© Borgis - New Medicine 2/2003, s. 15-17
Lidia Zawadzka-Głos, Beata Zając, Anna Gabryszewska, Mieczysław Chmielik
Endoscopic assesment of airways before tracheostomy decannulation in children
Department of Paediatric Otolaryngology Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
Twenty-two children underwent successful decannulation in the Department of Paediatric Otolaryngology of the Medical University in Warsaw from 1993 to 2002. An analysis of patients´ medical records was made. All patients had endoscopic examination – laryngoscopy and bronchoscopy,
before any attempt at decannulation. In some cases, in spite of resolution of the primary lesion for which tracheostomy had been carried out, decannulation was unsuccesful. The most frequent causes of decannulation failure were complications of long-term tracheostomy: suprastomal tracheal wall collapse and granulation tissue. Difficult decannulation was also related to functional factors known as "decannulation panic”. On the basis of their own clinical experience the authors suggest a surgical technique and methods of decannulation.
Tracheostomies are performed to bypass an obstructed airway, and to facilitate long-term ventilatory support. Before decannulation several conditions have to be met. First, the original conditions or disease that neccesitated the tracheostomy must be resolved or improved. Second, the patency of the entire airway: nose, pharynx, larynx and tracheobronchial tree must be adequate to support the respiratory needs of the patient. The main role in assessment of the airway is taken by endoscopic examinations - laryngoscopy and bronchoscopy.
MATERIAL AND METHODS
Twenty-two children underwent successful decannulation in the Department of Paediatric Otolaryngology at the Medical University in Warsaw between 1993 and 2002. Patients´ records were analysed and reviewed for the following items: age at tracheostomy and decannulation, indication for tracheostomy, endoscopy results, and method of decannulation.
RESULTS AND DISCUSSION
Nine girls and 13 boys were decannulated. Fifteen patients underwent tracheotomy in our department, the remaining 7 being operated on in other hospitals. The age at tracheotomy ranged from 10 days to 10 years (average age – 16 months). The duration of tracheostomy ranged from 2 to 51 months, with an average time from tracheostomy to decannulation of 22.9 months.The average time from tracheostomy to decannulation in the 15 patients who underwent tracheotomy in our department was 17.6 months, whereas the time for the 7 from other hospitals was 34.3 months. Indications for tracheotomy in our cases were: postintubation laryngeal stenosis in 7 cases, laryngeal haemangioma in 6 cases, congenital stenosis of the larynx in 3 cases, laryngotracheomalacia or tracheobronchomalacia in 3 cases, and bilateral vocal cord paralysis in 2 cases. In 1 patient tracheotomy was performed because of airway obstruction caused by Pierre-Robin syndrome.
Patients with laryngeal stenosis treated by endoscopic methods had periodic direct laryngoscopy and bronchoscopy performed at the endoscopic procedure every 2-4 months. The remaining patients had laryngoscopy and bronchoscopy at 2-7 month intervals, depending on the type of lesion and endoscopic findings. Endoscopic evaluation of the larynx and trachea was also performed in situations where problems such as bleeding and difficult tracheotomy tube changes occurred (24).
In patients with laryngeal haemangioma laryngoscopy and bronchoscopy were performed approximately once every 7 months, and in patients with vocal cord paralysis approximately every 4 months. Children who were tracheostomised because of laryngotracheomalacia or tracheobronchomalacia had endoscopic examinations of airways at 6 month intervals.
Regular endoscopic assessment is an essential component of management of children with tracheostomy. It permits accurate observation of the primary disease and monitors the development and resolution of airway lesion (21). Endoscopy is also necessary to detect lesions such as intraluminal granulomas and tracheal wall collapse, which are regarded as complications of tracheostomy.
During endoscopic examinations we only removed obstructing granulomas and granulation tissue, which may result in bleeding.
If the condition for which tracheotomy was performed had been resolved or improved, a decision to attempt removal of the tracheostomy tube was made. All patients underwent endoscopic examination just before decannulation. During laryngoscopy vocal cord motility was observed, and a ventilating bronchoscope was used to assess the subglottis, trachea, and bronchi. The tracheostomy entry into the trachea was examined, both with the tracheostomy tube in place and with the tube withdrawn. Special attention must be given to whether suprastomal granulation tissue exists and whether the anterior tracheal wall has collapsed (10).
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