Tracheostomy for Severe Pediatric Obstructive Sleep Apnea: Indications and Outcomes

Abstract

Objectives (1) To describe characteristics of pediatric patients undergoing tracheostomy for obstructive sleep apnea (OSA). (2) To highlight perioperative events and outcomes of the procedure. Study Design Case series with chart review. Setting Four tertiary care academic children's hospitals. Subjects and Methods Twenty-nine children aged <18 years from January 1, 2010, to December 31, 2015, who underwent tracheostomy for severe OSA, defined as an apnea-hypopnea index (AHI) >10, were included in the study. Data on patient characteristics, polysomnographic findings, comorbidities, and perioperative events and outcomes were collected and analyzed. Results Twenty-nine patients were included. Mean age at tracheostomy was 2.0 years (95% CI, -2.2 to 6.2). Mean body mass index z score was -1.2 (95% CI, -4.9 to -2.5). Mean preoperative AHI was 60.2 (95% CI, -15.7 to 136.1). Mean postoperative intensive care unit stay was 23.2 days (95% CI, 1.44-45.0). One procedure was complicated by bronchospasm. Thirteen patients had craniofacial abnormalities; 10 had a neurologic disorder resulting in hypotonia; and 5 had a diagnosis of laryngomalacia. Mean follow-up was 30.6 months (95% CI, -10.4 to 71.6). Six patients were decannulated, with a mean time to decannulation of 40.8 months (95% CI, 7.9-73.7). Five patients underwent capped sleep study prior to decannulation with a mean AHI of 6.6 (95% CI, -9.9 to 23.1) and a mean oxygen nadir of 90.0% (95% CI, 80%-100%). Conclusion OSA is an uncommon indication for tracheostomy in children. Patients who require the procedure usually have an associated syndromic diagnosis resulting in upper airway obstruction. The majority of children who undergo tracheostomy for OSA will remain dependent at 24 months.

Polysomnography Provides Useful Clinical Information in the Liberation from Respiratory Technology: A Retrospective Review

“…The diagnostic role of pre‐tracheostomy PSG in children has not been described clearly in the literature. We found only one study that showed a small number of children who had pre‐tracheostomy PSGs diagnosing severe OSA similar to our study . As pre‐tracheostomy PSG was only used in 15% of children in our study, our results suggest that pre‐tracheostomy PSG is useful when the clinician is deciding between conservative versus invasive management in a child with UAO.…”

“…We found only one study that showed a small number of children who had pretracheostomy PSGs diagnosing severe OSA similar to our study. 23 As pre-tracheostomy PSG was only used in 15% of children in our study, our results suggest that pre-tracheostomy PSG is useful when the clinician is deciding between conservative versus invasive management in a child with UAO. On the other hand, PSG was not used in children who required a tracheostomy to facilitate HMV due to technical limitations from intubation.…”

“…OSA is an uncommon indication for tracheostomy in children. Unlike adults, children who require a tracheostomy for OSA are not usually obese but rather have craniofacial abnormalities or neuromuscular disorders . The diagnostic role of pre‐tracheostomy PSG in children has not been described clearly in the literature.…”

“…Unlike adults, children who require a tracheostomy for OSA are not usually obese but rather have craniofacial abnormalities or neuromuscular disorders. 23 The diagnostic role of pre-tracheostomy PSG in children has not been described clearly in the literature. We found only one study that showed a small number of children who had pretracheostomy PSGs diagnosing severe OSA similar to our study.…”

Use of Noninvasive Ventilation with Volume-Assured Pressure Support to Avoid Tracheostomy in Severe Obstructive Sleep Apnea

“…Continuous positive airway pressure (CPAP) is indicated in children who are not candidates for or have an unsatisfactory response to adenotonsillectomy [ 1 ]. Children acutely at risk for significant morbidity with other therapies are candidates for a tracheostomy [ 4 ]. We present a pediatric patient with morbid obesity and severe OSA refractory to CPAP therapy.…”