Melissa Ameloti Gomes Avelino

Tracheostomy in childhood: review of the literature on complications and mortality over the last three decades

INTRODUCTION Tracheostomy is a procedure with unique characteristics when used on pediatric patients due to the greater technical difficulty and higher morbidity and mortality rates relative to the procedure in adults. In recent decades, there have been significant changes in the medical care available to children, particularly for those who need intensive care. Surgical conditions have also improved, and there has been an advent of new equipment and medications. These advances have brought changes to both tracheostomy indications and tracheostomy complications. OBJECTIVE To perform a review of the articles published over the last three decades on the complications and mortality associated with tracheostomies in children. METHODS Articles were selected from the Cochrane, Latin American and Caribbean Health Sciences Literature, SciELO, National Library of Medicine (Medline Plus), and PubMed online databases. The articles selected had been published between January 1985 and December 2014, and the data was compared using the Chi-square test. RESULTS A total of 3797 articles were chosen, 47 of which were used as the basis for this review. When the three decades were evaluated as a whole, an increase in tracheostomies in male children under one year of age was found. The most common complications during the period analyzed in descending order of frequency were granuloma, infection, and obstruction of the cannula, accidental decannulation, and post-decannulation tracheocutaneous fistula. In the second and third decades of the review, granulomas represented the most common complication; in the first decade of the review, pneumothoraces were the most common. Mortality associated with tracheostomy ranged from 0% to 5.9%, while overall mortality ranged from 2.2% to 59%. In addition, the review included four studies on premature and/or very underweight infants who had undergone tracheostomies; the studies reported evidence of higher mortality in this age group to be largely associated with underlying diseases. CONCLUSION Improved surgical techniques and intensive care, the creation of new medications, and vaccines have all redefined the main complications and the mortality rates of tracheostomy in children. It is a safe procedure that increases chances of survival in those who require the prolonged use of mechanical ventilation.

Balloon laryngoplasty for acquired subglottic stenosis in children: predictive factors for success

INTRODUCTION The treatment of subglottic stenosis in children remains a challenge for the otorhinolaryngologist, and may involve both endoscopic and open surgery. OBJECTIVE To report the experience of two tertiary facilities in the treatment of acquired subglottic stenosis in children with balloon laryngoplasty, and to identify predictive factors for success of the technique and its complications. METHODS Descriptive, prospective study of children diagnosed with acquired subglottic stenosis and submitted to balloon laryngoplasty as primary treatment. RESULTS Balloon laryngoplasty was performed in 37 children with an average age of 22.5 months; 24 presented chronic subglottic stenosis and 13 acute subglottic stenosis. Success rates were 100% for acute subglottic stenosis and 32% for chronic subglottic stenosis. Success was significantly associated with acute stenosis, initial grade of stenosis, children of a smaller age, and the absence of tracheostomy. Transitory dysphagia was the only complication observed in three children. CONCLUSION Balloon laryngoplasty may be considered the first line of treatment for acquired subglottic stenosis. In acute cases, the success rate is 100%, and although the results are less promising in chronic cases, complications are not significant and the possibility of open surgery remains without prejudice.

Interleukin-17A expression in patients presenting with nasal polyposis

UNLABELLED Sinonasal polyposis (SNP) is a chronic inflammatory pathology of the nasal/paranasal cavities which affects from 1%-4% of the population. Although polyps seem to be a manifestation of chronic inflammation of nasal/paranasal sinus mucosa in both allergic and non-allergic subjects, the pathogenesis of nasal polyposis remains unknown. Interleukin-17A (IL-17A) is a key inflammatory cytokine in many disorders. Little attention has been paid to the role of IL-17A in chronic inflammatory disorders. OBJECTIVE To investigate the expression of IL-17A in the SNP and verify if this expression is a marker of good or bad prognosis. METHOD Prospective study with 25 patients presenting with SNP were subjected to the immunohistochemistry technique. After a skin prick test, all patients were divided into atopic and nonatopic groups, and asthmatic or non-asthmatic. RESULTS The IL-17A expression was observed in both atopic and nonatopic patients. The numbers of IL-17A positive cells were greater in nasal polyps of atopic patients than nonatopic (p = 0.0128). CONCLUSION These results indicate that IL-17A may play an important role in the pathology of SNP. Considering the inflammatory properties of IL-17A, this study suggests that it could increase susceptibility to atopy and asthma.

