Seminars in Pediatric Surgery 24 (2015) 50–58

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Seminars in Pediatric Surgery

journal homepage: www.elsevier.com/locate/sempedsurg

Surgical management for complications of pediatric lung injury

T.K. Pandian, MD, MPHa, Chad Hamner, MDb,n
a
Mayo Clinic, Rochester, Minnesota
b
Cook Children's Medical Center, Fort Worth, Texas

a r t i c l e in f o abstract

The etiologies of pediatric lung injury requiring surgical intervention can be infectious, traumatic,
Keywords: congenital, or iatrogenic. Childhood pneumonia is a significant global health problem affecting
Pediatrics 150 million children worldwide. Sequelae of pulmonary infections potentially requiring surgery include
Lung injury bronchiectasis, lung abscess, pneumatocele, and empyema. Trauma, congenital conditions such as cystic
Tracheostomy fibrosis and iatrogenic injuries can result in pneumothoraces, chylothoraces, or bronchopleural fistulae.
Intubation Recurrence rates for spontaneous pneumothorax treated non-operatively in pediatric patients approach
Pneumothorax 50–60%. Chylothoraces in newborns may occur spontaneously or due to birth trauma, whereas in older
Empyema
children the etiology is almost always iatrogenic. This article examines the surgical management for the
complications of lung injury in pediatric patients. In addition, we review the available pediatric evidence
for early tracheostomy as well as treatment strategies for the negative ramifications of tracheostomy.
& 2014 Elsevier Inc. All rights reserved.

Introduction Bronchiectasis

Lung injuries requiring surgical intervention in the pediatric
critical care patient can be complicated to treat and, conse-
quently, require timely diagnosis and referral to a pediatric
surgeon. The etiologies of these conditions can vary and include
infection, trauma, congenital, and iatrogenic causes. Bacterial
pneumonia occurs at an estimated rate of 30–40 per 100,000
children in the United States and Europe1 and affects 150 million
children worldwide annually.2 Pneumonia may progress to
parapneumonic effusions in up to 53% of cases3 and can
ultimately lead to bronchiectasis, pulmonary abscess, pneuma-
tocele, or empyema; conditions that often require operative
treatment. Trauma, congenital abnormalities, and iatrogenic
injuries can result in recurrent pneumothoraces, chylothoraces,
or bronchopleural fistulae. We aim to review surgical manage-
ment for the complications of lung injury in pediatric patients in
the critical care setting. In addition, there appears to be a
paucity of data to recommend optimal duration of endotracheal
intubation in children requiring mechanical ventilation. We
attempt to answer this question by suggesting timing of trache-
ostomy and, additionally, offer management strategies for
tracheostomy-related complications in the pediatric intensive
care unit (PICU).
n
Corresponding author.
E-mail address: chad.hamner@cookchildrens.org (C. Hamner).
Initially described in 1819, bronchiectasis is the abnormal,
irreversible dilatation of bronchi due to destruction of elastic tissues
and muscles of the bronchial wall.4 Though the incidence has
declined considerably with the advent of effective antibiotics,
bronchiectasis continues to be encountered in pediatric patients,
primarily those with cystic fibrosis or severe pulmonary infection,
which is the major etiology overall.4 Symptoms include cough,
profuse sputum, wheezing, chest pain, and clubbing, which nearly
half of patients may exhibit. Bronchography or use of contrast-
enhanced radiographs have largely been replaced by high-resolution
computed tomography (CT) (Figure 1) to confirm diagnosis.5
Prevention of bronchiectasis initially targets management of the
underlying cause. For example, antibiotics, microbiologic surveil-
lance, nutritional support, appropriate vaccination, postural drain-
age, mucolytics, and chest physiotherapy have shown some benefit
preventing bronchiectasis when implemented in cystic fibrosis
patients.6–8 With conservative management strategies, mortality
rates for bronchiectasis patients have been reported as high as 19–
31% in developing countries.9 Outcomes are better in industrialized
nations for conservative management, but surgical resection is the
only treatment modality that can offer a permanent cure.9
Definitive indications for surgery in pediatric patients with
bronchiectasis have not been established. In adults, resistance to
antibiotics, postural drainage, and physical therapy for greater
than 2 years have been described as reasons for surgical excision of
diseased lung.10 While these indications are applicable to children,
pediatric patients with poor quality of life due to severe cough,

