Abstract

Background: In this study, we analyzed the data related to pediatric cardiac intensive care unit patients undergoing tracheostomy.

Methods: A total of 18 patients (10 girls, 8 boys; mean age 9.4±10.5 months; range 2 to 42 months) who were hospitalized in the pediatric cardiac intensive care unit at a single center between January 2010 and January 2015 and who underwent tracheostomy during the hospitalization period were retrospectively analyzed.

Results: At baseline, genetic disorders were identified in three patients. Among 1,450 patients who underwent cardiac surgery, 10 received total correction and eight received palliation. The mean intubation time without tracheostomy was 41.0±12.9 days and the number of extubation attempts was 4.2±0.8. Two patients had neurological damage. No patients developed pneumomediastinum, pneumothorax, wound site infection or mediastinitis following tracheostomy. One patient underwent revision of the tracheostomy site due to bleeding. None of the patients had late tracheostomy complications such as tracheal stenosis during the follow-up period. Six of 18 tracheostomy patients died in the pediatric cardiac intensive care unit and one died at home following discharge (mortality 38.8%). Eight of 12 tracheostomy patients who were discharged underwent decannulation. Three patients are currently under follow-up at home using a home-type ventilator.

Conclusion: Tracheostomy procedures may be performed in patients with prolonged intubation time following cardiac surgery with a low complication rate. However, the morbidity and mortality rates in this patient population still remain high due to several factors implicated in this complicated process.

In recent years, early and rapid extubation following pediatric cardiac surgery has become widely adopted.[1] The form of the cardiac pathology, the complexity of the operation, surgical complications, the presence of residual defects, myocardial dysfunction, presence of pulmonary parenchyma, and comorbid problems may complicate extubation, thereby, increasing the length of stay on the mechanical ventilator.[2-4]

Prolonged endotracheal intubation complicates postoperative procedures, leading to increased mortality and morbidity rates.[5] Tracheostomy emerges as an alternative method for the prevention of such problems.[5] Tracheostomy has been associated with shorter durations of sedation used, decreased respiratory workload, lower infection risk, more comfortable mobilization, and easier oral feeding, which is particularly important for infants.[6,7] However, no consensus on tracheostomy procedures, indications, and outcomes in patients treated in the pediatric cardiac intensive care unit (PCICU) has been reached yet. Therefore, in this study, we aimed to analyze the data related to PCICU patients undergoing tracheostomy at a single center.

Methods

A total of 18 patients (10 girls; 8 boys; mean age 9.4±10.5 months; range 2 to 42 months) who were hospitalized in the PCICU at a single center between January 2010 and January 2015 and who underwent tracheostomy during the hospitalization period were retrospectively analyzed. A study form was designed to gather data of each patient included in the study, including demographics, cardiac diagnoses, presence of genetic abnormalities, comorbidities, surgical procedures, and length of stay on the mechanical ventilator in the postoperative period. The duration and number of extubations, reason for tracheostomy, decannulation time, the presence of postoperative residual cardiac defects, and emerging complications were thoroughly analyzed. Each tracheostomy procedure was performed in the pediatric cardiovascular surgery clinic. For this procedure, a reverse flap incision in the shape of the letter “U” was performed. The mobilized flap was fixed under the skin.

The study only included patients who underwent tracheostomy following the performance of surgical or transcatheter intervention in the PCICU. Patients who did not undergo any interventions or who were over the age of 18 were excluded from the study. The study protocol was approved by the Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital Ethics Committee. A written informed consent was obtained from each parent. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Statistical analysis
Statistical analysis was performed using PASW version 17.0 (SPSS Inc., Chicago, IL, USA) software. Descriptive data were expressed in standard deviation, median and range. A p value of <0.05 was considered statistically significant.

Results

A total of 1,450 patients underwent cardiac surgery and hospitalized in the PCICU. Cardiac surgical/ transcatheter intervention was performed on 18 patients and the rate of tracheostomy was 1.2%. Ten patients (56%) undergoing tracheostomy were females and eight (44%) were males. The mean body weight was 5.8±2.9 kg (range, 3.8 to 14 kg). At baseline, genetic disorders were identified in three patients (n=2, Down syndrome; n=1, DiGeorge syndrome). For the diagnosis of genetic diseases, chromosome analysis was performed in two patients with Down syndrome and fluorescent in situ hybridization was used in the patient with DiGeorge syndrome. Among the patients who underwent cardiac surgery, 10 received total correction and eight received palliation (n=6, pulmonary banding; n=1, central shunt; n=1, patent ductus arteriosus stenting). Four patients had single-ventricle morphology. The mean intubation time without tracheostomy was 41.0±12.9 days (range, 20 to 77), while the number of extubation attempts was 4.2±0.8 (range, 2 to 6). Two patients had neurological damage; one of them who had mental retardation and muscular hypotonicity also had a neurological disorder at baseline, while the other with cerebral hypoxic damage developed a neurological disorder during the perioperative period. The main cardiac pathologies, operation types, duration of tracheostomy, risk factors for tracheostomy, and current overall condition of the patients are summarized in Table 1.

