykonywanych z powodu złożonych wad wrodzonych. 3. Nowymi grupami wskazań do tracheotomii u dzieci są choroby autoimmunologiczne oraz urazy; w tych grupach średni wiek pacjentów jest najwyższy. 4. Skuteczne leczenie farmakologiczne naczyniaków krtani spowodowało brak tracheotomii wykonywanych w tym wskazaniu. 5. Zmniejszyła się liczba tracheotomii przeprowadzanych z powodu zwężeń pointubacyjnych krtani. 6. Porażenie fałdów głosowych jako wskazanie do tracheotomii u dzieci najczęściej jest powikłaniem zabiegu kardiochirurgicznego wrodzonej wady serca; średni wiek pacjentów w tej grupie jest najniższy. 7. Infekcje wirusowe są nadal wskazaniem do tracheotomii u dzieci.
Summary
Introduction. Tracheostomy is the opening enabling breathing without the larynx, throat and mouth, which aims to restore and sustain airway patency. Indications of this intervention have changed over the years. The selection of patients for this procedure, as well as the moment, when it has to be performed are still not clearly defined. Those require a multidisciplinary approach and a standardized protocol. More analyses are necessary to create widely available guidelines.
Aim. Analysis of tracheotomy indications in children performed between 2015-2020 in the Department of Pediatric Otolaryngology, Medical University of Warsaw.
Material and methods. During the 5-year period (2015-beginning of 2020) 64 children with tracheostomy were treated in the Department of Pediatric Otolaryngology. Groups of tracheotomy indications were separated after a retrospective overview of the 64 cases from our clinic and after manual and electronic search through medical databases for indications for tracheotomy in previous years. Then patient’s data (age at the time of surgery, concomitant diseases and/or disabilities) was collated, which allowed to present the characteristics of children and compare the tracheotomy indications in previous years with the results of this research.
Results. Tracheotomy was performed among 64 children. The median patients’ age was 0.5 year and the average age was 4.26 years. Our patients were affected by many various conditions. We divided them into 8 main groups: congenital malformation syndromes, trauma, vocal folds palsy, perinatal complications, infection, autoimmune diseases, oncological and post-intubation subglottic stenosis. Currently, congenital malformation syndromes turned out to be the most common indication for tracheotomy.
Conclusions. 1. Tracheotomy indications in children have changed over the years. 2. There is increasing number of tracheotomies due to various congenital defects. 3. New groups of tracheotomy indications among children are autoimmune diseases and injuries; those groups have the highest average of age. 4. The result of effective pharmacological treatment of laryngeal hemangiomas is the lack of tracheotomy performed in this indication. 5. The number of tracheotomies performed due to post-intubation stenosis has decreased. 6. Vocal cords palsy as an indication for tracheotomy in children is most often a complication of cardiac surgery due to congenital heart defect; this group of patient’s is the youngest among all. 7. Viral infections are still the tracheotomy indication among children.
Słowa kluczowe: tracheostomia, wskazania, wiek, dzieci.
Introduction
Tracheotomy is the medical term for surgical incision in the trachea, while tracheostomy stands for the opening enabling breathing without the larynx, throat and mouth (1). In combination, they aim to restore and sustain airway patency. Although tracheotomy is a well-known surgical procedure for centuries, it has been performed in the pediatrics population only since the twentieth century (2, 3). Tracheotomy in children is performed less frequently than in adults (4). Indications of this intervention have changed over the years. Before the vaccination against Haemophilus influenzae and Corynebacterium diphtheriae became widely distributed the most common cause leading to tracheostomy were acute infections: epiglottitis and diphtheria (5). Recently upper airway obstruction due to prolonged ventilator dependence, vocal folds dysfunction, hypotonia secondary to neurologic impairment, and trauma are considered to be the main indications of tracheotomy (2, 6). Owing to the improved quality of neonatal and pediatric intensive care, raised survivability of children with congenital abnormalities and chronic diseases is being observed (6). Tracheostomy is no longer only an acute live saver, but it is also used as an ancillary therapy in treating children with protracted illnesses therefore tracheostomies became long-term (6, 7). The selection of patients for this procedure, as well as the moment, when it has to be performed are still not clearly defined. Those require a multidisciplinary approach and standardized protocol (4). More studies are necessary to create widely available guidelines (8). That is why, we need to continue our research.
Aim
Analysis of tracheotomy indications among children performed between 2015-2020 in the Department of Pediatric Otolaryngology, Medical University of Warsaw.
Material and methods
We analyzed all cases of children who had tracheotomy in the Pediatric Otolaryngology Department at the Children’s Hospital of Medical University of Warsaw over a 5-year period (2015-early 2020). A retrospective overview of all cases in our clinic reveals the indications and age for pediatric tracheotomy and the characteristics of our patients were created. For the purpose of clarity we divided the indications for the procedure into 8 main groups: congenital malformation syndromes, trauma, vocal folds palsy, perinatal complications, infection, autoimmune diseases, oncological and postintubation subglottic stenosis.