http://dx.doi.org/10.1053/j.sempedsurg.2014.11.009
1055-8586/& 2014 Elsevier Inc. All rights reserved.
 T.K. Pandian, C. Hamner / Seminars in Pediatric Surgery 24 (2015) 50–58
Fig. 1. Computed tomography of the chest from an adolescent with cystic fibrosis
showing prominent bilateral bronchiectasis (arrows), peribronchial cuffing, and
infiltrates.
life-threatening hemorrhage, failure to thrive/growth retardation,
or decrease in school attendance secondary to bronchiectasis
should also be considered for surgery. To date, retrospective
studies suggest complete symptom resolution in 42–73% of chil-
dren who undergo surgical resection of the bronchiectatic portion
of lung.10–12 Symptom recurrence primarily is due to incomplete
resection. Reported mortality rates for surgical resection are as
high as 5.6%. Postoperative complications including atelectasis,
prolonged air leak, empyema, and hemorrhage occur in 13–17% of
patients. Although open lobectomy traditionally has been the
standard for resection, an expanding body of literature supports
thoracoscopic resection of bronchiectatic lung segments. Thoraco-
scopic resection can be accomplished safely in selected children
with outcomes comparable to open thoracotomy.13
Pulmonary abscess
Lung abscess develops when localized pneumonia progresses
to necrosis and cavitation of lung parenchyma. Although lung
abscesses are a rare entity in children, with an estimated incidence
of 0.7 per 100,000,14 they often require surgical treatment.
Pneumonia is almost always the precursor disease, but in infants
and young children an underlying aspirated foreign body or
congenital lung abnormality should be considered. Symptoms
include fever, cough, chest pain, anorexia, productive sputum,
malaise, hemoptysis, or chills. Diagnosis can be made with a chest
radiograph (Figure 2) showing a cavity with an air–fluid level;
however, the radiographic appearance of an abscess may be
indistinguishable from empyema with an air–fluid level. CT scan
of the chest provides more detailed information regarding loca-
tion, size, and relation to other pulmonary structures.
Treatment should begin with intravenous antibiotics tailored to
the causative organism, typically administered for 2–3 weeks,
accompanied by postural drainage and physiotherapy.14 Sputum
for microbial analysis should be obtained to guide therapy.
Younger children who are not able to cough adequately to produce
sputum may require bronchoscopy with sputum sampling. Staph-
ylococcus or streptococcus species are typically the causative
organisms; however, Gram-negative and anaerobic species should
be suspected in patients with aspiration.
Percutaneous drainage has largely replaced surgical drainage
due to advancements in radiology-guided techniques. Typically,
such procedures are utilized in children who are severely ill or do
not respond to medical treatment within 7–10 days. Complications
of percutaneous drainage include pneumothorax, hemothorax,
51
Fig. 2. Chest radiograph of a child with a history of bone marrow transplant
showing upper lobe pulmonary abscess (arrow). Note central lucency indicating
area of cavitation.
incomplete drainage, and bronchopleural fistula.15,16 Very little
data has been published describing the outcomes of percutaneous
drainage in children, and no randomized controlled trials have
been reported. However, a recent review of published series dating
back to 1975, including 105 adult and pediatric cases, indicates
percutaneous drainage may be successful in 85% of patients with a
complication rate of 10% and mortality of 5%.16 Procedure failure
has been associated with a thick-walled or poorly defined abscess
or presence of multiple loculations within the abscess cavity. All of
the reported mortality occurred in a single series of 8 patients (5 of
8 died) with poor prognostic indicators including secondary
abscesses, comorbidity, and virulent pathogens.
Surgical drainage of lung abscess by segmental resection or
lobectomy has been described since the 17th century and is
reserved for chronic, large, thick-walled abscesses or for the few
patients who do not respond to intensive antibiotic therapy and
percutaneous drainage.17 Other indications include chronic
abscesses lasting greater than 3 months, bronchial stenosis,
bronchiectasis, pulmonary necrosis, and persistent hemoptysis
causing anemia. In immunocompromised children, who may be
susceptible to failure of medical therapy and drainage, more
extensive pulmonary resection may be preferable to limited
resection to adequately eradicate the abscess and prevent recur-
rent infection. Despite the inherent higher surgical risk of exten-
sive resection in these patients, morbidity and mortality for this
aggressive approach are comparable to that achieved in immuno-
competent patients undergoing less extensive resection.18 Suc-
cessful thoracoscopic drainage of pulmonary abscess has been
described19; however, comparisons of efficacy between percuta-
neous and thoracoscopic drainage techniques are lacking.
Pneumatocele
Pneumatoceles are thin-walled structures with single or multi-
ple air-filled cysts, which form due to bronchoalveolar necrosis.
Generally, the necrosis is a result of a staphylococcal infection but
may be due to Streptococcus, Haemophilus, Pseudomonas, Mycobacte-
rium, Serratia, Klebsiella, Escherichia coli, trauma, or hydrocarbon-
induced pneumonia.20 Radiologic evidence most often occurs on the
fifth to sixth day of hospitalization (Figure 3).20 Pneumatoceles
52 T.K. Pandian, C. Hamner / Seminars in Pediatric Surgery 24 (2015) 50–58

