Severely burned children are prone to develop acute upper airway obstruction, especially after adequate fluid resuscitation. One reason for this finding was the anatomy and physiologic characteristics of the patients. Another was related to the burn mechanism, as most of the burns were facial and neck burns, and IHTs. Therefore, establishment of a safe and effective airway is essential for the treatment of these patients. In view of the complexity and high incidence of complications, tracheostomy in pediatric patients has always been controversial [8, 9]. Recent studies have shown that early tracheostomy in critically burned pediatric patients is safe and effective. Early tracheostomy provides a stable airway and improves mechanical ventilation management, and the incidence of tracheotomy site infections and pneumonia is also extremely low [3–4, 10–11].
Compared with a tracheotomy, tracheal intubation has the advantages of being simple and rapid with fewer complications. Therefore, most physicians choose tracheal intubation as a better way to establish an artificial airway in the early stage of burns in children; however, tracheal intubation also faces many problems in the treatment of pediatric burns, as follows: (1) Children's vocal cords are anatomically forward, thus aggressive fluid resuscitation for patients with IHTs, and oropharynx and supraglottis burns aggravate airway edema and make intubation difficult. (2) Children’s tracheas are relatively short; body position changes during surgery and dressing changes increase the risk of endotracheal tube dislodgement or accidental decannulation. (3) Children's airways have a small inner diameter and therefore only a relatively narrow tracheal tube can be placed, resulting in increased airway resistance, particularly in patients with IHTs, and significant increases in airway secretions, which can easily lead to endotracheal tube obstruction. (4) Children cannot tolerate prolonged intubation and immobility; in most cases, sedation and neuromuscular blockade are required to prevent accidental extubation, and the use of these drugs can also cause corresponding complications . At the same time, prolonged tracheal intubation can significantly increase the incidence of airway complications. Therefore, the airway management method should be individualized to the patient's clinical course, especially in younger children.
There are two main indications for tracheotomy in children with severe burns: (1) acute upper airway obstruction; and (2) requirement for long-term ventilation support . Most of the tracheostomies were done for upper airway obstruction in our study (58.5%), which is similar to other reports . For early airway management in severely burned pediatric patients, we primarily chose tracheostomy rather than tracheal intubation, which is inconsistent with guidelines and protocols at other institutions [4, 12]. For early airway management, we primarily chose tracheostomy rather than tracheal intubation in severely burned pediatric patients, which is inconsistent with guidelines and other institutions. Most of the tracheotomies in our study were performed between 2004 and 2013. At that time, economic and medical conditions were very poor, and the monitoring equipment in our department was limited. Tracheotomy was considered to be an economic, safe, and effective airway management method to achieve satisfactory results. Our findings may serve as a reference for airway management of children with severe burns in developing countries with poor medical conditions and lack of monitoring equipment. In recent years, with the improvement in nursing and monitoring conditions in our department, we selected tracheal intubation instead of tracheostomy in the early airway management of younger children with oropharyngeal, facial, and neck burns. This study demonstrated that tracheal intubation is also safe and effective in early airway management for young patients. Previous reports also found that prolonged airway management in severely burned children can also be accomplished by tracheal intubation ; however, other reports also found that long-term (> 10 days) tracheal intubation increase the incidence of tracheal stenosis in severely burned pediatric patients [11, 14]. Our study indicated that most tracheotomy-related complications occurred in children 0–3 years of age. This finding may be related to the immature structure of the respiratory tract in this age group, patients more prone to developing airway obstruction after burns, and patients in whom it was more difficult in performing a tracheostomy. Therefore, airway management in the 0–3 year age group should be carefully considered unless there are clear indications for tracheostomy, such as an inability to intubate or patients who require long-term respiratory support; otherwise, tracheal intubation may be a preferred choice in these patients.
Decannulation was carried out successfully in 96.7% of surviving patients. This result is similar to other reports of pediatric burn patients, and higher than non-trauma pediatric patients [4, 10, 15–17]. This may be related to the duration of tracheostomy in trauma, since it is shorter in pediatric patients than in non-trauma pediatric patients, as we know the duration of tracheostomy is an important factor affecting the success rate of decannulation. Five patients (7.7%) died; all from disease related progression with no tracheotomy-related deaths in the study period. This result is similar to previous reports and once again confirmed that tracheostomy in critically ill burned children is safe and effective [3–4, 10].
Complications related to tracheotomy are traditionally classified into two types: early (within the first 7 days of surgery); or late (> 7 days of surgery) . The incidence of tracheotomy-related complications in children varies widely in the literature (3–84%) [19–24]. Fifteen patients (23.1%) had a tracheostomy-related complication in our study (seven and eight early and late complications, respectively). With the exception of two patients who developed tracheomalacia and who were discharged with the tracheostomy tube in place, most of the complications resolved, and no patients died from complications of the tracheostomy. In our study we did not identify any risk factors associated with early complications of the tracheotomy, but TBSA%, ventilation time, and the duration of tracheostomy were closely related to late complications. Early complications may be related to the skills of the operating physicians. Due to our limited number of case and no comparisons, we cannot draw a clear conclusion. Some experts suggest that children's tracheostomy should be performed by experienced physicians whenever possible . Due to the close relationship with ventilation time, duration of tracheostomy, and the occurrence of late tracheotomy-related complications, we should take effective measures to shorten the ventilation time and decannulate as early as feasible to reduce complications related to the tracheotomy.
Our study indicated that age, TBSA%, IHT, and ventilation time were independent factors influencing the duration of tracheostomy. The duration of tracheostomy will be longer if the patient is younger, the TBSA% is greater, the IHT is more serious, or the ventilation time is longer. Another study also showed that the duration of tracheostomy is negatively correlated with age ; however, a recent study of pediatric burn patients found that the duration of tracheostomy is mainly related to the TBSA%, but not to age . The difference between their conclusions and our conclusions may be mainly related to the different ways in which patients were grouped by age. Previous research showed that early decannulation can reduce complications related to tracheostomy, the negative emotional impact on the patient and their parents, and the economic burden of the family and the healthcare system [15, 26–28]. Due to the lack of a standard decannulation protocol for children with severe burns, we had to use decannulation methods for patients with other diseases. This reduced the success rate of decannulation and prolonged the tracheostomy time. Therefore, guidelines and decannulation protocols for severely burned pediatric patients are urgently needed.