Tracheostomy is performed in children with increased incidence for a number of indications including upper-airway obstruction, chronic respiratory failure due to neuromuscular conditions, prolonged ventilation, bronchopulmonary dysplasia, and various congenital heart and lung diseases.1 Increase in survival of patients with assisted ventilation in the pediatric and neonatal ICU has led to an increase in the number of patients requiring long-term ventilation and tracheostomy.2 The majority of tracheostomy procedures (41–63%) in the pediatric population occur in infancy.3,4 Children are at higher risk for morbidity and mortality related to tracheostomy, and risk is increased significantly below the age of 1 y.5
The primary complications of tracheostomy are granuloma, infection, obstruction, accidental decannulation, and post-decannulation tracheocutaneous fistula.4 Accidental decannulation is one of the delayed complications of tracheostomy, and it can lead to death if not appropriately and promptly managed.
In this issue of Respiratory Care, Villarroel et al describe risk factors for accidental decannulation in a group of tracheostomized children.6 They performed a retrospective case-control study of children admitted to a long-term care facility for patients needing prolonged mechanical ventilation. The authors identified 41 cases and 82 controls between 2013–2018. The main indication for tracheostomy was need for prolonged mechanical ventilation and/or upper-airway anomalies, which is consistent with the literature regarding tracheostomy in children.7
Almost two thirds of the children (63%) who had accidental decannulation were receiving mechanical ventilation. Similar to previously published data, the majority of events were due to self-manipulation and behavioral factors.8,9
The authors reported the following factors for accidental decannulation for children requiring 24 h a day of mechanical ventilation: young age able to reach midline in sitting position, presence of a tracheostomy tube with internal diameter ≤ 4.0 mm and short length, and less nursing supervision.
Infants start to bring hands to midline while supine at 3 months, and they start to sit unsupported at 6 months.10 These developmental milestones need to be closely monitored and used to make staffing decisions for nursing personnel taking care of tracheostomized children requiring mechanical ventilation. Although staffing is a modifiable risk factor for accidental decannulation, tracheostomy size is not. This is because size is usually selected to be the smallest that allows effective ventilation and avoids tracheal injury associated with oversized tubes.11
Ideally, the units where these children are placed should have central ventilator alarm systems. Nursing and respiratory therapy staffing should be adequate at all times including shift changes and lunch breaks. In addition, checking the tracheostomy holder, ties, and connection to the ventilator should decrease risk for accidental decannulation.
Lack of mortality due to accidental decannulation in the study is likely due to a combination of skillful staff and the tolerance of patients to being disconnected. It is essential to have the skills of managing emergent situations for tracheostomized children including tube blocking and decannulation to prevent harmful complications. Safety interventions such as educating the care team and use of ventilator circuit stabilizers can also reduce accidental decannulation in tracheostomized children.9
Limitations of the study include the retrospective design and inability to calculate the incidence of accidental decannulation. Events of accidental decannulation were described as rate of events per number of hours instead of 1,000 tracheostomy-days, which makes it difficult for comparison with other studies.9 Improved survival in this population will lead to greater numbers of children requiring tracheostomy and further drive policy and procedures to limit complications through education, adequate staffing, and technological advances.
Footnotes
- Correspondence: Samah Awad MD, 1 Children’s Way, Slot 512–17, Little Rock, AR 72202. E-mail: SAwad2{at}uams.edu
See the Original Study on Page 173
Dr Berlinski discloses relationships with the Cystic Fibrosis Foundation, Mylan, National Institutes of Health, Therapeutic Development Network, Trudell Medical International, Vertex, Hollo Medical, and the International Pharmaceutical Aerosol Consortium on Regulation and Science. Dr Awad has disclosed no conflicts of interest.
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