Fig. 3. (A) Anteroposterior and (B) lateral chest radiographs of a child with left lower lobe pneumatocele (arrows) following necrotizing pneumonia due to Pneumococcus.

typically regress spontaneously as the primary infection resolves;
however, they have the potential to rupture, leading to pneumo-
thorax or pyopneumothorax.21 Such situations should be treated
with prompt drainage. To date, there is a paucity of literature on the
topic in children.
We recommend drainage of pyo/pneumothorax, resulting from
pneumatocele. Large pneumatoceles causing compression of the
mediastinum or surrounding structures may eventually lead to
rupture; therefore, early surgical resection via thoracoscopy or
thoracotomy should be considered.
Empyema
Empyema is an accumulation of purulent fluid in the pleural
cavity that occurs in 2–8% of children hospitalized for pneumo-
nia.22 During the late 1990s to mid-2000s, the incidence of
empyema doubled in children less than 2 years and tripled
in children 2–4 years of age.23 Symptoms and signs include
respiratory distress, fever, and cough following a history of
pulmonary infection. Radiologic characteristics depend on the
stage of the empyema. Early exudative empyemas tend to have
free-flowing fluid (Figure 4), whereas organizing empyemas do not
move with changes in position (Figure 5). Often an empyema may
be difficult to distinguish from a simple effusion or the underlying
pneumonia on plain radiographs. Ultrasound is recommended to
delineate pleural fluid form intraparenchymal consolidation, iden-
tify loculations, and assist in guiding localization of walled off
empyemas (Figure 6). Utilization of CT scan in these cases is rarely
needed and may be inferior to ultrasound in experienced centers.
CT scan of the chest should be reserved for more complicated cases
when operative planning may be impacted by the extent of
intraparenchymal disease and to determine the presence of
pulmonary abscess.
Much like lung abscess, treatment of empyema begins with
parenteral antibiotics and is almost always combined with a
drainage procedure. Drainage and surgical treatment algorithms
tend to differ from institution to institution. Placement of soft

Fig. 4. (A) Anteroposterior and (B) lateral decubitus chest radiographs from a child with early empyema. Note the prominent left pleural fluid density (arrows) that shifts
position on decubitus imaging.
 T.K. Pandian, C. Hamner / Seminars in Pediatric Surgery 24 (2015) 50–58 53

Fig. 5. (A) Anteroposterior and (B) lateral decubitus chest radiograph from a child with organizing empyema. Note the prominent left pleural fluid density (arrows) that
remains unchanged on decubitus imaging.

