Compared with the past, significant changes have been made in the indications for pediatric tracheostomy at present. Previously, upper airway obstruction caused by viral and bacterial infections such as croup, diphtheria, and epiglottitis were the most common indications for pediatric tracheostomy. However, with the development of vaccines and antibiotics, the incidence of these infections causing airway obstruction has decreased.[5] In addition, advances in critical care have improved the survival rate of pediatric patients with critical illness requiring prolonged respiratory support, including premature infants.[3] As a result, the indications for pediatric tracheostomy have shifted. A Canadian study of pediatric tracheostomy in 30 years found that infection-related tracheostomies decreased, whereas those due to neurological impairments increased significantly.[6] Similarly, a 20-year study of tracheostomies in the PICU in India found that upper airway obstruction was the most common indication in the early 10 years, whereas central neurological impairment was the most common indication in the later 10 years.[7] Currently, the most frequent indications for tracheostomy in children are congenital upper airway anomalies causing airway obstruction or prolonged mechanical ventilation due to respiratory failure.
Neurological diseases leading to a bedridden state often require prolonged mechanical ventilation. Children with neurological impairments are more susceptible to respiratory insufficiency than their healthy counterparts. Malnutrition-related respiratory muscle wasting in the presence of neurological impairments leads to ineffective breathing, and frequent aspiration and decreased cough efficacy with retention of secretions increases the likelihood of recurrent and chronic lung infections. Hypoxemia due to obstructive sleep apnea syndrome is also common in these patients. Thus, children with neurological impairments are at risk of respiratory failure and often require respiratory support such as mechanical ventilation.[1, 8] Tracheostomy may offer specific advantages to children with neurological impairments who are dependent on ventilation. It can reduce the sedation requirement, increase the duration of awake and interactive periods with caregivers, and facilitate discharge from the PICU to an appropriate supported environment, such as home, rather than hospital.[9] Therefore, tracheostomy should be considered in children with neurological impairments requiring prolonged mechanical ventilation.
This study investigated the characteristics of pediatric patients with neurological impairments who underwent tracheostomy. The patients were typically bedridden because of underlying diseases, with refractory epilepsy being the most common, followed by HIE and CP (Fig. 1). Upon hospital admission, the median GCS score was 10 (IQR 6.3–13) points, indicating moderate brain injury. Nearly half of the patients had kyphoscoliosis and FTT at the time of tracheostomy, and some patients also had gastrostomy. In addition, the majority of patients who received tracheostomy had central venous access, and nearly all patients underwent tracheostomy for prolonged mechanical ventilation. Given the scarcity of studies specifically investigating pediatric tracheostomy in patients with neurological impairments, the information presented here can help identify the characteristics of this patient population.
No consensus or guidelines have been established for the appropriate timing for tracheostomy in children with neurological impairments who require prolonged mechanical ventilation in the PICU. Wakeham et al. [10] conducted a study on tracheostomy use in 82 North American PICUs and found significant variations in both the rate and timing of tracheostomy use across different units. This variability appears to be influenced by local PICU characteristics, available resources, unit practice patterns, and practitioner attitudes toward tracheostomy. Establishing a consensus and guideline for pediatric tracheostomy timing is challenging because of the heterogeneity and complexity of potential risks associated with underlying diseases in patients requiring tracheostomy. Several recent studies have investigated the optimal timing for tracheostomy in pediatric patients requiring prolonged mechanical ventilation in the PICU.[11–13] All these studies compared and analyzed early and late groups based on an intubation period of 14 days, and similar results were obtained. Early tracheostomy was found to be associated with lower rates of complications, higher rates of successful weaning, and decreased utilization of intensive care resources. Moreover, it was linked to a reduction in the duration of mechanical ventilation, length of PICU stay, and overall hospital stay. The underlying diseases of the patients included in the above three studies were heterogeneous. In this study of patients with neurological conditions, the median duration of mechanical ventilation before tracheostomy was 14.5 (IQR, 6.8–20) days. To compare the outcomes of early versus late tracheostomy, patients were divided into two groups based on the median value, and a comparative analysis was conducted. A statistically significant difference was found between the early and late groups in terms of total hospital stay and length of PICU stay, with both being shorter in the early group (p = 0.003, p < 0.001). However, no significant difference was found in the complication or mortality rate between the two groups. These findings provide valuable insights into the effect of mechanical ventilation duration on patient outcomes and suggest that shorter durations of mechanical ventilation may be associated with shorter total PICU and hospital stay.
