2017 Sec 1 Green Book

patient care, potentially reduce the risk of unnecessary

procedures, and decrease the economic burden of chronic

tracheostomy care. This study investigates the utility of

surveillance DLB in pediatric tracheostomy patients to

help facilitate the development of clinical practice guide-

lines regarding chronic tracheostomy care.

MATERIALS AND METHODS

Data Collection

The current practice of nine pediatric otolaryngologists at

Texas Children’s Hospital (TCH) is to perform annual surveil-

lance DLB on all pediatric patients with tracheostomies. A ret-

rospective chart review was conducted of all of the children

years of age with tracheostomies who underwent surveillance

DLB between 2003 and 2012 at TCH, an academic tertiary

referral center. Patients with existing tracheostomies who

transferred care to TCH and underwent surveillance DLB at

TCH were included in the study. The institutional review board

at Baylor College of Medicine approved this study. Charts were

reviewed for demographic data, date of tracheostomy, indication

for tracheostomy, symptoms prior to surveillance DLB, dates of

surveillance DLB, operative findings, and interventions. Indica-

tions for tracheostomy were categorized as congenital anomaly,

neuromuscular disease, bronchopulmonary dysplasia, and

trauma. Congenital anomalies included craniofacial dysmor-

phism, laryngeal anomalies, laryngomalacia, subglottic stenosis,

hemangioma, tracheal anomaly, and other congenital syn-

dromes. Interventions included debridement of suprastomal

granulation tissue, change in tracheostomy tube size or type,

tracheal dilation, and tracheostomy stoma revision. Charts were

also reviewed for plans for decannulation or laryngotracheal

reconstruction following surveillance DLB. Patients with incom-

plete medical records were excluded from this study. Those

patients with subglottic hemangioma and recurrent laryngeal

papillomatosis were excluded from this study, as these patients

require serial DLB with planned intervention. Patients who

underwent DLB in conjunction with a planned procedure,

including intraoperative decannulation, laser cordotomy, or lar-

yngotracheal reconstruction, were also excluded.

Surgical Technique

Yearly surveillance bronchoscopies are performed in all

children with chronic tracheostomies. Patients were taken to

the operating room, and general anesthesia was induced via

tracheostomy, and spontaneous ventilation maintained. All

patients received a dose of intravenous steroids. Direct laryn-

goscopy was performed with application of topical anesthesia to

the glottis, and rigid tracheoscopy and bronchoscopy was per-

formed. The tracheostomy tube was removed, allowing the sur-

geon to thoroughly examine the entire airway, supraglottis,

glottis, subglottis, trachea, carina, and mainstem bronchi with

photodocumentation of all subsites. When necessary, debride-

ment of suprastomal or peristomal granulation tissue was per-

formed with a combination of techniques depending on surgeon

preference, including sharp dissection or microdebrider. Simi-

larly, there were several techniques used for dilation of subglot-

tic stenosis when indicated, including balloon dilation,

microlaryngoscopy and CO

laser, serial dilation with rigid

bronchoscopes, or a combination of techniques. The tracheos-

tomy tube may have been exchanged with one of different type

or size, depending on intraoperative findings. The patient was

allowed to recover in the postanesthesia care unit and was typi-

cally discharged home the same day depending on the intrao-

perative findings and stability of the airway. Caregivers were

provided photodocumentation of intraoperative findings, and

outpatient follow-up was typically scheduled for 4 to 6 weeks in

uncomplicated cases.

Data Analysis

Data analysis was performed with assistance from the Texas

Children’s Hospital Outcomes and Impact Service. Continuous

variables were reported as medians with a minimum-maximum

range or means with standard deviation (SD). Categorical varia-

bles were reported with frequencies and percentages. Statistical

analysis was performed using logistic regression and multivariate

analysis.

RESULTS

A total of 489 patients underwent 1,094 screening

DLBs with a mean 2.3 procedures per patient (range, 1–

14). Two hundred seventy-nine patients (57%) were

males, and the mean age was 5.1 years (SD 4.9 years).

The most common indication for tracheostomy was con-

genital anomaly (49%), followed by neuromuscular dis-

ease (19%), isolated bronchopulmonary dysplasia (17%),

and trauma (6%). Nine percent of patients had congeni-

tal anomalies with bronchopulmonary dysplasia (9%).

Forty-one percent of patients were premature (Table I).

The mean interval time between surveillance DLB was

430 days. Two hundred fifty-three DLBs (23%) were

accompanied by preprocedural symptoms. The most com-

mon complaint prior to DLB was increased tracheal

secretions (78%). Other preoperative symptoms included

bleeding from tracheostomy (8%), intermittent difficul-

ties ventilating (7%), voice complaints (1%), aspiration of

secretions (1%), tracheitis (1%), dysphagia (1%), and

stoma erythema (1%) (Table II, Fig. 1).

There were a total of 619 procedures that required

817 interventions, accounting for 58% of the total num-

ber of DLBs. Two hundred sixty-six patients (54%)

required an intervention during surveillance DLB. The

most common intervention performed was debridement

of suprastomal granulation tissue (41%), followed by

tracheostomy tube exchange (27%), tracheal dilation

(10%), and stoma revision (6%) (Table III, Fig. 1). Of the

patients who had tracheostomy tube changes, 47% of

TABLE I.

Demographic Data.

Patients, No. (%), N

489

Patients

Male

279 (57%)

Female

210 (43%)

Indications for tracheostomy

Congenital anomaly

240 (49%)

Neuromuscular disease

93 (19%)

Bronchopulmonary dysplasia

83 (17%)

Trauma

29 (6%)

Congenital anomaly and

bronchopulmonary dysplasia

44 (9%)

Premature

200 (41%)

Laryngoscope 125: October 2015

Richter et al.: DLB in Children With Tracheostomies