10 Year Review of Paediatric Tracheostomies

The Leeds Teaching HospitalsNHS Trust

Changing times

• Changing indications for tracheostomy

• Fewer short-term tracheostomies

• Most for chronic problems leading to tracheostomy use for months or years

Parental competency in tracheostomy management

• 2 carers trained• Gain competencies in:– Suctioning tube– Changing tapes– Changing tubes– Coping with emergencies• Tube obstruction• Tube dislodgement

– Basic paediatric life support

Study Objectives

• To review indications and length of hospital stay in children undergoing tracheostomy

• To highlight reasons for prolonged hospitalisation once medically fit

• Identify impediments to timely discharge

Methods

• 10 year retrospective study 2000 – 2010

• All children undergoing tracheostomy in LTH– Mr Knight, Mr Crabbe

• Identified using theatre database

• Case notes reviewed

Data collected

• Demographics• Indication for tracheostomy• Length of hospital stay• Reasons for extended stay • Destination on discharge• Mortality

Results

• 109 children identified

• 101 notes reviewed – Age range 0-15 years

• ENT - Mr Knight – 47

• Paed Surgery - Mr Crabbe – 45

• Other - 9

Age distributionN

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Age distribution (<18 months)

Age distribution (<18 months)

40%

Indications

To facilitate artificial ventilation

To relieve upper airway obstruction

Indications

To facilitate artificial ventilation

• Weaning from ventilator• Needs prolonged ventilation• Needs regular pulmonary

toilet

To relieve upper airway obstruction

• Bypass blockage or narrowing in upper airway

Indications

Indications for tracheostomySubglottic stenosis (congenital = 4) 34

Wean from ventilator (infection / tracheomalacia) 15

Wean from ventilator (head injury) 14

Ventilator dependant (myopathy / hypoventilation) 11

Micrognathia / Macroglossia 10

Lymphangioma / Cyst 5

Haemangioma 4

Bilateral vocal cord palsy 4

Oral tumour 2

Vocal cord granuloma 1

Nasopharyngeal stenosis 1

Indications for tracheostomySubglottic stenosis (congenital = 4) 34

Wean from ventilator (infection / tracheomalacia) 15

Wean from ventilator (head injury) 14

Ventilator dependant (myopathy / hypoventilation) 11

Micrognathia / Macroglossia 10

Lymphangioma / Cyst 5

Haemangioma 4

Bilateral vocal cord palsy 4

Oral tumour 2

Vocal cord granuloma 1

Nasopharyngeal stenosis 1

Indications for tracheostomySubglottic stenosis (congenital = 4) 34

Wean from ventilator (infection / tracheomalacia) 15

Wean from ventilator (head injury) 14

Ventilator dependant (myopathy / hypoventilation) 11

Micrognathia / Macroglossia 10

Lymphangioma / Cyst 5

Haemangioma 4

Bilateral vocal cord palsy 4

Oral tumour 2

Vocal cord granuloma 1

Nasopharyngeal stenosis 1

Indications for tracheostomySubglottic stenosis (congenital = 4) 34

Wean from ventilator (infection / tracheomalacia) 15

Wean from ventilator (head injury) 14

Ventilator dependant (myopathy / hypoventilation) 11

Micrognathia / Macroglossia 10

Lymphangioma / Cyst 5

Haemangioma 4

Bilateral vocal cord palsy 4

Oral tumour 2

Vocal cord granuloma 1

Nasopharyngeal stenosis 1

Indications for tracheostomySubglottic stenosis (congenital = 4) 34

Wean from ventilator (infection / tracheomalacia) 15

Wean from ventilator (head injury) 14

Ventilator dependant (myopathy / hypoventilation) 11

Micrognathia / Macroglossia 10

Lymphangioma / Cyst 5

Haemangioma 4

Bilateral vocal cord palsy 4

Oral tumour 2

Vocal cord granuloma 1

Nasopharyngeal stenosis 1

Indications for tracheostomySubglottic stenosis (congenital = 4) 34

Wean from ventilator (infection / tracheomalacia) 15

Wean from ventilator (head injury) 14

Ventilator dependant (myopathy / hypoventilation) 11

Micrognathia / Macroglossia 10

Lymphangioma / Cyst 5

Haemangioma 4

Bilateral vocal cord palsy 4

Oral tumour 2

Vocal cord granuloma 1

Nasopharyngeal stenosis 1

Indications for tracheostomySubglottic stenosis (congenital = 4) 34

Wean from ventilator (infection / tracheomalacia) 15

Wean from ventilator (head injury) 14

Ventilator dependant (myopathy / hypoventilation) 11

Micrognathia / Macroglossia 10

Lymphangioma / Cyst 5

Haemangioma 4

Bilateral vocal cord palsy 4

Oral tumour 2

Vocal cord granuloma 1

Nasopharyngeal stenosis 1

Indication vs. Age

Indication vs. Age

Indication vs. Age

Mortality

Mortality

Time in hospital after tracheostomy

Mean 81 days Range 1 – 603 days

Time in hospital after “medically fit”

• Mean: 19 days

• Range: 0 – 265 days

Time in hospital after “medically fit”

Time (days)

Time in hospital after “medically fit”

Time (days)

56 children delayed

Time in hospital after “medically fit”

Time (days)

56 children delayed23% for > 1 month

Time in hospital after “medically fit”

Time (days)

56 children delayed23% for > 1 month

• Less than 2 weeks• 2 to 4 weeks• 4 to 8 weeks• 8 to 12 weeks• More than 12 weeks

Up to 2 weeks - 20

Up to 2 weeks - 20

Up to 2 weeks - 20

Up to 2 weeks - 20

Up to 2 weeks - 20

Up to 2 weeks - 20

Up to 2 weeks - 20

Up to 2 weeks - 20

2 to 4 weeks - 13

2 to 4 weeks - 13

2 to 4 weeks - 13

2 to 4 weeks - 13

2 to 4 weeks - 13

2 to 4 weeks - 13

4 to 8 weeks - 14

4 to 8 weeks - 14

4 to 8 weeks - 14

4 to 8 weeks - 14

4 to 8 weeks - 14

4 to 8 weeks - 14

8 to 12 weeks - 4

8 to 12 weeks - 4

8 to 12 weeks - 4

More than 12 weeks

• 5 children

• Multiple factors– awaiting changes to housing – 3 – social problems – 3 – tracheostomy training – 1

Delays due to….

• Equipment provision• Changes to home environment• Parental tracheostomy training – 22 children

• Social factors

Social & external factors

• Concerns about parenting ability

• Parental drug and alcohol abuse

• Family on “at risk register”

• Children placed in foster care– 5 children

Social & external factors

• Parental separation / divorce

• Single parents

• Effects on employment

Social & external factors

• English not as 1st language

–18 families

– Interpreters required

What can we do?

• Can’t prevent external factors

• Early enrolment of parents on structured training programme

• Early involvement of social care organisations• Good integration of medical, social and

outreach services

What can we do?

• Dedicated paediatric tracheostomy nurse specialist to coordinate the discharge of infants and children with tracheostomies

Summary

Paediatric tracheostomy may result in:

• significant impact on both child and family

• direct and indirect financial burden to both family and health service

• prolonged hospitalisation

• delayed discharge due to social factors