In this study, which focused solely on patients with neurologic diseases, tracheostomy-related complications occurred in approximately two-thirds of the patients (23/38, 60.5%). Granuloma formation was the most commonly observed complication, and none of the cases required surgical removal. Most of these complications were detected during the regular follow-up and were treated topically. A recently published systematic review of tracheostomy-related complications in children found an average complication rate of 40%, with rates varying based on factors such as age, birthweight, prematurity, comorbidities, and whether the procedure was elective or performed as an emergency. Consistent with our study, the most common complications reported were granulomas and cutaneous lesions.[14] Another cross-sectional analysis of pediatric tracheostomy-related complications examined a total of 5,309 tracheostomies and reported a complication rate of 8%.[15] Recent single-center studies have reported complication rates ranging from 25–55% [16–19], which may vary depending on the characteristics of the underlying disease or patient age. The study participants were patients who required tracheostomy for home ventilation and did not require decannulation, indicating that tracheostomy was necessary in the long term. Given this, the complication rate observed in our study is expected to be higher than that in other studies. Therefore, active collaboration between healthcare providers and caregivers is essential to prevent tracheostomy-related complications in patients with neurological impairments.
The mortality rate can vary depending on the composition of the study participants. Recent single-center studies with heterogeneous patient etiologies reported an overall mortality rate of 17–37% and a tracheostomy-related mortality rate of 1.2–27%.[17, 18, 20, 21] In this study, the overall mortality and tracheostomy-related mortality rates were 36.8% and 7.9%, respectively, which is consistent with the findings of other single-center studies. In a study involving 917 children who underwent tracheostomy, the relationship between comorbid clinical conditions and mortality was analyzed. The study found that mortality rates and hospital-resource utilization were higher in cases with neurological impairments.[22] Furthermore, other studies have reported that severe neurocognitive disability and seizures were associated with high mortality rates.[20, 21] Two tracheostomy-related deaths were attributed to accidental decannulation, which could have been prevented with timely and appropriate intervention by medical staff. Patients with neurologic diseases are at a higher risk of mortality following tracheostomy than other disease groups, underscoring the need for vigilant attention and care from both medical staff and caregivers.
This study has several limitations that should be considered when interpreting the findings. First, it was a retrospective analysis of medical records from a single institution, which raises the possibility of missing data. Second, the sample size was relatively small, which limited the statistical power of the Cox proportional hazards regression analysis used to identify mortality-related risk factors. Therefore, more robust and reliable results can be obtained through a prospective multicenter study that overcomes these limitations. However, unlike other single-center studies that focus on a heterogeneous population, this study exclusively includes bedridden patients with neurological impairments, providing unique insights into their tracheostomy use and characteristics. In addition, the study highlights the significant reduction in total hospital and PICU stay associated with early tracheostomy, which may aid in decision-making for patients with neurological impairments requiring tracheostomy in the future.
Children with neurological impairments who are typically bedridden may experience respiratory difficulties, which can be addressed through tracheostomy. Patients with neurological impairments may present with comorbidities such as kyphoscoliosis, FTT, and dependence on gastrostomy and central venous access. This study categorized patients based on the timing of tracheostomy and found that the early tracheostomy group had significantly shorter hospital and PICU stay than the late group. Given the potential for high complications and mortality rates in this patient population, careful and appropriate care by medical staff and caregivers is crucial.