Table 1: Main cardiac pathologies, operation types, duration of tracheostomy, risk factors for tracheostomy, and current overall condition of the patients undergoing tracheostomy

The risk factors associated with tracheostomy were sepsis (n=14, 78%), chromosomal abnormality (n=3, 17%), neurological impairment (n=2, 11%), pleural effusion (n=3, 17%), diaphragmatic paralysis (n=3, 17%), chylothorax (n=2, 11%), ventilatorassociated pneumonia (n=2, 11%), and tracheomalacia (n=1, 5.5%). Ventilator-associated pneumonia was defined as the presence of infiltration on chest X-ray, increased acute phase reactants, worsening overall condition, and positive cultures from lower respiratory tract secretions. Such patients were observed to have proliferations of Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter in their tracheal secretion cultures, respectively. The diaphragmatic paralysis was diagnosed in the catheterization laboratory under fluoroscopy. Diaphragm plication was performed in two patients and clinical follow-up was performed for one. The patients who received diaphragm plication were unable to be weaned from the mechanical ventilation. In one of the two patients who underwent plication, successful decannulation following tracheostomy was performed. The other patient in whom plication failed was followed with a home-type ventilator. For both patients with chylothorax, this complication was associated with ductus thoracicus injury. For the treatment, drainage with a thoracic tube (12 days in one patient and five days in the other patient), total parenteral nutrition support and a diet containing medium-chain fatty acids were applied. For the first patient, intravenous octreotide was also included in the treatment. No surgical ligations were required due to chylothorax. One patient underwent total revision of the tracheostomy site due to bleeding. No patients developed pneumomediastinum or pneumothorax following tracheostomy. Povidone iodine was used for dressings and no wound infections or mediastinitis were observed in any patients. Of 18 patients, six died in the PCICU, while one died at home following discharge (mortality 38.8%). Eight of 12 patients who were discharged (at 1 month, 3 months, 4 months, 4 months, 5 months, 6 months, 6 months, and 8 months after tracheostomy, respectively) underwent decannulation. Three patients are currently under follow-up at home using a home-type ventilator. The follow-up periods of these patients were two, three, and five months. The overall post-tracheostomy conditions of the patients are summarized in Figure 1. Late tracheostomy complications such as tracheal stenosis were not observed in any patients during the follow-up period.

Figure 1: The overall post-tracheostomy conditions of the patients undergoing tracheostomy.

Discussion

Prolonged intubation may jeopardize comfort, nutrition, or mobility in children. Therefore, at several centers, tracheostomy has been performing at an increasing frequency in children with prolonged intubation. Tracheostomy has several potential advantages compared to the nasotracheal or orotracheal intubation procedures. Initially, it reduces the workload during respiration, improves pulmonary drainage, controls airway safety, enables patient mobilization, and facilitates weaning from mechanical ventilation.[3,8] Furthermore, in an adult study, tracheostomy following cardiac surgery was associated with reduced morbidity, shorter total length of stays in the hospital and intensive care unit, and reduced in-hospital mortality without increased mediastinitis.[5] Another important advantage of tracheostomy is that it enables oropharyngeal coordination in breastfed infants and young children. Despite all these advantages, long-term mechanical ventilation support (>7 days) has remained limited to a small number of cases.[5] As a result, no sufficient clinical data are available on the procedures or results of tracheostomy following cardiac surgery in infants and children. The medical indications for tracheostomy include a prolonged need for mechanical ventilation, preservation of the airway, a need for airway access to externalize secretions, avoidance of translaryngeal intubation complications, improved patient comfort, provision of improved in-patient care outside the ICU, and enhanced patient safety.[9,10]

With the developments in prenatal diagnosis, neonatal resuscitation, intraoperative techniques, and perioperative intensive care, complicated congenital cardiac surgeries have been performing in the pediatric population at an increasing frequency.[5] On the other hand, despite these developments, a small proportion of patients may still require prolonged respiratory support following surgical intervention. The major risk factors for prolonged mechanical ventilation support include high-risk surgical procedures which involve poor cardiac function, a tendency toward residual lesions following surgical repair, and underlying complicated congenital heart diseases.[11] Since complicated congenital heart diseases are currently correctible and positive efforts have increased to overcome postoperative complications, prolonged mechanical ventilation support has been used more frequently in this patient population. In a study of 37 infants and children with tracheostomy following cardiothoracic surgery, 24 underwent surgery for congenital heart disease; 15 of these received biventricular repair, while nine underwent palliative surgical procedures.[2]

In terms of palliative procedures, two children received total cavopulmonary connection, three underwent staging procedures before corrective intervention, and four received single-ventricle palpation. In our study, nine patients (50%) with tracheostomy had a complicated congenital heart disease and four of these had a single-ventricle morphology. Among the patients who received interventions (surgical or interventional), eight underwent palliation and 10 had total correction.

