Neonatal Tracheotomies Found to be Safe and Effective

Management of the neonatal airway has proven to be key in increasing the survival rates of preterm infants in intensive care units. Now that neonatologists have enhanced their understanding and techniques of caring for the infant requiring ventilatory support, there is a need for fewer days of intubation and ventilation. Despite these advances, the need still exists for tracheostomy in the preterm infant with multiple failed extubations, whether due to prolonged ventilator dependence, prematurity, bronchopulmonary dysplasia, or congenital anomalies.

One key study has found an increase in the number of tracheostomies performed for prolonged ventilation and a concomitant decrease in tracheostomies done for airway obstruction during 1980 to 1990. The rate of tracheostomy for patients with congenital abnormalities has been reported as 10-14 percent, with co-morbid factors present in 77 percent of these patients. More recent studies have shown a general trend toward lower rates of tracheostomies. The children who do undergo tracheostomy tend to be smaller in size, the youngest, and more critically ill.

Tracheostomy in the pediatric patient has been associated with significant morbidity and mortality when compared to adults. Infants incur a higher complication rate, particularly those born prematurely. Past medical research has examined the complications associated with pediatric tracheostomies, but none have studied the factors influencing the need for tracheostomy in the preterm infant. In order to assess these factors, a research team reviewed the charts of children admitted to the neonatal intensive care unit (NICU) who required a tracheostomy, analyzing their co-morbidities and the indications for tracheostomy.

In a first of its kind study, researchers have examined the events surrounding a tracheostomy in high-risk preterm infants. The mortality rate of low birth weight, extremely premature infants with multiple complications precluded such research. With the present advances in neonatal care, such research has become possible. The authors of "Tracheostomy in High-Risk Pre-Term Infants: Current Trends" are Kevin D. Pereira MD, Allison R. MacGregor MD, and Chad M. McDuffie, from the Department of Otolaryngology, The University of Texas at Houston Medical School, Houston, TX; and Ron B. Mitchell MD FRCS, from the Department of Otolaryngology, The University of New Mexico, Albuquerque, NM. Their findings are to be presented at the Annual Meeting and OTO Expo of the American Academy of Otolaryngology--Head and Neck Surgery Foundation, September 22-25, 2002, at the San Diego Convention Center, San Diego, CA.

Methodology: A retrospective review was conducted of all neonatal patients who received a tracheostomy and direct laryngoscopy at Memorial Hermann Children's Hospital in Houston, Texas, and the University of New Mexico Medical Center in Albuquerque, New Mexico, between January, 1997 and January, 2001. Data on the subjects' weight, gestational age, number of intubations, other illnesses and outcomes was collected. Only premature (gestational age less than 37 weeks) infants were included in the study.

Infants were divided into two groups by birth weight and gestational age. Group 1 included infants born at less than 30 weeks gestational age and less than 1500 grams. Group 2 included infants born at greater or equal to 30 weeks and 1500 grams. A scoring system was devised to grade patients according to their significant comorbidities. One point was given for each congenital anomaly, and one each for the presence of patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), or retinopathy of prematurity (ROP). Additional points were tabulated for bronchopulmonary dysplasia (BPD) and intraventricular hemorrhage (IVH), as these conditions had a more significant impact on overall health. Scoring was also provided for oxygen requirement at the time of tracheostomy.

Results: During the time period reviewed, 3,793 patients were admitted to the combined neonatal intensive care units. There were 873 (23 percent) infants admitted at less than 30 weeks gestational age and less than 1500 grams, and 787 (21 percent) infants admitted at greater than or equal to 30 weeks and >/= 1500 grams. Infants greater than or equal to 37 weeks gestational age were excluded from the study. Thirty-three (0.87 percent) children had tracheostomies performed. Of these 33 infants, 23 (70 percent) were placed into Group 1 (infants less than 30 weeks and less than 1500 grams), while ten (30 percent) were placed into Group 2 (infants greater than or equal to 30 weeks and 1500 grams). The percentage of infants in Group 1 and in Group 2 that required tracheostomies was 2.6 and 1.3 respectively.

Group 1 had a higher incidence of patent ductus arteriosus, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing colitis, and retinopathy of prematurity. Group 1 had a higher average number of failed extubations (4.9 v. 3.29), oxygen requirement, and lower average weight at tracheostomy when compared to Group 2. Subglottic stenosis (39 percent v. 20 percent) and laryngotracheomalacia (30 percent v. 20 percent) were more common in Group 1. Group 2 had more congenital anomalies than Group 1. Group 1 infants were more prone to have other illnesses.

Conclusion: High-risk preterm infants with very low birth weight are surviving in larger numbers due to greatly improved neonatal intensive care, alleviating the need for a tracheostomy in this population. For the premature infants that do require this procedure, the indications have changed. Fewer children are requiring tracheostomy for upper airway obstruction. Those who do are usually older preterm infants with congenital or genetic abnormalities. Very low birth weight preterm infants generally require a tracheostomy for prolonged ventilatory support due to respiratory distress syndrome and its consequences. These infants have higher comorbidity scores reflecting the severity of their pulmonary disease.

This study shows that out of a large number of preterm infants only a very few will require airway intervention despite prolonged ventilation and therefore validates and supports current neonatology practices. The incidence of complications of tracheostomy in the neonatal population has decreased secondary to improved technique, anesthesia, transport and post-operative care. When required, it can be done safely with minimal morbidity.