Developing a Standard of Care for Pediatric Tracheostomy Decannulation

Abstract

Objectives: 1) Recognize which diagnostic modalities are helpful to facilitate safe decannulation. 2) Provide data-driven conclusions about pediatric tracheostomy management, given the recent American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) Consensus Statement on Tracheostomy Management (January 2013), which was based on expert opinion alone. 3) Define a pediatric tracheostomy decannulation protocol that can be extended to a large subset of patients. Methods: Study type: 10-year retrospective review of one surgeon’s pediatric tracheotomy decannulation methods. Inclusion criteria: Patients less than 18 years old. Setting: Tertiary care pediatric hospital. Outcome measurements: Airway endoscopy findings, sleep study results, capping trial tolerance, successful decannulation, and tracheocutaneous fistula repair and management. Results: 167 patients underwent tracheotomy during this period, and 52 were decannulated. Of these, 22 had suprastomal granulation tissue removed and 4 patients had tonsillectomies, adenoidectomies, epiglottopexies, and/or supraglottoplasties prior to decannulation. Seventeen patients had subglottic stenosis; 9 underwent laryngotracheal reconstruction. Twenty-five patients developed tracheocutaneous fistulas; 24 patients elected repair with 100% success rate. Conclusions: Decannulation of the pediatric patient requires a starkly different approach compared to the adult population, as many require surgical intervention prior to decannulation, and a much higher percentage of pediatric patients will keep a tracheocutaneous fistula. Our decannulation protocol includes daytime capping, rigid airway endoscopy to detect anatomic airway abnormalities, flexible endoscopy during simulated sleep to detect dynamic airway problems, and capped sleep studies. We also describe our novel trapdoor stomal flap technique, which has a 100% success rate for closure of tracheocutaneous fistulas.