percutaneous pigtail catheters has been shown to have a higher
failure rate compared to more rigid chest tubes.24 Early decortica-
tion through either VATS (Figure 7) or thoracotomy has been
shown to have more favorable outcomes in the pediatric popula-
tion.25 Studies comparing VATS to thoracostomy with or without
fibrinolytics have found conflicting results. A systematic review of
retrospective studies published in 2004 found that hospital length
of stay was shorter for children treated with VATS or thoracotomy
(mean ¼ 10.5 days or 9.9 days, respectively), compared with
thoracostomy alone (16.4 days) or combined with fibrinolytic
therapy (18.9 days).22 More recent prospective, randomized, con-
trolled studies from St. Peter et al. and Sonnappa et al. found no
advantage of VATS with decortication to tube thoracostomy with
fibrinolytics in terms of length of stay or other major clinical
outcomes. These studies did identify, however, a significantly
higher cost associated with VATS and decortication.26,27 In an
effort to clarify the significance of published reports and stand-
ardize empyema treatment, the American Pediatric Surgical Associa-
tion (APSA) developed a treatment algorithm based on a
comprehensive review of the available literature in 2012 (Figure 8).23
The guideline calls for thoracostomy drainage and intrapleural
fibrinolytics as first-line surgical therapy for empyema when
individual institutional resources allow, reserving VATS for persis-
tent pleural space disease following fibrinolytic therapy. We
recommend following this algorithm for pediatric patients who
develop empyema.
Middle lobe syndrome
Initially described in 1948, middle lobe syndrome (MLS) is a
rare entity characterized by recurrent or chronic collapse of the
right middle lobe or lingula as a result of obstructive and non-
obstructive pulmonary pathology.28 Extrinsic compression or
intraluminal stenosis of the middle lobe bronchus from lympha-
denopathy, neoplastic, or endobronchial lesions can lead to
obstructive MLS. Nonobstructive causes are less understood and
may involve inefficient collateral ventilation, asthma, or bron-
chiectasis. MLS involves a spectrum of diseases including atelec-
tasis, pneumonitis, and bronchiectasis.28,29 It is more common in

