Tracheostomies consist of a surgical opening of the trachea and the insertion of a tube that allows for the trachea to have a direct exchange with the external environment.1–4 It is one of the oldest known surgical procedures; it was first described in 100 AD by Asclepiades in Ancient Greece. It came to be used more frequently in routine medicine in the mid-nineteenth century when Armand Trousseau employed the technique to treat many patients with dyspnea associated with diphtheria.1,2,4–9

In recent decades, the tracheostomy has changed in terms of its indications, its complications, and the epidemiological profile of the patients that undergo this procedure. These changes are attributed to the development of new intensive care techniques, as well as to alterations in the epidemiology of infectious diseases, the increase in premature newborn survival rates, and the increase in the survival rates of newborns with birth defects.2,10–16

This procedure is technically more difficult in pediatric patients relative to their adult counterparts, since children's trachea are smaller and softer and because the surgical space is more limited. In addition, some risks to the procedure are directly linked to age, and more specific such as premature birth, low birth weight, the duration of the tracheostomy, and associated serious underlying diseases. Thus, this group experiences higher morbidity and mortality rates than adult patients.1,2,4,5,7,10,15,17,18

The objective of this study was to perform a review of the literature from the last three decades in order to trace a profile of complications and mortality rates of tracheostomies in children, and also to determine whether this profile has changed between decades.

A review of the literature was performed using the Cochrane, Latin American and Caribbean Health Sciences Literature (LILACS), SciELO, National Library of Medicine (Medline Plus), and PubMed databases. It included articles published between January 1985 and December 2014. After the articles were read, a review of the articles’ bibliographical references was performed in order to identify other potentially relevant studies.

In the Medline and PubMed databases, the MeSH terms “tracheotomy” and “tracheostomy” were used; they were associated with “complications”, “child”, and “mortality” as qualifiers. Meanwhile, in the SciELO, LILACS, and Cochrane databases, associations between the terms “tracheostomy/tracheotomy”, “complication”, “mortality” and “pediatric/child” were used. The search was limited to articles written in Portuguese, Spanish, and English and to a patient age group of 0–18 years of age.

The articles were independently evaluated by two of our study's authors. Articles that represented case reports and case series were excluded. Articles that did not contain sufficient data to evaluate complications and mortality in children that had undergone tracheostomies were also excluded.

The data was organized in Excel® and analyzed using the Statistical Package for Social Sciences (SPSS®) software, version 21.0. The data from each decade was compared to the data from the other decades using the Chi-square test. The Confidence Interval was set at 95%, and values were considered significant when p<0.05.

A total of 3797 articles were identified using the MeSH terms and the key words outlined in the methodology. From these articles, studies that included an age group of 0–18 years of age, were written in Portuguese, English, or Spanish, and were published between January 1985 and December 2014 were included; there were a total of 595 articles. One hundred and 32 articles that represented case reports and case series were excluded. After another review for relevance by two independent otolaryngologists, 547 articles were excluded and 47 articles remained.1–47 Most of the papers excluded at this time did not have sufficient data for review. Of these 47 articles, five studies were published between 1985 and 1994, 15 were published between 1995 and 2004, and 27 were published between 2005 and 2014. The distribution of the number of articles and the total number of patients per decade is shown in Table 1.

The objective of this review was to evaluate the occurrence of complications and of mortality associated with tracheostomy over the last three decades. Many children younger than one year of age who had undergone a tracheostomy were found to be included in these studies; rates of this age group varied from 41.3% to 63.0%. This finding reflects the trend of progressively younger children receiving this procedure, as was observed in many studies.6,10,15,23,27,39,46,47 This age distribution may be attributed to advances in intensive care techniques, changes in the epidemiology of infectious diseases, and the increase in survival rates of premature newborns and of newborns born with birth defects.2,10–16 Tracheostomies were predominantly performed in male children, perhaps because males are more susceptible to both congenital and acquired defects.10,44

Tracheostomy in children is associated with higher rates of complications than tracheostomy in adults.1,2,4,5,7,10,15,17,18,24,25,28,29 The highest rates of pneumothorax and pneumomediastinum occurred between 1985 and 1994, with a significant reduction in the following two decades. These complications occur due to damage to the pleura during the procedure, since pleural apices are found at a higher position in children than in adults. They may extend into the inferior portion of the neck, which makes complications more likely.30 The drop in these complications in recent years may be explained by the decrease in tracheostomies performed in patients with any kind of airway infection, as well as by the greater frequency of the procedure being performed in the operating room and under general anesthesia.31

In the 1995–2005 period, the main complication observed was granuloma followed by infection, tracheocutaneous fistula, and obstruction of the cannula. This data is inconsistent with the studies from this decade that report the most common complications to be obstruction and decannulation.23,28,30 However, these complications are considered more important among those that precede or are most highly associated with death, and the present study did not analyze the frequency of early and late post-operative complications separately because there was no distinction in the literature to allow for this evaluation. It was also for this same reason that the causes of morality directly associated with tracheostomy were not evaluated. The frequency of granuloma was also considered. Some authors argue that granuloma should not be consider as complication of tracheostomy, but instead an expected result.27 However, among those who considered it to be a complication, granuloma was one of the most common.1,2,4,8,14,26

