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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 167-171

Pattern of pediatric tracheostomy at university of Benin teaching hospital, Benin city: A ten-year review


Department of Otorhinolaryngology, University of Benin Teaching Hospital, Benin City, Nigeria

Date of Web Publication8-Dec-2014

Correspondence Address:
Dr. Ngozi C Onyeagwara
Department of Otorhinolaryngology, University of Benin Teaching Hospital, Benin City
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.146428

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  Abstract 

Background: Tracheostomies are often performed in children to relieve severe respiratory difficulties. However, complications are associated with this life-saving surgery. The objective of this study was to establish the pattern, indications, complications, timing of surgery and outcomes following tracheostomy in children.
Patients and Methods: We carried out a 10-year retrospective review of medical records of children (0-15 years) who had undergone tracheostomy, between June 2003 and May 2013 in a single tertiary hospital. Data retrieved included demographics, indications, timing of surgeries and complications.
Results: In this review, 127 cases that include 83 boys and 44 girls were considered for the study. In all, 64 percent (83) of the patients were boys whereas 44 (34.6%) were females with M/F ratio of 1.8:1. Age ranged between 2 months-15 years with a mean age of 3.56 (SD ± 2.56). About 15.7% (20 cases) were preschoolers whereas 57.5% (73 cases) were between 3-5 years, which accounted for majority of the cases. The most common indication was to relieve upper airway obstruction secondary to foreign body aspirations in 90 children (70.8%). Other indications include infections in 27 children (21.6%). Complications were noted in 36 children (28.3%) including tube blockage in 9 (7.08%), tube dislodgement in 4 (3.1%), and peritubular granulation tissue in 4 cases (3.1%). Tracheostomy-related death occurred in 1 case (0.8%).
Conclusion: Tracheostomy is a life-saving procedure with potential causes for complications occurring in children. If avoidable indications are excluded, the morbidity will be reduced. Parents and caregivers must monitor their children to avoid aspiration of foreign bodies eventually leading to tracheostomy.

Keywords: Pediatric, tracheal foreign bodies, tracheostomy complications, tracheostomy


How to cite this article:
Onyeagwara NC, Emokpaire EO. Pattern of pediatric tracheostomy at university of Benin teaching hospital, Benin city: A ten-year review. Arch Int Surg 2014;4:167-71

How to cite this URL:
Onyeagwara NC, Emokpaire EO. Pattern of pediatric tracheostomy at university of Benin teaching hospital, Benin city: A ten-year review. Arch Int Surg [serial online] 2014 [cited 2022 May 23];4:167-71. Available from: https://www.archintsurg.org/text.asp?2014/4/3/167/146428


  Introduction Top


The first successful tracheostomy was done by Antonio Brasavola for the removal of foreign body and subsequently over 200 cases of the procedure were done by Pierre Bretonneau for the treatment of diphtheria in children, and by 1887, approximately 20,000 of these operations had been reported in western Europe and the United States [1]

The scope of the procedure broadened when Galloway reported using the procedure for the respiratory care of patients with poliomyelitis; the poliomyelitis epidemics of the early 1950s stimulated the use of tracheostomy for positive-pressure ventilation, and this opened the doors for similar treatment in tetanus, cardiac surgery, severe burns, and the care of preterm infants [2] . The incidence and indications for pediatric tracheostomy have changed over the years. Upper airway obstruction secondary to infectious disorders was once the most common indication for tracheostomy but currently in the developed world such as Europe and America, the most common indication is for prolonged ventilation necessitated by neuromuscular, congenital and craniofacial respiratory problems. [1],[2],[3]

This changing trend was possible because vaccination programs, improvements in material engineering, and anesthetic skills have dramatically reduced the number of emergency tracheostomies performed for acute upper airway obstruction. Today, the main indications for tracheostomy in a child generally involves either anticipated long-term cardiorespiratory compromise resulting from chronic ventilatory, (or, rarely, cardiac) insufficiency or the presence of a fixed upper airway obstruction that is unlikely to resolve for a significant period of time. [4],[5] It is yet to be seen in our environment where respiratory infection is still common if there is a significant change in trend.

