Overview
Definition:
Tracheostomy, a surgical procedure to create an opening in the trachea, is vital for managing pediatric airway compromise
However, it is associated with several complications, particularly in children, including granulation tissue formation and complete or partial obstruction of the tracheostomy tube.
Epidemiology:
The incidence of tracheostomy complications in children varies, with granulation tissue formation reported in 5-40% of cases and obstruction being a significant cause of emergency presentations
Factors like prolonged intubation, tracheostomy tube size, and underlying comorbidities influence complication rates.
Clinical Significance:
Understanding and proactively managing these complications is critical for pediatric residents and DNB/NEET SS candidates
Granulation tissue can lead to stenosis, bleeding, and airway obstruction, while complete obstruction can be immediately life-threatening, requiring prompt recognition and intervention to ensure patient safety and favorable outcomes.
Clinical Presentation
Granulation Tissue:
Intermittent or persistent bleeding from the stoma
Difficulty inserting or changing the tracheostomy tube
Stridor or increased work of breathing
Coughing or gagging
Visible or palpable tissue at the stoma site or within the airway lumen.
Obstruction:
Sudden onset of severe respiratory distress
Cyanosis
Inability to pass air through the tracheostomy tube
Increased secretions and ineffective coughing
Suprasternal and intercostal retractions
Alarms on mechanical ventilation indicating high peak airway pressures or no exhaled volume.
Diagnostic Criteria:
Diagnosis is primarily clinical, confirmed by visualization of granulation tissue during laryngoscopy or bronchoscopy
Tracheostomy tube obstruction is a clinical diagnosis based on the inability to pass air through the tube and evidence of airway compromise.
Diagnostic Approach
History Taking:
Detailed history of the tracheostomy: duration, type of tube, recent changes, presence of secretions, coughing effectiveness
History of previous airway procedures or conditions
Any recent trauma or infection
Onset and progression of respiratory symptoms
Red flags: sudden change in respiratory status, stridor, inability to vocalize or cry effectively.
Physical Examination:
Assess vital signs: heart rate, respiratory rate, oxygen saturation, blood pressure
Inspect the tracheostomy site for signs of bleeding, infection, or visible granulation tissue
Auscultate the chest for air entry and adventitious sounds
Assess for signs of respiratory distress: retractions, nasal flaring, grunting
Attempt to pass a suction catheter down the tracheostomy tube – resistance indicates potential obstruction
Check for tube patency by listening for air movement.
Investigations:
Flexible laryngoscopy or bronchoscopy is the gold standard for visualizing granulation tissue and assessing airway patency
If infection is suspected, culture and sensitivity of tracheal secretions may be performed
Chest X-ray can help rule out pneumonia or other pulmonary causes of respiratory distress but is less sensitive for direct airway obstruction
Arterial blood gas analysis to assess oxygenation and ventilation status.
Differential Diagnosis:
For obstruction: mucus plugging, foreign body aspiration, tracheomalacia, kinking of the tube, dislodgement of the tube, accidental decannulation, tracheal stenosis (late presentation)
For granulation tissue: stomal infection, foreign body at stoma, poor stoma care, pressure necrosis from the tube.
Management
Initial Management Obstruction:
Immediately attempt to suction the tracheostomy tube
If suctioning is unsuccessful, remove the existing tube and attempt to insert a clean, appropriately sized tracheostomy tube (or a smaller one if swelling is suspected)
If a new tube cannot be inserted easily or the airway is not secured, consider emergency intubation via the natural airway or needle cricothyroidotomy followed by percutaneous dilatational cricothyroidotomy if no other option exists
Provide supplemental oxygen and ventilatory support as needed.
Medical Management Granulation:
Topical treatments: Silver nitrate application to cauterize granulation tissue
Steroid inhalations or topical steroids to reduce inflammation
Antibiotics if stomal infection is present
Humidification of inspired air to reduce drying and irritation.
Surgical Management Granulation:
Laser excision of granulation tissue using a bronchoscope
Direct surgical excision of granulation tissue
Tracheal resection and reconstruction for severe stenosis
Tracheostomy tube changes with careful attention to avoiding trauma to the stoma site.
Supportive Care:
Aggressive pulmonary toilet: frequent suctioning, chest physiotherapy, and positioning to clear secretions
Humidification of inspired air
Adequate hydration and nutrition
Close monitoring of respiratory status, oxygen saturation, and work of breathing
Pain management
Education for parents/caregivers on stoma care, suctioning techniques, and recognition of warning signs.
Complications
Granulation Tissue Formation:
Can occur at the stoma site (external granulation) or within the trachea (internal granulation)
Leads to progressive airway narrowing, bleeding, and obstruction
May result in tracheomalacia or tracheoesophageal fistula in severe cases.
Obstruction:
Can be acute due to mucus plugging, blood clots, tube kinking, or dislodgement
Chronic obstruction can be due to granulation tissue formation or tracheal stenosis
Leads to hypoxemia, hypercapnia, and respiratory failure
Can be fatal if not managed promptly.
Prevention Strategies:
Proper tracheostomy tube selection and sizing
Regular and meticulous stoma care
Humidification of inspired air
Adequate hydration
Gentle suctioning techniques
Avoidance of excessive traction on the tube
Regular monitoring for early signs of granulation tissue
Prompt management of secretions
Use of a speaking valve when appropriate to promote airflow and reduce stomal issues
Careful surgical technique during tracheostomy creation.
Prognosis
Factors Affecting Prognosis:
Severity and extent of granulation tissue or obstruction
Promptness and effectiveness of management
Underlying medical condition of the child
Presence of associated airway anomalies
Skill and experience of the medical team.
Outcomes:
With timely and appropriate management, most children with granulation tissue and obstruction can achieve resolution and maintain a patent airway
Severe stenosis or complications may require extensive surgical intervention
Recurrence is possible if preventive measures are not maintained
Long-term outcomes depend on the underlying reason for tracheostomy and the success of managing complications.
Follow Up:
Regular follow-up with pediatric pulmonologists and surgeons is essential
This includes periodic bronchoscopic evaluations, assessment of airway patency, and monitoring for recurrence of granulation tissue or signs of stenosis
Education for caregivers on ongoing stoma care and emergency preparedness is crucial.
Key Points
Exam Focus:
Granulation tissue formation and obstruction are common and potentially life-threatening pediatric tracheostomy complications
Bronchoscopy is the diagnostic gold standard
Management of obstruction requires immediate airway assessment and intervention, potentially including tube replacement or emergency airway access.
Clinical Pearls:
Always have a correctly sized spare tracheostomy tube and a smaller obturator readily available at the bedside for emergency changes
Suctioning is key to preventing obstruction
perform it proactively
Remember that bleeding from the stoma can be a sign of granulation tissue or be related to vigorous suctioning.
Common Mistakes:
Delaying intervention in cases of suspected obstruction
Failure to have emergency equipment readily accessible
Inadequate stoma care leading to infection and granulation
Over-reliance on imaging without clinical assessment for obstruction
Insufficient caregiver education on recognizing and managing complications.