The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single-center experience.

BACKGROUND: Children with end-stage liver disease and multi-organ failure, previously considered as poor surgical candidates, can now benefit from liver transplantation (LT). They often need prolonged mechanical ventilation (MV) post-LT and may need tracheostomy to advance care. Data on tracheostomy after pediatric LT are lacking. METHOD: Retrospective chart review of children who required tracheostomy in the peri-LT period in a large, freestanding quaternary children's hospital from 2014 to 2019. RESULTS: Out of 205 total orthotopic LTs performed in 200 children, 18 (9%) required tracheostomy in the peri-transplant period: 4 (2%) pre-LT and 14 (7%) post-LT. Among those 14 needing tracheostomy post-LT, median age was 9 months [IQR = 7, 14] at LT and 10 months [9, 17] at tracheostomy. Nine (64%) were infants and 12 (85%) were cirrhotic at the time of LT. Seven (50%) were intubated before LT. Median MV days prior to LT was 23 [7, 36]. Eight (57%) patients received perioperative continuous renal replacement therapy (CRRT). The median MV days from LT to tracheostomy was 46 [33, 56]; total MV days from initial intubation to tracheostomy was 57 [37, 66]. Four (28%) children died, of which 3 (21%) died within 1 year of transplant. Total ICU and hospital length of stay were 92 days [I72, 126] and 177 days [115, 212] respectively. Among survivors, 3/10 (30%) required MV at home and 8/10 (80%) were successfully decannulated at 400 median days [283, 584]. CONCLUSION: Tracheostomy though rare after LT remains a feasible option to support and rehabilitate critically ill children who need prolonged MV in the peri-LT period.

Perioperative and Long-Term Outcomes in Infants Undergoing a Tracheostomy from a Neonatal Intensive Care Unit.

OBJECTIVE: The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy. METHODS: This single-center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long-term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long-term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy. RESULTS: One-hundred eighty-three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post-conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44-8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator-dependent 2 years following their tracheostomy. CONCLUSION: Our study provides critical perioperative complications and long-term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1945-1954, 2024.

Comparing Outcomes Between Standard Mepilex and Mepilex Silver for Tracheotomy Dressings.

OBJECTIVE: The purpose of the study is to compare the incidence of early postoperative tracheotomy stoma wound complications in pediatric patients using a silver-impregnated barrier dressing (Mepilex Ag) versus a standard absorbent foam dressing (standard Mepilex). METHODS: This is a prospective, non-blinded, randomized trial of pediatric patients undergoing tracheotomy at a tertiary care children's hospital. Patients were randomized to receive Mepilex Ag versus standard Mepilex tracheostoma dressings following tracheotomy. All patients received standard postoperative wound care and daily stomal examination. Wound related complications, breakdown, granulation, and infection were recorded for the first 7 days after surgery. A non-inferiority study design was used to test the hypothesis that the Mepilex group had a non-inferior wound complication rate (within 10% margin) compared to the Mepilex Ag group. RESULTS: Eighty-two patients were enrolled; 52 received Mepilex Ag, and 30 received standard Mepilex. There was no difference between the groups with respect to age, sex, race, surgical indication, or postoperative length of stay. Non-inferiority testing demonstrated that the Mepilex standard cohort had no more than 10% greater stomal wound complication rate than that of Mepilex Ag dressing group (p = 0.0108). CONCLUSION: Standard Mepilex was found to be non-inferior to Mepilex Ag in the prevention of tracheotomy stomal wound complications. Standard Mepilex may be used effectively in the postoperative period, potentially reducing costs to caregivers and the institution. Further work is needed to analyze additional factors that could contribute to poor postoperative stoma healing such as bacterial colonization. LEVEL OF EVIDENCE: Randomized Controlled Trial, Level 2 Laryngoscope, 2024.

Pediatric tracheostomy decannulation: what's the evidence?

PURPOSE OF REVIEW: Pediatric decannulation failure can be associated with large morbidity and mortality, yet there are no published evidence-based guidelines for pediatric tracheostomy decannulation. Tracheostomy is frequently performed in medically complex children in whom it can be difficult to predict when and how to safely decannulate. RECENT FINDINGS: Published studies regarding pediatric decannulation are limited to reviews and case series from single institutions, with varying populations, indications for tracheostomy, and institutional resources. This article will provide a review of published decannulation protocols over the past 10 years. Endoscopic airway evaluation is required to assess the patency of the airway and address any airway obstruction prior to decannulation. There is considerable variability in tracheostomy tube modification between published protocols, though the majority support a capping trial and downsizing of the tracheostomy tube to facilitate capping. Most protocols include overnight capping in a monitored setting prior to decannulation with observation ranging from 24 to 48 h after decannulation. There is debate regarding which patients should have capped polysomnography (PSG) prior to decannulation, as this exam is resource-intensive and may not be widely available. Persistent tracheocutaneous fistulae are common following decannulation. Excision of the fistula tract with healing by secondary intention has a lower reported operative time, overall complication rate, and postoperative length of stay. SUMMARY: Pediatric decannulation should occur in a stepwise process. The ideal decannulation protocol should be safe and expedient, without utilizing excessive healthcare resources. There may be variability in protocols based on patient population or institutional resources, but an explicitly described protocol within each institution is critical to consistent care and quality improvement over time. Further research is needed to identify selection criteria for who would most benefit from PSG prior to decannulation to guide allocation of this limited resource.

