© 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.
Summary
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.
INTRODUCTION
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).
After resolution of the primary lesion, the most frequent causes of decannulation failure are complications of long-term tracheostomy: suprastomal tracheal wall collapse, and granulation tissue. In our group we found granulation tissue in 12 patients. In all cases granulation tissue was located above the tracheostomy entry into the trachea. In one patient granuloma was also noted in the subglottic region, and in another in the tracheal lumen, at the tip of the tracheostomy tube. Suprastomal collapse, caused by a flap of anterior tracheal wall cartilage above the stoma, was seen at endoscopy in 9 patients, although the degree of obstruction was variable. In 5 cases tracheal wall collapse was not significant, causing obstruction of the tracheal lumen of less than 1/3rd of the diameter. These patients required no treatment and were succesfully decannulated. The remaining 4 patients developed severe tracheal wall collapse, resulting in an obstruction of the airway greater than 1/3rd of the tracheal lumen. These cases required surgical treatment, and were managed by an external approach and elevation of the collapsed flap into the stoma using a specially placed suture. Two patients were decannulated, but in two cases this method was not satisfactory. The second attempt was performed by an external approach, placing a suture to elevate the anterior wall collapse, after which a T-tube was used to provide internal support for the collapsed flap for 4 weeks. In one patient the tracheostomy tract was excised in a horizontal ellipse down to the trachea. Anterior tracheal wall collapse was elevated by suturing the flap to tissue and skin, to which it adhered.
The operative methods used in the management of anterior tracheal wall collapse are discussed in the literature. Some authors perform elevation of the tracheal flap by placing a suture (2, 3, 15, 21), using a T-tube (15) or nasotracheal intubation (1, 3, 15). Excision of the tracheostomy tract or surgical decannulation with closure of the stoma are also advocated (1, 2, 3, 8, 17).
Endoscopy was performed in all patients before decannulation. If there was no obstruction in the airways, a decision to attempt removal of the tracheostomy tube was made. Decannulation just after endoscopy was successful in 8 cases. In the remaining patients, instead of clear and unobstructed airways, problems in decannulation occurred. After removal of the tube and covering the tracheostomy opening with a dressing, these children developed varying degrees of respiratory distress with inspiratory stridor. Such problems had a functional aetiology and are called "decannulation panic” in the literature (4, 19, 22, 23). Removal of the tracheostomy tube results in an increase in anatomical dead space, and an increase in resistance to airflow (4). Phasic abduction of the vocal cord occurs synchronously with inspiration; in long-term tracheostomy this physiological reflex decays (19). These factors may result in decannulation failure in children, although no structural upper airway abnormality can be found. To manage "decannulation panic” we used a decannulation method based on gradual breathing training. During training we prefer to use a fenestrated tracheostomy tube, which is temporarily blocked. The same result may be achieved by a step-wise reduction of the trachestomy tube diameter (3, 4, 10, 19, 22).
CONCLUSIONS
1. In patients with long-term tracheostomy, regular endoscopic examinations should be considered as an essential part of treatment and care. 2.
2. Laryngoscopy and bronchoscopy should be performed at 2-7 month intervals, depending on the type of lesion and endoscopic findings. 3.
3. Interval endoscopic assessment permits accurate diagnosis of the primary disease, monitors the development and resolution of the airway lesion, and assists the decision to decannulate at the proper time.
4. Endoscopic examination of the larynx, trachea and bronchi should be performed prior to decannulation to evaluate airway patency.
5. Special attention must be given to detection of any obstructive lesions, such as granulation tissue and tracheal wall collapse, which are the main factors in decannulation failure.
6. Indications for surgical treatment should be established on the basis of endoscopic picture of the airways.
7. Anterior tracheal wall collapse causing an obstruction of the airway greater than 1/3rd of the tracheal lumen requires surgical treatment.
8. If endoscopic examination reveals no structural upper airway abnormality and airway patency is normal, decannulation failure may be caused by functional factors, known as "decannulation panic”.