Although tracheostomy is life-saving, it is not without risk of acute and long-term complications, such as pneumonitis, emphysema and tracheal stenosis.The risks of the procedure are higher in children than in adults due to the fragility of the trachea, short neck, closeness of the upper lobe of the lungs to the neck, poor cough reflex leading to accumulation of secretions and infections and the inability to withstand anesthetic agents for long duration. [4]

It is disturbing that while other parts of the world are presently doing tracheostomies for long-term ventilation in chronic and congenital diseases, it is still performed in sub-saharan Africa for indications such as foreign body aspirations and infections with their attendant complications including death. [5],[6]

This retrospective study was done using data retrieved from medical records of children less than 15 years who underwent tracheostomy in the University of Benin Teaching Hospital, Nigeria. We hope that this information will highlight the indications and complications of this procedure when carried on children and further aimed at reducing the number of tracheostomies in children by increasing awareness on preventable indications and potential complications.


  Patients and Methods Top


This is a 10-year retrospective study of all subjects less than 15 years who underwent tracheostomies for various indications in the University of Benin Teaching Hospital between June 2003 and May 2013. Permission was obtained from ethical committee of the University of Benin Teaching hospital to retrieve medical records.

Medical records of patients who underwent tracheostomies were retrieved. Information obtained included the sex, age, indications for the tracheostomy, timing, and complications. Data was analyzed using Statistical Package for the Social Sciences software (SPSS 16.0) and results were represented in tables and figures.


  Results Top


A total of 127 pediatric tracheostomies were performed during the 10-year study period. In all, 64 percent (83) of the patients were boys while 44 (34.6%) were females with M/F ratio of 1.8:1. Age ranged from 2 months-15 years with a mean age of 4.25 (SD ± 2.56). About 24.4% (31 cases) were preschoolers whereas 57.5% (73 cases) ranged between 4-6 years of age, which accounted for majority of the cases [Table 1]. Major indication was upper airway obstruction resulting from laryngeal foreign bodies in 77 cases (60.6%) while diphtheria accounted for 11 cases (8.7%), ranking high among the infectious indications [Table 2].
Table 1: Age distribution of patients (n = 127)

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Table 2: Indications for tracheostomy in 127 patients

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Complications following tracheostomy were recorded in 36 patients (28.3%). The most frequent complication was tube blockage (7.08%). There was one tracheostomy-related death and two due to the underlying diseases. Overall, 85% of complications were from emergency as against 15% from elective tracheostomies [Table 3].
Table 3: Complications of tracheostomies

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Most of the tracheostomies (84.04%) were done under emergency compared to 15.96% electives. The timing of surgery is shown in [Figure 1].
Figure 1: Timing of surgery

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  Disscussion Top


Tracheostomies are often performed on children in case of severe respiratory difficulty. In our series, majority of tracheostomies were done in children between 0-6 years (81.9%). This compares with studies by Onotai and Etawo, where children less than 6 years had more tracheostomy than the older ones [6],[7],[8] but is at variance with studies where children less than one year were in the majority. [1],[9],[10] In the studies of Mehmet et al. and Adoga, majority of their patients were 9 and 6-10 years, respectively [6],[11] . Our result could be attributed to the less congenital anomaly, which does not require early respiratory assistance in our setting. Our series revealed a male predominance which may be attributable for their hyperactive and inquisitive nature. Again studies have shown that males are more prone to laryngeal foreign bodies than their female counterparts. [6],[12]

The incidence and indications for pediatric tracheostomy have changed over the years. Upper airway obstruction secondary to infectious disorders was once the most common indication for tracheostomy. Currently, however, the most common indication is for prolonged ventilation necessitated by congenital, neuromuscular or respiratory problems. [1],[2],[3],[9] . The global change from infection can be attributed to the judicious use of antibiotics, improved intensive care management and vaccinations. [1],[13],[14] While this statement is true for some regions of the world, our study and other relevant studies still record trauma and infective inflammatory obstructive processes as the most common although with lower incidence. [5],[6] In our study, foreign body aspiration (57.5%) was the most common indications for tracheostomy. This agrees with some reports in this environment [6],[15],[16] and contrasts with recent trend elsewhere where prolonged intubation for congenital, neuromuscular and chronic respiratory problems are major indicatons. [1],[2],[3],[4],[8],[11] In a study, in Singapore, this congenital anomalies ware attributed to consanguinous marriages as practiced in this region. [1] Our result may be attributable to the increased number of children in day care centere under few carer takers, increased use of coloured toys and reduced public awareness. [17]