Results
Tracheotomies were performed in 64 children from our clinic, the median patient age during the 5-year period was 0.5 year and the average patient age was 4.26 years (tab. 1). Two youngest patients were 1 day old and congenital arteriovenous malformation of a tongue was the indication for tracheotomy; 4 oldest patients were 16 years old and in 3 cases communication trauma was the indication. The age distribution is shown in figure 1 where it is visible that children after injury and with autoimmune diseases are the oldest and the ones with congenital malformations and vocal folds palsy are the youngest.
Tab. 1. Correlation of tracheotomy indications as well as mean and median age of patients and percentage for each indication
IndicationTotal patientsMean (SD)Median (range)Percentage for each indication
Congenital malformation syndromes291.4 (3.25)0.25 (0.003-16)45
Trauma910.6 (6.72)15 (0.166-15)14
Perinatal complications76.7 (5.77)10 (0.166-15)11
Vocal folds palsy70.2 (0.15)0.17 (0.083-0.5)11
Autoimmune410.5 (4.15)11.5 (4-15)6
Infection45.4 (5.68)3 (0.583-15)6
Oncological37.3 (4.71)4 (4-14)5
Postintubation subglottic stenosis11.3 (0)1.25 (1.25-1.25)2
Total patients640.54.26 (0.003-16)100
Fig. 1. Indications for tracheotomy with mean and median patient's age
We have classified the indications for tracheotomy in 8 groups which have been shown in table 1. Congenital malformation syndromes were the most common indications for tracheotomy in 29 children (45.31%). In this broad group of very complex developmental defects we can distinguish several cases to approximate the characteristics of patients. As one subgroup we can differentiate 6 patients who had tracheostomy due to congenital central nervous system defects (NTDs), 2 patients had the procedure because of congenital arteriovenous malformation of the tongue, 2 patients had congenital craniofacial anomaly including Pierre Robin; tracheostomy in the case of 2 other was due to tracheoesophageal fistula (TEF) associated with tracheomalacia. Among 8 patients from this group, congenital heart disease was present, including one case of Bland-White-Garland syndrome (BWGS), and one case of hypertrophic cardiomyopathy (HCM). It is worth pointing out the single cases of laryngeal cyst, craniofacial teratoma and spinal muscular atrophy (SMA).
The second most common indication was trauma. In this group we have 9 patients (14%). We differentiate 5 cases after traffic accident and 2 cases being a result of child abuse. We can single out trauma caused by activities: 1 case of trauma during horse riding and 1 case of tetraplegia due to drowning.
In the group of tracheotomized patients with vocal folds palsy we have 7 children (11%) out of whom 4 had paralysis after cardiac surgery due to congenital malformation, 2 had idiopathic paralysis of the vocal folds. This group also included one case of vocal folds palsy in the course of congenital Arnold-Chiari malformation (ACM).
In 7 patients (11%) tracheotomy was performed as a result of perinatal complications.
In the group of 4 patients (6%) where indication for tracheotomy was infectious disease in 3 cases the etiological factor was the influenza virus and in 1 case it was recurrent respiratory papillomatosis (RRP) due to HPV infection.
It should be noted that autoimmune diseases also make important group of patients with tracheostomy. In this group there are 4 patients (6%); there are case of Guillain-Barre syndrome (GBS), ANCA-associated vasculitis (AAV), autoimmune encephalitis (AE) and diabetic encephalopathy (DE).
The oncological group was also created mainly because of statistical significance in our work. This group included 3 cases – 2 with acute lymphoblastic leukaemia (ALL) and 1 with testicular tumor.
In table 1, as a summary, the indications for tracheotomy were calculated as a percentage of the 64 tracheostomies.
Discussion
Tracheotomy is performed on children with mechanical (anatomical) airway obstruction or respiratory insufficiency, originating from various reasons, most of which are congenital malformations (including craniofacial malformations), conditions requiring prolonged intubation, muscular hypotonia secondary to neurological disorders and trauma (4, 5, 9, 10).
Division of patients into groups due to tracheotomy indications differs among assays (4, 11, 12). Indications are generally divided into: neurological, cardiovascular, upper airways obstruction, craniofacial anomalies and craniofacial injuries. Grouping is contractual and often inhomogeneous because of a frequent coexistence of pathologies, what regards especially to patients with congenital malformation syndromes. Cardiovascular malformation which requires cardiac surgery may be complicated by postoperative vocal folds palsy. Besides visible phenotypic abnormalities, complex congenital defects are often accompanied by neurological disorders. Preterm birth can be an effect of congenital defects. Immaturity of child can also be the reason of breathing disorders, hypoxia and neurological impairment.

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otrzymano: 2020-05-29
zaakceptowano do druku: 2020-06-19

Adres do korespondencji:
*Monika Jabłońska-Jesionowska
Klinika Otolaryngologii Dziecięcej Warszawski Uniwersytet Medyczny
ul. Żwirki i Wigury 63A, 02-091 Warszawa
tel.: +48 (22) 317-97-21
laryngologia@spdsk.edu.pl

New Medicine 2/2020
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