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[Prolonged endotracheal intubation or tracheostomy in children (author's transl)]
Insights
Prolonged endotracheal intubation can lead to subglottic tracheal stenosis in children. Tracheostomy may be a safer alternative in certain cases to minimize this risk.
Area of Science:
- Pediatric critical care medicine
- Otolaryngology
- Respiratory medicine
Background:
- Subglottic tracheal stenosis is a potential complication of prolonged endotracheal intubation in pediatric patients.
- Understanding the risk factors associated with tracheal stenosis is crucial for patient management.
Observation:
- This report details five cases of subglottic tracheal stenosis following prolonged endotracheal intubation.
- The incidence of stenosis is similar between prolonged intubation and tracheostomy.
- Risk factors include intubation duration, laryngotracheal trauma, infection, and patient age.
Findings:
- Prolonged intubation requires sedation and intensive care, while tracheostomy carries higher mortality but offers easier airway management.
- Tracheostomy in children can reduce the need for sedation and simplify airway toileting.
- Neither intubation nor tracheostomy is universally superior; proper application minimizes complications.
Implications:
- Careful patient selection and monitoring are essential to minimize tracheal stenosis.
- Tracheostomy should be considered for pediatric patients requiring prolonged intubation beyond three days, especially if extubation is unlikely.
- Younger children (<2 years) require a more cautious approach to tracheostomy, with it being reserved for situations where no alternative exists.
Abstract:
Five patients with subglottic tracheal stenosis following prolonged endotracheal intubation are reported. To minimize tracheal stenosis the indications for prolonged intubation should be well defined and tracheostomy considered as an alternative. The incidence of tracheal stenosis following prolonged intubation is stimilar to that following tracheostomy. The risk of stenosis increases with the duration of intubation, the degree of physical trauma to the laryngotracheal mucosa (suction, tube changing, restlessness), infection of the trachea or larynx, and with the age of the child. Prolonged intubation necessitates sedation and intensive care. Tracheostomy has a higher mortality but this and the risk of stenosis depend greatly on the operative technique. Particularly in cases where prolonged intubation increase the risk of tracheal stenosis, the advantages of tracheotomy become evident. Tracheostomised children rarely need sedation, the tracheobronchial tree can be easily and carefully toileted and the changing of the tube is without risk. Neither method is absolutely preferable, but the correct application of both will minimise the complication rate. The indications for each may be summarised as follows: for primary treatment of acute respiratory distress in children prolonged intubation is the treatment of choice. If after 3 days there is no chance of extubation, tracheostomy should be considered but this depends also on the child's age and behaviour, and on the laryngotracheal mucosal reaction. The younger the child the more cautiously should tracheostomy be considered. Children under 2 years of age should only be tracheostomised if there is no alternative.