MINI-SYMPOSIUM: TRACHEOSTOMY IN CHILDREN
Indications for tracheostomy in children

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Summary

Vaccination programs, improvements in material engineering and anaesthetic skills have dramatically reduced the number of emergency tracheostomies performed for acute upper airway obstruction. Today, the indication to tracheotomise a child is generally ruled by the anticipation of long-term (cardio)respiratory compromise due to chronic ventilatory or, more rarely, cardiac insufficiency, or by the presence of a fixed upper airway obstruction that is unlikely to resolve for a significant period of time. As many of the younger candidates for tracheostomy have complex medical conditions, the indication for this intervention is often complicated by ethical, funding and socio-economic concerns that necessitate a multidisciplinary approach. Unfortunately, these considerations are frequently not made until the first catastrophe has occurred, even in those patients in whom imminent cardiorespiratory failure has been foreseeable. Non-invasive ventilation via a face mask and newer developments such as the in-exsufflator device have gained importance as an alternative to tracheostomy in selected patients.

Introduction

The history of tracheostomy portrays the history of medical advance and of progress in material engineering. Depicted on Egyptian tablets as early as 3600 BC, tracheostomy has been a subject of medical debate ever since. Despite this, it did not enter routine medical practice until the 19th century, when doctors became increasingly open-minded towards the procedure as a means of providing immediate relief to patients with acute laryngeal obstruction, the majority of cases at that time being related to diphtheria.1, 2

Although a variety of indications for tracheostomy, for example ‘pulmonary toilet’ or application of anaesthetics, were sporadically proposed, scepticism prevailed in view of an unacceptably high mortality. The procedure therefore remained the last resort for acute life-threatening upper airway obstruction.3 This only changed in the early 20th century, when Chevalier Jackson standardised the procedure and its after care measures, reducing morbidity and mortality related to the intervention.4 In the years to come, the list of indications for tracheostomy gradually increased to comprise diseases of the entire respiratory apparatus, a development that gained momentum with the famous Copenhagen poliomyelitis epidemic of 1952.5 Tracheostomy became standard of care for basically all patients with respiratory insufficiency.1

Although the idea of endotracheal intubation performed through the mouth dates back to Hippocrates (460–375 BC), who objected to the idea of tracheostomy for fear of injuring the carotid arteries, attempts to do this were not undertaken until the 19th century.6 Advances in material engineering and technical refinements, however, have since allowed a circumvention of tracheostomy in various areas of respiratory care. The replacement of rubber and sterling silver tubes by thermosensitive polyvinyl chloride tubes reduced the discomfort and laryngeal damage associated with prolonged transpharyngeal intubation.7 Thus, modern high-volume, low-pressure cuffed tubes have rendered endotracheal intubation via the oropharyngeal or the nasopharyngeal route an attractive and feasible alternative for even extended periods of intubation, and the decision to proceed to tracheostomy is generally guided by the anticipation of long-term respiratory compromise. Similarly, the ability to modulate face masks individually to each patient's facial contours, along with the excellent tolerance towards the new materials, provides opportunity for long-term non-invasive positive-pressure ventilation in many patients with neuromuscular diseases.8, 9 In addition, the introduction of fibreoptic intubation has made nasopharyngeal intubation a valuable alternative in difficult airway management.10 As a consequence, the indications for tracheostomy have changed during the years, and they continue to do so.

Section snippets

Indications

Publications suggest that the range of indications for tracheostomy has broadened over the past decades. This is strictly speaking not true because tracheostomy in children is indicated for the same reasons as before; i.e. either it serves as a bypass round an upper airway obstruction or it is being instituted for long-term respiratory support and/or pulmonary toilet.11, 12 What has changed, however, is the range of underlying conditions that may warrant tracheostomy (Table 1). Upper airway

Future developments

Percutaneous dilational tracheostomy has increased in popularity for temporary respiratory management in adult intensive care units.35, 54 Little experience, however, exists in children.55 Provided that dilators and cannulas of appropriate sizes are available, percutaneous dilational tracheostomy might be an alternative in selected patients, for example children with Guillain-Barré syndrome or traumatic brain injury. Similarly, transtracheal oxygen catheters used for long-term oxygen therapy in

Conclusion

The indications for tracheostomy have changed over time. Few children are now tracheotomised for airway emergencies; instead, the procedure is mostly performed for long-term problems. As a consequence, there is in most clinical situations no unity of approach, and the indication for tracheostomy is influenced by multiple circumstantial factors.

Practice points

  • In patients with progressive neuromuscular or respiratory disease, the possibility of tracheostomy should be discussed with the caregivers and the patient before a foreseeable emergency situation arises.

  • Tracheostomy in burn patients should be considered early if significant mucosal damage is seen by laryngoscopy.

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