© Borgis - New Medicine 4/2010, s. 115-117
*Lidia Zawadzka-Głos1, Mansoor Sharifi1,2, Mieczysław Chmielik1
Influence of laryngeal and general diseases on postintubation changes of the larynx
1Department of Pediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head of the Department: prof. Mieczysław Chmielik, MD, PhD
2Department of Descriptive and Clinical Anatomy, Center of Biostructure Research,
Medical University of Warsaw, Poland
Head of Department: prof. Bogdan Ciszek, MD, PhD
Summary
Introduction. There are numerous indications for tracheotomy in children. At present the dominating indications are laryngeal postintubation complications. In recent years laryngeal postintubation complications in children have been noticeable.
Aim. The aim of the study was to analyze additional diseases and local conditions of the larynx preceding intubation in children in whom tracheotomy was performed due to postintubation complications.
Material and method. A group of 124 children with tracheotomy treated in our clinic in the period of 1990-2009 was available for our study. The main indication for tracheotomy in 92 (75%) of the children was postintubation complications. In this group of 92 patients with postintubation complication we have evaluated the presence of accompanying additional general diseases and local condition of the larynx, which could have affected the development of postintubation complications.
Results. In the group of 92 children with postintubation complications, 62 children (67.39%) had a healthy larynx and in the other 30 children (32.61%) other additional diseases or laryngeal malformations were observed. In that group of children with laryngeal malformations, 22 children had laryngomalacia (73.33%), and 8 (26.67%) had paralysis of the vocal cords with etiology other than postintubation. Only 11 children (11.96%) had no additional general diseases and in the other 81 patients (88.04%) other serious general diseases were diagnosed. Among the accompanying diseases were: heart and cardiovascular diseases requiring cardiosurgical operations in 17 children (18.48%), diseases of the nervous system in 17 patients (18.84%), diseases of the respiratory system in 15 patients (16.3%), multisystem congenital malformations in 23 patients (25%), and hypoxia of the CNS at birth in 9 patients (9.78%). In the group of 92 patients with laryngeal postintubation complications clinical symptoms such as laryngeal stridor were observed in 37 patients (40.22%) in the period of 1-21 days after extubation. On the other hand, in 55 patients (59.78%), extubation was not possible for longer than 1 day due to increasing stridor and respiratory failure of the patient.
Conclusions. At present the most common reasons for tracheotomy in children are laryngeal postintubation complications. Children with changes in the vicinity of the larynx, and especially those with laryngomalacia, are more at risk of developing postintubation complications. Severe general diseases related to hypoxia increase the risk of laryngeal postintubation complications. Patients with history of cardiosurgical operations are at greater risk of developing laryngeal postintubation complications.
INTRODUCTION
Indications for tracheotomy in children have changed in the last 30 years. This is directly due to significant changes in the years 1960 to 1970, when tracheal intubation in treatment of respiratory failure reduced the risk of tracheotomy in those patients. At first children were intubated for 48 hours, and then the decision of tracheotomy was taken (4). In the 1970s it was practiced that in cases where intubation lasted longer than 7 days tracheotomy was inevitable (3). Further development of pediatric anesthesiology and intensive care, together with introduction of new materials of which the intubation tubes are made, allowed longer intubation time and furthermore limited the need for tracheotomy. Analyzing the data from the literature from the last 30 years one can evidently observe a decreasing number of tracheotomies. A decrease in the number of tracheotomies due to acute infections of the respiratory system such as laryngotracheobronchitis or epiglottitis is evident. Prolonged intubation replaced tracheotomy in the above-mentioned respiratory conditions. On the other hand, the number of tracheotomies due to congenital anomalies of the larynx or postintubation narrowing of the larynx is increasing. Also noticeable is an increase in the number of tracheotomies for ensuring ventilation and hygiene of the respiratory tract in chronic diseases, severe congenital malformations or in terminally ill patients (1, 3, 4, 5, 6, 7).
Early indications for tracheotomy can be divided into three groups of diseases:
1st group ? disturbances of respiratory tract patency,
2nd group ? diseases in which ventilation monitoring and aided ventilation are needed,
3rd group ? diseases in which permanent hygiene of the respiratory tract is needed.
The widest group of indications for tracheotomy comprises those with disturbances in patency of the respiratory tract such as: congenital defects of the larynx and trachea (congenital stenosis of the larynx and the trachea, laryngeal webs, laryngeal angiomas, laryngomalacia, tracheomalacia, laryngeal cysts); acquired postintubational laryngeal stenosis; paralysis of the vocal cords; inflammatory conditions of the larynx, trachea and bronchi; foreign body of the larynx; external traumas of the larynx and the trachea; massive maxillofacial trauma obscuring intubation; chemical and thermal burns of the respiratory tract; congenital maxillofacial malformations and blockage of patency of the respiratory tract by tumors in the vicinity of the nasopharynx, throat, larynx and trachea which apply direct pressure from the exterior; and tumors of the neck and the mediastinum.
According to the literature from the last 10 years, the most common indications for tracheotomy in children with disturbed patency of the respiratory tract are:
1. Acquired postintubation stenosis of the larynx.
2. Congenital malformations of the larynx and the trachea.
3. Prolonged intubation (2, 3, 6, 7).
AIM OF STUDY
The aim of the study was to analyze additional diseases and local condition of the larynx before intubation in children in whom tracheotomy was performed due to postintubational complications.
MATERIAL AND METHODS
In the period of 1990-2009, in our pediatric ENT clinic 124 tracheotomies were performed in children with disturbed patency of the respiratory tract. The indication for tracheotomy in 92 patients (75% of cases) was due to postintubation complications.
RESULTS
In the group of 92 patients with postintubation complications, additional systemic diseases and changed local conditions of the larynx were noticed. They might have had an impact on postintubation complications. In this group of 92 children with postintubation complications, in 62 patients (67.39%) the larynx was normal before intubation and in 30 patients (32.61%) additional diseases or laryngeal malformations were observed.
In the group of children with laryngeal malformation, 22 children had laryngomalacia (73.33%), and 8 children (26.67%) had paralysis of the vocal cords with etiologies other than postintubation.
Only 11 children (11.96%) did not have additional diseases, while in the remaining 81 patients (88.04%) severe general diseases were diagnosed. Diseases of the heart and circulatory system requiring cardiosurgical treatment were diagnosed in 17 (18.48%) patients, respiratory tract diseases in 15 (16.3%), congenital multisystem malformation in 23 (25%), and hypoxia of the central nervous system at birth in 9 (9.78%). In the group of 92 children with postintubation complications of the larynx, clinical signs of laryngeal stridor appeared in the period of 1-21 days after extubation in 37 patients (40.22%). On the other hand, in 55 patients (59.78%) extubation for longer than 1 day was not possible due to stridor and respiratory failure of the patients. All children had undergone tracheotomy in order to reverse the patency of the respiratory tract.
DISCUSSION
In the presented study 124 cases of tracheotomy in children were analyzed. Indications for tracheotomy were the following conditions: paralysis of the vocal cords, laryngeal angiomas, laryngeal cysts, maxillofacial malformations and postintubation stenosis of the larynx. Postintubation stenosis of the larynx was the most common indication for tracheotomy in the above-mentioned group.
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Piśmiennictwo
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