Fig. 6. Corresponding ultrasound images from the patients depicted in Figure 5 showing empyema with pleural fluid, septations (arrows) and collapsed lung parenchyma
(arrow heads).
54 T.K. Pandian, C. Hamner / Seminars in Pediatric Surgery 24 (2015) 50–58
Fig. 7. Intraoperative photographs during videoscopic-assisted thoracoscopic surgery (VATS) showing (A) visceral and parietal pleura covered with fibrinopurulent exudate
with bridging septations and (B) exposed pleural surfaces following VATS decortication.
females and the most common symptoms include chronic cough,
wheezing, dyspnea, and chest pain. Diagnosis can be made with
chest radiographs (Figure 9), CT scan, and/or bronchoscopy.28
Treatment should initially target the underlying cause. Anti-
biotics should be administered to patients in whom infection has
led to severe lymphadenopathy. Steroids and bronchodilators may
be indicated for those with asthma or inflammatory disease states.
Bronchoscopy may be both diagnostic and therapeutic and is most
effective if performed early in the course of treatment, ideally
within 7 months of symptom deterioration.28
Surgery is generally reserved for refractory disease. To date, no
specific absolute operative criteria have been established; how-
ever, surgery should be considered if there is persistent hemopt-
ysis, abscess formation, bronchial stenosis, recurrent disease
lasting greater than 6 months, or if symptoms are debilitating to
the child.28–30 Pulmonary lobectomy has relatively high success
rates (72–95%) and a low number of complications.28,30
Pneumothorax
Spontaneous pneumothoraces are estimated to occur in 4 per
100,000 male and 1.1 per 100,000 female children.31 Primary
pneumothoraces have no specific, identifiable underlying etiology,
although blebs and bullae are frequently identified on imaging or
at surgery. Secondary pneumothoraces are due to diseases such as
Fig. 8. Treatment algorithm for empyema in children. (Reprinted with permission
fromIslam et al.23)
asthma, cystic fibrosis, or connective tissue disorders. The most
common symptoms include dyspnea and chest pain, and diagnosis
is usually made with chest radiographs.32 Although there are a
number of methods to define the size of a pneumothorax, these
have not been validated in children.31,33
The principles of treatment begin with administration of
supplemental oxygen and pleural drainage for patients who are
exhibiting signs or symptoms of respiratory distress. Generally
speaking, patients who are asymptomatic and have pneumothora-
ces less than 15–20% in size on radiologic imaging can be treated
noninvasively.31 Tension pneumothorax should be treated imme-
diately with needle decompression, followed by tube thoracos-
tomy. In non-emergent situations, surgical therapy of spontaneous
pneumothorax is aimed primarily at prevention of recurrence or
treatment of persistent air leaks following thoracostomy and lung
re-expansion. Surgical options include VATS or thoracotomy with
blebectomy alone or combined with pleurodesis. VATS has essen-
tially replaced thoracotomy as the standard approach for blebec-
tomy in pediatric patients due to improved postoperative pain and
lower complications.34 Pleurodesis by mechanical means (thora-
coscopic pleural abrasion) or chemical means (talc poudrage)
appears to be effective without significant advantage of one
method over the other. It is unclear which technical approach is
optimal; however, a recent single center, retrospective review of
Fig. 9. Chest radiograph, lateral view from adolescent with middle lobe syndrome.
Note the wedge-shaped area of increased density with the apex at the hilum and
the base towards the pleura. (Reprinted with permission from Romagnoli et al.28)
 T.K. Pandian, C. Hamner / Seminars in Pediatric Surgery 24 (2015) 50–58
surgical intervention for spontaneous pneumothorax in children
found better outcomes for VATS with blebectomy combined with
either form of pleurodesis as compared with either VATS with
blebectomy or pleurodesis alone. Chemical pleurodesis resulted
in fewer recurrences but longer hospital stays and chest tube
drainage than mechanical pleurodesis. However, the series did
not have enough patients in each group to make a definitive
recommendation.35
Recurrence rates of spontaneous pneumothorax are higher in
older children and adolescents than adults. Adolescent patients
treated without intervention or with thoracostomy alone develop
a second, ipsilateral pneumothorax in 40–60% of cases32 compared
to 6–9% following operation.36 A contralateral spontaneous pneu-
mothorax develops in as many as 50% of adolescent patients
regardless of the treatment chosen at the initial presentation.36
With these data in mind, some surgeons offer unilateral or
bilateral surgical management during the initial event. The deci-
sion to intervene on the symptomatic side may be influenced by
the presence of blebs or bullae or other pulmonary pathology on
screening CT scan of the chest, or for patients with high-risk
behaviors for recurrence or known poor compliance or limited
access to medical care. Surgical intervention on the asymptomatic,
contralateral side is controversial but offered when blebs or bullae
are identified by screening CT scan of the chest. For those patients
who develop a recurrence in the ipsilateral hemithorax, non-
operative management has a very high recurrence rate of 75%.36
It is for this reason surgical intervention is standard therapy
following a second recurrence with rare exceptions.
Currently there are no consensus guidelines outlining the
optimal modality or timing for treatment in children. However,
retrospective reviews of initial non-operative management fol-