Development and implementation of a pre-tracheostomy multidisciplinary conference: An initiative to improve patient selection.

OBJECTIVE: To describe our institutional experience in implementing a pre-tracheostomy multidisciplinary conference and assess its effects on patient selection and communication between team members and with families. METHODS: Descriptive study and retrospective review of patient outcomes in a period prior to (4/2016-1/2018) and following (2/2018-11/2019) implementation of the conference and conference participant survey. RESULTS: In the 21 months prior to the conference, 53 patients out of 67 consults (79%) went on to have a tracheostomy. After implementation, 96 patients, 42 females and 54 males, between 2 weeks and 22 years of age were discussed. 58 (60%) of patients referred for tracheostomy ultimately underwent surgery. Of those managed without tracheostomy, 16% were extubated, 11% were managed with noninvasive respiratory support, and 13% of families chose to redirect care. There was no difference in time between consultation and surgery (p = 0.9), or post-surgical length of stay after the conference was implemented (p = 0.9). Survey responses were gathered from 34 conference participants. Respondents agreed that the conference was useful in facilitating communication among the care team (91%), promoting understanding of the patient's treatment options (85%), promoting understanding about long-term outcomes and progression of underlying disease process (79%), clarifying risks, benefits, and alternatives of treatment options (82%), and informing discussions with the family (70%). DISCUSSION: Potential benefits of a multidisciplinary pre-tracheostomy conference include improved provider communication and shared decision making between the medical team and family. We found a reduction in the proportion of patients who ultimately underwent tracheostomy as a result of a formal multidisciplinary discussion, but did not find either any delays in care, or reduction in post-operative length of stay. IMPLICATIONS FOR PRACTICE: A multidisciplinary team approach to patient selection can foster communication between team members, identify barriers to discharge and quality care at home, and provide caregivers with information necessary to make an informed decision about their child's care.

Decannulation protocol for short term tracheostomy in pediatric head and neck tumor patients.

BACKGROUND: While the majority of pediatric tracheostomies are performed in the setting of chronic and complex medical comorbidities, perioperative tracheostomies following head and neck tumor ablation are generally short-term. Deliberate planning is required for decannulation in this setting and no published protocols currently exist. Our study outlines a management strategy for short-term tracheostomy in pediatric patients following head and neck surgery. METHODS: A retrospective study of pediatric head and neck tumor patients undergoing tracheostomy was performed at a quaternary children's hospital from February 1, 2016 to December 31, 2018. Charts were reviewed for demographics, surgical operation, relevant tracheostomy-related complications, and time to decannulation. RESULTS: Eleven patients with a mean age of 10.4 years (st.dev. 6.7, range: 0.5-23) underwent tracheostomy during their primary ablative/reconstructive surgery. Trans-tracheal pressure monitoring helped direct the need for tracheostomy downsizing and readiness for capping trials. All patients were decannulated before hospital discharge after a mean of 12.8 days (st.dev. 2.5, range: 9-18) and were discharged after a mean of 14.8 days (st.dev. 2.5, range: 11-20). CONCLUSION: Pediatric head and neck surgery patients can be quickly and safely decannulated with an instructive protocol and multidisciplinary care.

Complete esophageal stenosis secondary to peptic stricture in the cervical esophagus: case report.

Complete esophageal stenosis secondary to peptic stricture in the upper esophagus is rare. It is, however a serious medical problem that may require otolaryngologic intervention because of life-threatening dysphagia and weight loss. We report the case of an elderly patient who presented with an upper esophageal stricture, without the typical symptoms of gastroesophageal reflux disease, that progressed to complete esophageal obstruction despite use of proton pump inhibitors and esophageal dilatation. Definitive management of this difficult problem required esophagectomy and gastric pull-up. We discuss the pathophysiology, clinical presentation, differential diagnosis, and multidisciplinary management of peptic esophageal strictures. This case illustrates the difficulty in managing high peptic strictures.