2017 Sec 1 Green Book

Reprinted by permission of Laryngoscope. 2015; 125(10):2393-2397.

The Laryngoscope V C 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Surveillance Direct Laryngoscopy and Bronchoscopy in Children With Tracheostomies

Amy Richter, MD; Diane Wenhua Chen, BS; Julina Ongkasuwan, MD, FAAP, FACS

Objectives/Hypothesis: To determine utility of surveillance direct laryngoscopy and bronchoscopy (DLB) in children with chronic tracheostomies by examining the frequency of operative intervention in children undergoing an annual DLB. Study Design: Retrospective medical record review and analysis of operative findings and interventions. Methods: A retrospective chart review was conducted of all children with tracheostomies who underwent surveillance DLB between 2003 and 2012 at a tertiary children’s hospital. Charts were reviewed for demographics, indication for tracheot- omy, symptoms prior to DLB, dates of DLB, and operative findings and interventions. Results: A total of 489 patients underwent 1,094 DLBs. Two hundred fifty-three DLBs (23%) were accompanied by pre- procedural symptoms including bleeding; increased secretions; infection; and changes in ventilation requirement, swallow, or voice. Six hundred nineteen procedures (58%) required 817 interventions. Common interventions performed included debridement of granulation tissue (41%), tracheostomy tube exchange (27%), and subglottic dilation (10%). The presence of preprocedural symptoms and indication for tracheostomy did not predict need for intervention during DLB ( P > .05). Conclusions: In pediatric tracheostomy patients undergoing surveillance DLB, most procedures (58%) required opera- tive intervention for airway optimization. These data support our current practice of yearly surveillance DLB in asymptomatic pediatric tracheostomy patients and aim to facilitate the development of clinical practice guidelines regarding chronic trache- ostomy care in pediatric patients. Key Words: Pediatric tracheostomy, direct laryngoscopy and bronchoscopy, surveillance, suprastomal granulation. Level of Evidence: 4 Laryngoscope , 125:2393–2397, 2015

INTRODUCTION Tracheotomy is a common procedure in otolaryngol- ogy. Indications for tracheostomy tube placement and the associated morbidity and mortality of adult and pedi- atric tracheostomies have been well documented. Com- pared to adult tracheostomies, pediatric tracheostomies are associated with greater risk of complications with higher morbidity and mortality. 1 Children with pro- longed tracheostomy are at elevated risk for respiratory infections, airway bleeding, accidental decannulation, and death. 1–3 Screening direct laryngoscopy and bron- choscopy (DLB) may be used to detect lesions that may lead to eventual complications or decrease time to decan- nulation. 4 However, there is a general paucity of literature investigating current practice patterns for surveillance of patients with chronic tracheostomies, particularly in the pediatric population. Practice patterns for screening endoscopy vary between institutions. Indications for DLB include bleed- ing, difficult tracheostomy tube changes, ventilator From the Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery ( A . R ., J . O .), Baylor College of Medicine ( D . W . C .), Texas Children’s Hospital, Houston, Texas, U.S.A. Editor’s Note: This Manuscript was accepted for publication February 18, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Julina Ongkasuwan, MD, 6701 Fannin, Suite 640, Houston, TX 77030. E-mail: julinao@bcm.edu

dependence, poor phonation, anatomic abnormalities, and preparation for laryngotracheal reconstruction. 4,5 A survey of pediatric otolaryngologists found that most practitioners perform at least yearly surveillance endos- copy in children under age 2 years, but many only per- form endoscopy on patients prior to decannulation or in those experiencing difficulties. 6 Surveillance DLB in asymptomatic patients with chronic tracheostomies may result in documentation of an improved airway or no change in airway status, diagnosis of new tracheal lesion, including development of suprastomal granuloma, need for change in tracheostomy tube size, or decannula- tion. The goal of surveillance DLB is to optimize the air- way, reduce the risk of accidental decannulation, and facilitate easier tracheostomy tube changes so that care- givers can manage the airway more easily at home. However, surveillance DLB is not without risks. These risks include the cardiopulmonary risks of general anes- thesia, airway and oral cavity instrumentation, and pro- longed hospitalization. Despite the lack of current clinical practice guidelines for surveillance DLB, most practitioners agree that moni- toring of children with tracheostomies in inpatient and outpatient settings is necessary to prevent tracheostomy- related complications. 4,6 In a survey of members of the American Academy of Otolaryngology–Head and Neck Surgery Foundation, most members agreed that a clinical practice guideline regarding tracheostomy care would be useful (54%). 7 Standardization of post-tracheostomy care in pediatric patients may help to improve the quality of

DOI: 10.1002/lary.25254

Laryngoscope 125: October 2015

Richter et al.: DLB in Children With Tracheostomies

14