lowed by surgical treatment for recurrence with or without
contralateral surgery found a significant cost advantage without
incurring higher risk in those with initial non-operative or
thoracostomy tube management only.32,36 We routinely follow
this management approach and reserve screening chest CT
scan and contralateral treatment for patients with special
circumstances.
Bronchopleural fistula
Although rare, bronchopleural fistulas (BPF) in children may
necessitate operative management.37 The exact incidence is not
known in children but the majority of pediatric BPF is likely the
result of advanced necrotizing pneumonia38,39 and may occur
more frequently if empyema is inadequately drained.37 Symptoms
include a productive cough consisting of serosanguineous or
purulent fluid, fever, malaise, or shortness of breath. A BPF should
be suspected in patients who have a persistent air leak or chest
radiograph findings of a new or enlarging air–fluid level. Diagnosis
can be made with bronchoscopy or chest CT scan.
Management largely depends on the etiology. BPF associated
with infection should initially be drained and subsequent persis-
tent air leaks can be addressed endobronchially or surgically.
Successful use of fibrin glue via bronchoscopy has been described
in pediatric patients.40 Small case reports have suggested positive
outcomes with thoracotomy and oversewing of visible defects in
low-birth-weight infants.41 However, surgical treatment is often
more challenging than in adults given a child's smaller chest cavity
and limited availability of adequate options for local muscle flaps.
Recently, Jester et al. published their 10-year experience on the use
of a serratus anterior muscle digitation flap in children with BPF
following drainage, debridement, and clearance of infection. In
20 patients (age range: 0.6–6.8 years) with a median 4-year
follow-up, they achieved a 100% BPF closure rate without
55
complications.37 Lobectomy or pneumonectomy is associated with
significant morbidity including hemorrhage and recurrent fistula
from the bronchial stump and should be reserved as a treatment of
last resort for rare cases when BPF fail to respond to less radical
surgical options.37
Chylothorax
Chylothorax is accumulation of chyle in the pleural space and
may be due to acquired or congenital etiologies. Although rare in
newborns, chylothoraces are the leading cause of pleural effusions
in neonates,42 whereas in children undergoing cardiac surgery,
incidence rates are reported to be between 1% and 7%.43 Congen-
ital chylothoraces may occur spontaneously, as a result of birth
trauma, or in association with other congenital abnormalities
including Noonan syndrome, Down syndrome, congenital lym-
phangiectasia, or thoracic duct cysts. Trauma leading to hyper-
extension of the spine with stretching and rupture of the thoracic
duct has been reported with activities such as high diving and
wrestling.42 Symptoms and signs are generally those of respiratory
distress. Prolonged chyle leaks may result in malnutrition, hypo-
proteinemia, fluid and electrolyte imbalances, metabolic acidosis,
and immunodeficiency.42 Diagnosis is based on pleural fluid
analysis with 41.1 mmol/L triglycerides (110 mg/dL) and an abso-
lute cell count 41000 cells/mL, with a lymphocyte fraction
480%.42 Identification of the site of leakage is often difficult;
however, lymphoscintigraphy has been shown to be safe and
effective in the pediatric population.42
Management of chyle leaks is generally progressive. Chylo-
thoraces causing respiratory compromise should initially be
drained via thoracentesis or tube thoracostomy. Dietary modifica-
tion with low-fat, medium-chain triglyceride (MCT) foods or
formulas should be initiated. High-output or persistent chyle leaks
may necessitate total parenteral nutrition (TPN).43 Some institu-
tions begin TPN without enteric intake as an initial measure
(especially in critically ill intubated patients) based on data that
any enteral feeding, even with clear fluids, significantly increases
thoracic duct flow.
Somatostatin and its synthetic analog, octreotide, have been
shown to be beneficial in the treatment of pediatric chylothorax.42
The response to octreotide has been documented as early as 2 days
after initiation.42 Somatostatin has a short half-life and therefore is
typically administered intravenously, whereas octreotide is given
subcutaneously. Patients given a continuous infusion of octreotide
had a median treatment time of 7 days compared with 17 days for
those patients receiving it subcutaneously.42 Nearly all of this data
is based on case reports; therefore, a recent Cochrane review
concluded that there is insufficient data to recommend octreotide-
based practice guidelines in neonates with chylothorax.44
Surgical intervention is typically reserved for patients in whom
3–4 weeks of non-operative therapy is ineffective.43 Procedural
options include ligation of the thoracic duct on the ipsilateral side,
pleurodesis, application of fibrin glue, or placement of a pleuro-
peritoneal shunt. There is very little data in the literature compar-
ing these modalities; the largest number of articles focus on
thoracic duct ligation and generally have shown favorable
results.45 Based on the available literature, Panthongviriyakul
et al. proposed a chylothorax management algorithm in 2008
(Figure 10). We concur with their recommendations.
Endotracheal intubation
Endotracheal intubation (EI) is a common intervention in the
PICU and neonatal intensive care units (NICU). The optimal
duration of endotracheal intubation and timing of tracheostomy
56 T.K. Pandian, C. Hamner / Seminars in Pediatric Surgery 24 (2015) 50–58