Our study data of infective indications like diphtheria, juvenile laryngeal respiratory papillomatosis was low compared to the studies by Ozmen and Unal, who recorded 35.6% infection. In the study by Adoga and Ogunleye where laryngeal respiratory papillomatosis was a major indication [5],[16],[18] The reduction in our study is attributed to improved adherence to national vaccination programs. We hope that the newly introduced vaccine against human papilloma virus for girls and women of reproductive age will further reduce its incidence in our environment if the cost is reduced and the vaccines available.

Malignancies are rare in pediatric age but when they cause airway compromise, tracheostomy is indicated. Our study revealed 4.0% malignancies of various types. This is in contrary with other reports which had 1.9% and 7.2% of malignancies, respectively. [11],[19] Of note is the presence of nasopharyngeal carcinoma in a 6-year-old patient, which was the first in our locality though reports of 0.3% incidence, 17% and 30% frequencies in the United Kingdom, Tunisia and Casablanca respectively are found in the literature. [20],[21],[22] This is associated with Epstein Barr virus, genetic and environmental factors. [23] These countries in Africa including Uganda, Kenya and Sudan are said to be the areas of intermediate incidence. [21] This data suggests vigilance in our setting. Adjunct to facial surgeries was low (4.0%), which attest to global improvement in anesthetic skill and increased endotracheal intubation. [4],[5]

Pediatric tracheotomy is associated with several complications which are understandably higher in children. [7],[9],[24] We reported an overall complications of 28.3% which is comparable with the results ranging from 19% to 51% reported in other studies [5],[6],[9],[24],[25],[26],[27] but contrast with result of Adoga and Ma'an who reported 15.2% 5 . Most of our complications were related to the tube as indicated in [Table 3]. The high incidence may be attributed to insufficient intensive care support and lack of experienced personnel (e.g nurses), which is a serious but preventible complications, which can be overcomed by improving intensive care services. Further, the urgent nature of the procedures due to late presentation and poor technique are contributory to our high incidence of complications.

Most tracheostomies were performed on emergency and had more complications in our series. This agrees with other reports [6],[14],[28] , but contrasts with Mehmet et al. who reported no difference in both [11] . Some authors have advocated the creation of cartilage window to prevent tracheal stenosis [7] but we used horizontal skin incision 2-finger breath above the sternal notch and a vertical incision on the trachea between 2-4 tracheal rings, a recent trend, and recorded a 0.8% stenosis which was a result of repeated surgeries and this was managed with laryngofissure and stenting. This result compares with those of other authors but contrasts with those of Onotai and Etawo who recorded 6.68% in their series. [5],[11] Tracheostomy-related death is reported to range from 0-6% [24] ; however, we reported 0.8% tracheostomy-related death due to accidental decanulation compared to other studies. [7],[8],[28],[29] In contrast, other reports recorded no death. [1],[5],[6],[7] This death could have been avoided if there were experienced personnel.

We report a 100% decannulation success. Our follow-up ranged from 2 days-7 months, which contrasts with most studies elsewhere where success was as low as 14.8% -66%, [1],[8],[10],[11],[18],[30] This may be attributed to the fact that we had no children in our series with chronic respiratory insufficiency as a result of congenital malformations. The possible reason that children never get to the hospital alive or there may be lower incidence of congenital abnormalities in our environment.

In conclusion, tracheostomy is a life-saving procedure with potential for complications in children. If avoidable indications are excluded and standard protocols practiced, the morbidity will be reduced if carried out at the hospital by a trained and experienced team. However, prevention of foreign body aspiration by children should be the main target.

 
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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[Pubmed] | [DOI]



 

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