Piśmiennictwo
1. Al-Sati A. et al.: Surgical decannulation of children with tracheostomy. J. Laryngol. Otol. 1993,107,217-221. 2. Azizkhan R.G. et al.: Anterior Cricoid Suspension and Tracheal Stomal Closure for Children With Cricoid Collapse and Peristomal Tracheomalacia Following Tracheostomy. J. Ped. Surg.1993,28 (2),169-171. 3. Benjamin B., Curley J.W.A.: Infant tracheotomy – endoscopy and decannulation. Int. J. Ped. Otorhinolaryngol. 1990,20,113-121. 4. Black R.J. et al.: Tracheostomy decannulation panic in children: fact or fiction? J. Laryngol. Otol. 1984,98,297- -304. 5. Carr M.M. et al.: Complications in Pediatric Tracheostomies. Laryngoscope 2001,111,1925-1928. 6. Carron J.D. et al.: Pediatric Tracheotomies: Changing Indications and Outcomes. Laryngoscope 2000,110,1099--1103. 7. Donnelly M.J. et al.: A twenty year (1971-1990) review of tracheostomies in major paediatric hospital. Int. J. Ped. Otorhinolaryngol. 1996,35,1-9. 8. Filston H.C. et al.: Infant Tracheostomy. Am. J. Dis. Child. 1978, 132, 1172-1176. 9. Friedberg J.: Tracheotomy revision in infants: to facilitate extubation and restore phonation. Int. J. Ped. Otorhinolaryngol. 1987,13,61-68. 10. Gray R.F. et al.: Tracheostomy Decannulation in Children: Approaches and Techniques. Laryngoscope 1998,108,8-12. 11. Joseph H.T. et al.: Pediatric tracheostomy: persistent tracheo-cutaneous fistula following decannulation. Int. J. Ped. Otorhinolaryngol. 1991,22,231-236. 12. Kremer B. et al.: Indications, Complications, and Surgical Techniques for Pediatric Tracheostomies – An Update. J. Ped. Surg. 2002,37 (11),1556-1562. 13. Merrit R.M. et al.: Suprastomal Granulation Tissue and Pediatric Tracheotomy Decannulation. Laryngoscope 1997,107,868-871. 14. Prescot C.A.J., Vanlierde M.J.R.: Tracheostomy in children- The Red Cross War Memorial Children´s Hospital Experience 1980-1985. Int. J. Ped. Otorhinolaryngol. 1989,17,97- -107. 15. Prescot C.A.J.: Peristomal complications of paediatric tracheostomy. 1992,23,141-149. 16. Reilly J.S., Myer Ch.M.: Excision of suprastomal granulation tissue. Laryngoscope 1985,95, 1545-1546. 17. Rogers J.H.: Decannulation by external exploration of the tracheostome in children. J. Laryngol. Otol. 1980,94,563-567. 18. Rosenfeld R.M., Stool S.E.: Should Granulomas Be Excised in Children With Long-term Tracheotomy? Arch Otolaryngol. Head Neck Surg. 1992,118,1323-1327. 19. Sasaki C.T. et al.: Tracheostomy Decannulation. Am. J. Dis. Child. 1978,132,266-269. 20. Swift A.C., Rogers J.H.: The outcome of tracheostomy in children. J. Laryngol. Otol. 1987,101,936-939. 21. Tom L.W. et al.: Endoscopic Assesment in Children With Tracheotomies. Arch. Otolaryngol. Head Neck Surg. 1993,119,321-324. 22. Waddell A. et al.: The Great Ormond Street protocol for ward decannulation of children with tracheostomy: increasing safety and decreasing cost. Int. J. Ped. Otorhinolaryngol. 1997,39, 111- 118. 23. Wind J.: Reflections on Difficult Decannulation. Arch. Otolaryng. 1971,94,426-431. 24. Yellon R.F.: Totally obstructing tracheotomy-associated suprastomal granulation tissue. Int. J. Pediatr. Otorhinolaryngol. 2000,53,49-55.