For the additional malformations associated with other systems accompanied by congenital heart diseases, acute perioperative process and long-term treatment are critical in the management of these conditions. Neurological disorders and abnormalities are among the major factors for tracheostomy. Kabbani et al.[12] reported neurological factors to be the foremost reason for tracheostomy, occurring in 68% of the patients in his study. In our study, neurological disorders were observed in two patients undergoing tracheostomy in the PCICU. While the neurological condition was present in one of these patients at baseline, it developed during the perioperative period in the other. Furthermore, three patients (42%) who underwent tracheostomy also had genetic abnormalities in addition to congenital heart disease in our study.

On the other hand, the optimal timing of tracheostomy is still controversial, which should be individualized by taking into account patient-specific medical concerns and considerations regarding the patient and his or her family. In the 1980s, early tracheostomy was performed before day 21 of translaryngeal intubation.[9] Devarajan et al.[5] examined the effects of early tracheostomy in patients requiring prolonged mechanical ventilation following cardiac surgery and revealed that tracheostomy within 2 to 10 days postoperatively shortened the length of hospital stay and reduced morbidity and mortality. On the other hand, some authors suggest that tracheostomy should be performed, if the intubation time is to be longer than to three weeks.[2,11-15] The overall approach of our clinic, in the presence of underlying complicated cardiac disease or additional genetic or neurological abnormalities, in particular, is that patients should not remain intubated for more than three weeks, if there have been repeated attempts at extubation; it would be more appropriate to monitor these patients by performing tracheostomy. In our study, the mean duration of tracheostomy was 41.0±12.9 days (range, 2 to 77). The reasons behind this prolonged time were that the majority of our patients were in the infant age group, our tendency to observe the recovery possibilities without the need for an artificial airway, the high complexity-percentage of the underlying heart disease, the complexity of the surgical procedures performed, and the failure of the families of some patients to provide a written informed consent for tracheostomy within given time. Furthermore, particularly in pediatric patients with complicated congenital cardiac diseases and labile conditions, the patient’s hemodynamic or clinical condition (i.e. acute kidney/liver failure, bleeding diathesis secondary to coagulation disorder, sepsis) may not be appropriate for tracheostomy, even if that procedure is planned and this situation may result in delayed tracheostomy.

Furthermore, respiration and airway complications are particularly common after cardiac surgery.[3] Other surgery-related complications include diaphragmatic dysfunction secondary to phrenic nerve injury and vocal cord paralysis secondary to laryngeal nerve injury.[14,15] Additional well-defined complications in these patients, which may lead to prolonged mechanical ventilation following cardiac surgery and may deteriorate respiratory function, are chronic pleural effusion and chylothorax.[15,16] In consistent with the literature data, we also observed three patients (16.6%) with diaphragmatic paralysis, three (16.6%) with pleural effusion, two (11%) with chylothorax, and one (5.5%) with tracheomalacia.

In the present study, the mortality rate in the patient group who underwent tracheostomy following cardiac surgery remained high. In the study of Hoskote et al.,[2] 15 patients (41%) were in the neonatal period and 12 (32%) had accompanying chromosomal abnormalities. In addition, 15 patients (41%) died on admission: nine patients died due to sepsis and multi-organ failure, five had persistent myocardial dysfunction, and three had major chromosomal abnormalities. In our study, six of 18 patients died in the PCICU, while one died at home following discharge (total mortality 38.8%). Six patients died due to sepsis and multi-organ failure and two died due to persistent myocardial dysfunction (one of these patients also had sepsis).

In conclusion, tracheostomy may be more frequently indicated in patients with underlying complicated congenital heart disease or additional genetic or neurological disorders compared to patients undergoing cardiac surgery due to congenital heart disease. The number of infant cases with complicated congenital heart disease who undergo palliative surgery is a significant proportion of this patient population. Based on our study results, tracheostomy procedures may be performed in patients with prolonged intubation time following cardiac surgery with a low complication rate. However, the morbidity and mortality rates in this patient population still remain high due to several factors implicated in this complicated process.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

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