Fig. 10. Treatment algorithm for postoperative chylothorax in children. (Reprinted with permission from Panthongviriyakul et al.42)

are somewhat controversial in the adult literature. A randomized
controlled trial comparing prolonged EI to early tracheostomy in
adults requiring mechanical ventilation for greater than 14 days
showed reductions in mortality, frequency of pneumonia, duration
of mechanical ventilation, and length of time in intensive care in
favor of tracheostomy.46 However, a recent meta-analysis of
randomized, controlled trials showed no benefit.46 Complications
of prolonged EI include injury to the mouth, larynx, and trachea as
well as the dangers of self-extubation and malposition, para-
sinusitis, physical discomfort, and need for increased sedation.
Tracheostomy can make oral feedings possible, enhances commu-
nication, permits earlier ambulation, and facilitates pulmonary
toilet and oral hygiene.46 However, tracheostomy does have
inherent surgical complications such as stomal infection, pneumo-
thorax, subcutaneous emphysema, hemorrhage, tracheal stenosis,
tracheomalacia, and endotracheal granulation tissue.47
Infants typically undergo tracheostomy for bronchopulmonary
dysplasia, or congenital or acquired airway lesions with an average
post-gestational age of 40–50 weeks.47–50 A small retrospective
study recommends tracheostomy at 3 months of age for infants
 T.K. Pandian, C. Hamner / Seminars in Pediatric Surgery 24 (2015) 50–58
Fig. 11. Intraoperative photographs of bronchoscopy showing (A) occlusive granulation tissue (arrow) proximal to tracheostomy and (B) patent trachea following laser
ablation.
with bronchopulmonary dysplasia if there is no improvement in
respiratory support.51 On the contrary, a study by Rane et al.47
found no significant associations between timing of tracheostomy
and outcomes in this age group. Holscher et al. reviewed
91 pediatric trauma patients undergoing tracheostomy. They
found that those undergoing tracheostomy within the first week
of injury had fewer ventilator days, ICU days, hospital days, and
tracheal complications compared to those undergoing tracheos-
tomy after post-injury day 7.52 At this time, there is insufficient
data to recommend clear guidelines on optimal timing of trache-
ostomy in infants and children.
Once tracheostomy becomes warranted, the decision to pursue
open or percutaneous tracheostomy in the ICU versus the operat-
ing theater is largely surgeon dependent. Bedside percutaneous
tracheostomy in critically ill children has proven to be safe53 and
there are no major differences in complications between the open
or percutaneous technique.54 However, until more data and
experience with bedside approaches becomes available, tracheos-
tomy in the pediatric population, especially infants, is likely to
remain an operation primarily performed in the operating theater.
Tracheostomy complications
In the pediatric literature, tracheostomy complication rates are
variable and range from 15% to 77%.55 Complications can be
classified as perioperative, postoperative, and long term. Perioper-
ative complications include major bleeding and pneumothorax.
Early postoperative complications include obstruction by mucous
plugging and inadvertent decannulation,56 problems that can be
quite devastating due to the small diameter of a child's airway.
Consequently, careful and thorough maintenance by respiratory
and nursing staff is critical to ensure that the tracheostomy is
patent, carefully suctioned, and well secured around the neck to
prevent accidental decannulation. Later sequelae of tracheostomy
include local infection, granulation tissue formation, and trache-
oinnominate fistula (TIF).
Local infection
Stomal cellulitis, tracheitis, or chondritis are relatively rare
entities in a mature stoma tract. Patients who develop such
complications are typically immunosuppressed or have poor
57
nutritional states. Treatment should begin with local antimicrobial
packing, frequent dressing and cannula changes, and systemic
antibiotics if there is no improvement with local care.
Granulation tissue
Suprastomal granulation tissue formation can be expected in
nearly all patients due the presence of a chronic foreign body in
the stoma tract. Some authors recommend routine tracheostomy
tube exchanges to prevent granulation tissue from forming. Large
amounts of granulation tissue have been known to cause airway
obstruction and/or bleeding.57 In general, data in the pediatric
literature would suggest no major benefit in routine removal of
granulation tissue, unless it has the potential to cause obstruction,
hemorrhage, or may lead to malposition of the cannula.57,58
Options for management of granulation tissue include broncho-
scopy with excision, electrocautery or laser ablation (Figure 11),
dilation with balloon or Bougie devices, or endotrachial application
of topical steroids or mitomycin C.57 In rare, worst-case scenarios
open transtracheal excision or tracheal resection may be required.
Literature on specific methods to remove granulation tissue is
lacking.
Tracheoinnominate fistula
The incidence of TIF in adults is less than 1%59; however, the
mortality rate can be as high as 46%.59 Specific data for children is
not available. TIF is a surgical emergency and immediate resusci-
tative efforts should include tracheal cuff inflation and retrosternal
finger pressure.60 Clinical staff involved in the care of patients with
tracheostomy should be aware of these initial measures. Broncho-
scopy is the diagnostic modality of choice and prompt operation
with division of the innominate artery and separation of the
trachea from the artery by viable tissue is mandatory.60
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