TRACHEOSTOMY IN CHILDREN AND INFANTS: INDICATIONS, COMPLICATIONS AND OUTCOME

Varnholt V., Ringe H., Nietsch L., Kluwe W., Reich S.

Kinderklinik and Kinderchirurgische Klinik, Charité, Humboldt University, Berlin, Germany

OBJECTIVE: In adult intensive care medicine, tracheostomy will often be performed already after 1-2 weeks of mechanical ventilation, whereas in children this procedure is frequently done only after several weeks on ventilatory support. Because there is a lack of information concerning the clinical data of children undergoing tracheostomy in the recent years, we reviewed the patients' charts of all tracheotomized children in our interdisciplinary pediatric intensive care unit (PICU) in the years 1996 - 1999.

METHODS: Out of 242 mechanically ventilated children and infants, 13 (5 %; age 0.1 - 19 years) underwent tracheostomy. The indications, the complications, the outcome, and the follow-up were analysed.

RESULTS: Indications for tracheostomy were: inborn or acquired stenosis of the upper airways (n = 4), neurologic/neuromuscular diseases (n = 6), chronic lung disease (n = 3). In 9 children tracheostomy was performed after prolonged ventilatory support (3 - 10 weeks), in 4 children it was done earlier (after 2-10 days on ventilator) due to severe intubation problems. After tracheostomy, 9 children could eventually be discharged to home (2 of them still ventilated), 1 was discharged to a long-term mechanical ventilation unit, 1 child died in hospital and 2 recently tracheotomized patients are still in the PICU. 1 patient at home got a tube obstruction and consecutive cardiorespiratory arrest with hypoxic encephalopathy; 2 children died 1 respectively 3 years after tracheostomy due to deterioration of their underlying disease.

CONCLUSIONS: Because longer times of intubation are well tolerated in childhood, tracheostomy is more seldomly performed than in adults. In some cases however, the tracheostomy remains the only possibility after long-term ventilation/in cases with intubation problems to be weaned from the ventilator and/or to be discharged from the PICU to home/to specialised care facilities. For this reason, we would - in spite of the potentially life-threatening complications after tracheostomy -recommend it also for small infants in selected cases; and in most cases it will be well accepted by the parents of our patients.

References: Kollef MH et al. (1999) Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care init. Crit Care Med 27, 1714 - 20