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patients had an increase in tracheostomy tube size, 51%

of patients underwent decrease in tracheostomy tube

size, and 2% of patients had tracheostomy tube exchange

for a different style of tube in the same diameter. If a

patient underwent tracheal dilation, balloon dilation was

the most common technique used (50%), followed by use

of microlaryngoscopy and carbon dioxide (CO

) laser

(23%), and serial dilation using rigid bronchoscopes

(20%). The remaining tracheal dilations were performed

using a combination of stellate CO

laser incisions with

balloon or rigid dilation (7%). For those patients who

presented with symptoms prior to DLB, 54% of those

DLB required an intervention. This was not statistically

significant compared to patients who were asymptomatic

(77% of all patients) prior to surveillance DLB (

.05).

In addition, age at tracheostomy, duration of tracheos-

tomy, interval time to DLB, prematurity, and indication

for tracheostomy did not predict need for intervention

(

.05). There were no perioperative complications. One

hundred sixty-seven patients (34%) were eventually dec-

annulated, and 43 patients (9%) underwent laryngotra-

cheal reconstruction.

DISCUSSION

There is no current consensus on endoscopic sur-

veillance of children with chronic tracheostomies. At our

institution, asymptomatic children with chronic trache-

otomies undergo yearly surveillance DLB. The most

common indication for tracheostomy was upper airway

obstruction due to congenital anomaly and airway

obstruction, including craniofacial dysmorphism, sub-

glottic stenosis, vocal fold paralysis, and laryngomalacia.

These findings are consistent with current literature

that demonstrates a trend in indications for pediatric

tracheostomies due to airway obstruction, rather than

prolonged mechanical ventilation support.

2,8–10

Forty-

one percent of patients in our study were premature,

which is consistent with other international case

studies.

All patients with chronic tracheostomies at our

institution are scheduled for yearly endoscopic evalua-

tion with rigid bronchoscopy. Twenty-three percent of

bronchoscopies were preceded by symptoms that were

reported at the preoperative evaluation. The most com-

mon symptom was presence of tracheal secretions, inter-

mittent difficulties with ventilation, voice complaints,

tracheitis, dysphagia, or erythema surrounding the

stoma. Of those patients with complaints prior to sur-

veillance DLB, 54% required operative intervention com-

pared to 58% of the entire cohort. This suggests that

preoperative symptoms are not predictive for need for

operative intervention. Over half of these children in

this study, 58%, required operative intervention with

debridement of granulation tissue, airway dilation, or

tracheostomy tube exchange. This suggests that children

are frequently asymptomatic from suprastomal granula-

tion tissue, airway stenosis, or inappropriate tracheot-

omy tube size.

By addressing potential airway complications in

advance, we hope to reduce the morbidity and mortality

related to pediatric tracheostomies. According to a sur-

vey of the American Society of Pediatric Otolaryngology,

a large portion (41%) of physicians only perform endos-

copy on patients with difficulties ventilating.

Our study

suggests this practice may overlook patients with

asymptomatic suprastomal granulomas that may benefit

from operative intervention to optimize the airway and

prevent more dangerous complications in the future.

The complication rate in tracheostomies ranges from

13% to 88%, and late complications are more common

than perioperative complications related to tracheos-

tomy.

1–3

Late complications include accidental decannu-

lation, tube occlusion, suprastomal granulation, and

tracheitis, which may be increased in patients with a

history of prematurity and low body weight at the time

of tracheotomy.

9,12,13

Yearly surveillance DLB is not without risks, as the

anesthetic risk and economic burden cannot be over-

looked. The variability in current care practices accord-

ing to institutional practices or geographic influence

may affect reimbursement and variable quality in

patient care.

This study demonstrates an opportunity to

develop care practice guidelines for long-term surveil-

lance of children with chronic tracheostomies to optimize

patient care and reduce healthcare costs.

The American Thoracic Society (ATS) published

consensus clinical practice guidelines for management of

pediatric tracheostomies, and recommended routine rigid

or flexible bronchoscopy every 6 to 12 months and fur-

ther research to validate this recommendation.

In our

study, the presence of preoperative symptoms, age at

tracheostomy, prematurity, and presence of preoperative

symptoms did not predict need for intervention. Based

on this finding, the standard of care at our institution is

to perform yearly surveillance DLB on all asymptomatic

TABLE II.

Surveillance DLB Preoperative Findings.

No. of Patients (%)

Surveillance DLB, n

1,094

Mean no. of DLBs per patient,

median (range)

2.2, 2 (1–14)

No. of DLBs requiring intervention

639/1094 (58%)

No. of DLBs with preoperative symptoms

253/1094 (23%)

No. of DLBs with preoperative

symptoms that required intervention

137/639 (54%)

No. of patients requiring multiple DLBs

156/489 (32%)

Preoperative symptoms, n

253

Tracheal secretions

197 (78%)

Bleeding from tracheostomy

20 (8%)

Difficulties with ventilation

17 (7%)

Voice complaints

2 (1%)

Aspiration of secretions

2 (1%)

Air leak surrounding tracheostomy tube

3 (1%)

Tracheitis

3 (1%)

Dysphagia

2 (1%)

Erythema surrounding tracheostomy stoma

3 (1%)

DLB

direct laryngoscopy and bronchoscopy.

Laryngoscope 125: October 2015

Richter et al.: DLB in Children With Tracheostomies