Between 2005 and 2014, granulomas were found to be the most common complication, followed by infection, obstruction of the cannula, and accidental decannulation. A single study that evaluated a population of 72 patients between 1990 and 2007 represented 62 of the 206 of granuloma 30.1%) and 87 of the 194 of infection (44.8%).14 This study defined infection as the increase in secretions by the tracheostomy, increased neutrophil counts in the secretion, and/or positive cultures. The authors defended the use of medication as treatment in cases in which it was impossible to distinguish between colonization and infection. This may have influenced the order of the most important complications in this decade. In the review of the literature, infection increased significantly in the second decade relative to the first and third decades (p<0.001). It was the second most common complication in the 1995–2004 period, during which time it represented 10.6% of cases. It is important to note that, in this review, the terms “operative wound infection”, “stroma infection”, “abscess”, “cellulitis”, “tracheitis”, and “pneumonia” were considered as a set; in some articles, they were considered individually. However, some authors emphasize that there needs to be a distinction between infection and colonization at the tracheostomy site.30 Children who use a tracheostomy for an extended period of time are more frequently colonized by Pseudomonas aeruginosa and/or Staphylococcus aureus, which suggests that the colonization does not require treatment unless there are signs of infection. Unfortunately, this distinction was not possible in this paper because of insufficient or inadequate data.

Obstruction of the cannula was most frequent in the articles published between 1995 and 2004; it increased in this period relative to the other two decades evaluated. However, there was no significant decrease relative to the first or third decades (p=0.193). During this 30-year period, it was therefore among the four most common complications of tracheostomy when both early and late post-operative complications were considered. The frequency of accidental decannulation decreased significantly in the third decade relative to the first and second decades (p=0.004 and p<0.001), though it still remained among the five most common complications during the period studied. The cannula obstruction is a common problem and its high frequency in younger children is likely associated with the narrow inner radius of small tracheostomy cannulas, as well as with the common condition of bronchopulmonary dysplasia, which is itself associated with viscous bronchial secretions in premature newborns.15,32 It has been believed that both obstruction and decannulation are complications that can be avoided with adequate tracheostomy tube care.30 The continual administration of humidified air should be performed until the first cannula change in order to prevent its obstruction. In addition, the entire team involved in the tracheostomy patient's care should be trained to know how to handle obstruction and accidental decannulation, as well as emergency cannula changes and even CPR, in order to avoid catastrophic consequences when these events occur.

Stenosis was a complication that did not differ significantly when the 1985–1994 period was compared to the 2005–2014 period (p=0.059). Though the operative technique has changed over the years, some authors report that there is a debate in the literature regarding the formation of tracheal stenosis that depends on the technique used; however, no consensus has been reached.29–31 Most studies do not report this association, despite the fact that animal studies have confirmed it.31 This complication should be considered even in extremely underweight newborns, and there has been reported that the larger the tracheostomy tube, the more common stenosis is.20

The tracheocutaneous fistulas were significantly less frequent in the third decade relative to the first two decades under study; between 2005 and 2014, they were present in 1.2% of cases. However, they were most frequent during the second decade under study. An hypothesis is that prolonged use of a tracheostomy cannula may cause the stroma to decrease to a non-functional size, though it does not close completely; this change leads to the formation of a tracheocutaneous fistula and some authors consider that tracheocutaneous fistulas may be more common depending on the technique used for the tracheostomy.15,18,30 One example is the starplasty technique, which attaches the stroma to the skin using sutures in order to reduces indices of pneumothorax and accidental decannulation, but it often requires later intervention to correct the fistula, which is expected.38,41,46

Only four studies specifically focused on premature and/or extremely underweight newborns who received tracheostomy were selected from the literature of the last thirty years. Thus, there were limits to the evaluation of this group in terms of the complications and mortality these patients experience. However, some studies have noted that this group is more susceptible to higher rates of both complications and mortality due to the conditions presented at birth, which also contribute to a higher rate of mortality associated with the surgical procedure.29

Various studies have demonstrated that many complications associated with tracheostomy in children may be avoided by the use of specific surgical techniques, of adequate tubes, and of careful maneuvers to maintain the tracheostomy and to remove cannulas.11,33,41,46

Mortality associated with tracheostomy is higher in the pediatric age group than among adults1,2,4,5,7,10,15,17,18,24,25,28; however, most pediatric deaths are associated not with the procedure itself, but with underlying diseases. Morbidity and mortality rates depend significantly on how well informed and trained the medical team, the patients’ parents, and the patients’ caregivers are.2,4,7,17 Furthermore, the association between lower indices of complications and death with the performance of the procedure in hospitals of reference by surgeons trained in the management of airway obstruction in children was found.4 This analysis of the literature revealed that, among the studies that evaluated all pediatric age groups, there was a significant decrease in morbidity and mortality between the 1985–1994 period and the 2005–2014 period (p=0.012); the frequency fell from 2.1% to 0.9%. There was a significant difference in mortality rates between each of the decades, with the highest number of deaths between 1995 and 2004. When only the articles that exclusively analyzed premature and/or extremely underweight newborns were considered, a significant increase in overall mortality was found in the data from 2006 relative to the data from 2013 (p=0.033), as was a significant decrease in overall mortality in the data from 2013 relative to 2014.19–22 None of these studies reported mortality to be directly associated with tracheostomy, though the literature reports higher morbidity and mortality rates in this patient group, as well as among children under one year of age.4,7,15,17,28,29,33

In this review of the literature, we found that complications and mortality rates of tracheostomy have undergone certain changes over the last three decades. The complications that were previously the most frequent were pneumothoraces and pneumomediastinum; today, these complications have become less common. Meanwhile granuloma, infection, and obstruction of the cannula are the most common complications experienced by patients who have received a tracheostomy. Accidental decannulation decreased considerably in the in the last decade under study. During this last decade, we also observed a decrease in the mortality rate associated with the procedure.

The authors declare no conflicts of interest.