Earwax: an innovative tool for assessment of tobacco use or exposure. A pilot study in young adults

The present work represents a novel approach using earwax (cerumen) for the evaluation of the smoking status with regards to tobacco use/exposure. The method utilizes the difference in the concentration profiles of nicotine and its related compounds in earwax to discriminate among non-, passive, and active smokers. Earwax samples were collected from three study groups (non-, passive, and active smokers) and subjected to analysis by headspace gas chromatography–mass spectrometry. The nicotine levels in earwax were much lower than cotinine levels, even for active smokers; however, it was reported that the nicotine levels in scalp hair were much higher than the cotinine levels. Therefore, it is obviously correct that earwax is protected from external contamination to a larger extent than expected. The concentration profiles of nicotine and its related compounds (o-nicotine, cotinine, and anabasine) in the analyzed earwax samples were treated by data mining techniques. It was possible to discriminate the studied groups using the evolutionary tree (evtree) algorithm and support vector machine discriminant analysis as the statistical models with the best discrimination accuracies of 96.7 and 95.0%, respectively. The analytical method applied requires no sample pretreatment which makes it easy, fast, and a low-cost alternative method to those employing other biological matrices, such as blood, urine, and hair. The earwax, which is considered a neglected body secretion, is a useful tool to determine the exposure to tobacco smoke noninvasively and without the influence of external contamination.

Revealing the needs of children with tracheostomies

INTRODUCTION Small children with tracheostomy are at potential risk and have very specific needs. International literature describes the need for tracheostomy in 0.5% to 2% of children following intubation. Reports of children submitted to tracheostomy, their characteristics and needs are limited in developing countries and therefore there is a lack of health programs and government investment directed to medical and non-medical care of these patients. The aim of this study was to describe the characteristics of these children and identify problems related to or caused by the tracheostomy. METHODS A retrospective cohort study was performed based on a common database applied in four high complexity healthcare facilities to children submitted to tracheostomy from January 2013 to December 2015. Data concerning childrens demographics, indication for tracheostomy, early and late complications related to tracheostomy, airway diagnosis, comorbidities and decannulation rates are reported. Patients who did not present a complete database or had a follow-up of less than six months were excluded. RESULTS A total of 160 children submitted to tracheostomy during the three-year period met the criteria and were enrolled in this study. Median age at tracheostomy was 6.9 months (ranging from 1 month to 16 years, interquartile range of 26 months). Post-intubation laryngitis was the most frequent indication (48.8%). Comorbidities were frequent: neurologic disorders were reported in 40%, pulmonary pathologies in 26.9% and 20% were premature infants. Syndromic children were 23.1% and the most frequent was Downs syndrome. The most common early complication was infection that occurred in 8.1%. Stomal granulomas were the most frequent late complication and occurred in 16.9%. Airway anomalies were frequently diagnosed in follow-up endoscopic evaluations. Subglottic stenosis was the most frequent airway diagnosis and occurred in 29.4% of the cases followed by laryngomalacia, suprastomal collapse and vocal cord paralysis. Decannulation was achieved in 22.5% of the cases in the three-year period. The main cause for persistent tracheostomy was the need for further treatment of airway pathology. Mortality rate was 18.1% during this period but only 1.3% were directly related to the tracheostomy, the other deaths were a consequence of other comorbidities. CONCLUSION Tracheostomies were performed mostly in very small children and comorbidities were very common. Once a tracheostomy was performed in a child in most cases it was not removed before a year. The most common early complication was stoma infection followed by accidental decannulation. The most frequent late complication was granuloma and suprastomal collapse. Airway abnormalities were very frequent in this population and therefore need to be assessed before attempting decannulation.

Microbiology of Tracheal Secretions: What to Expect with Children and Adolescents with Tracheostomies

Introduction  People with tracheostomies exhibit a higher risk of colonization of the lower respiratory tract, acute tracheitis and pneumonia. Despite this, the culture of tracheal secretions is not a routine in most hospitals, and sometimes empiric therapy is based on personal experience, which is not an ideal situation. Objective  To recognize the pathogens present in the tracheal secretions collected from people up to 18 years old with tracheostomies. Methods  Prospective evaluation of patients under the age of 18 of a tertiary care hospital. A standardized questionnaire was completed, and tracheal secretion aspirates were sent for microbiological cultures and antibiograms. Results  Twenty patients under 18 years of age were evaluated, 65% of whom were male. The microbiological culture was positive in 90% of the patients, and the most common microorganisms found were Pseudomonas aeruginosa (55.5%) and Staphylococcus aureus (27.7%). Discussion  Tracheostomized children and adolescents have respiratory tracts colonized by pathogens, the most common of which is Pseudomonas aeruginosa . These patients must undergo tracheal secretion cultures, whether they present symptoms or not, to determine if there is a correlation between the colonization and the infections. This finding could guide the adequate treatment, avoiding the inappropriate use of antibiotics and indicating the better therapy in cases of laryngeal reconstruction. Conclusion  In this sample, the culture of tracheal secretions was mainly positive, and the most common agent was P. aeruginosa . We suggest the routine access to Brazilian children and adolescents tracheal secretion cultures, which could help to make a profile of these children and guide the use of antibiotics.