2016 ESPO Congress
International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Management of suprastomal collapse in the pediatric population

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Abstract

Introduction

Suprastomal Collapse (SuStCo) is a common complication of prolonged tracheostomy in children. There is a paucity of literature on this subject, especially regarding how to manage significant suprastomal collapse that prevents safe decannulation.

Objective

Provide a definition, classification system, and recommend management options for significant suprastomal collapse in children with tracheostomy.

Methods

Members of the International Pediatric Otolaryngology Group (IPOG) who are experts in pediatric airway conditions were surveyed and results were refined using a modified Delphi method.

Results

Consensus was defined as > 70% agreement on a subject. The experts achieved consensus:

  • on a standard definition of Suprastomal Collapse

  • that there is clinical importance between significant and insignificant collapse

  • that the gold standard diagnostic modality is endoscopic examination under anesthesia

  • that the severity of collapse is a major determinant in the surgical approach

  • that surgical intervention is the first line management in combined anterior and lateral Suprastomal Collapse.

Conclusion

This consensus statement provides recommendations for medical specialists who manage infants and children with tracheostomies with significant Suprastomal Collapse. It provides a classification system to facilitate diagnosis and treatment options for this condition.

Introduction

Pediatric tracheostomy can be a life-saving procedure. Once a child overcomes their need for their tracheostomy, decannulation becomes the main goal. Though this is not always possible due to factors such as ventilator dependence, some causes of failed decannulation are potentially reversible. One reason for failure to decannulate is significant Suprastomal Collapse (SuStCo). The incidence of SuStCo has been reported to be as high as 20% in young children with longstanding tracheostomies [1]. SuStCo results from a lack of structural integrity of the trachea above a tracheostomy site resulting in collapse of tissue and a variable degree of airway obstruction [2]. Though etiologies remain unclear, SuStCo may be due to chondritis that weakens tracheal cartilage or the curved posterior wall of the tracheostomy tube that constantly displaces tracheal cartilage posteriorly. The degree of collapse can range from mild to severe where it can prevent safe decannulation.

Various surgical treatments for SuStCo have been reported in the literature. These range from primary closure of the tracheostomy stoma to anterior costal cartilage graft laryngotracheoplasty [3] and tracheal resection with primary anastomosis [4]. Less invasive suggestions include anterior cricoid suspension [5], and excision of the malacic segment using cold instruments or the KTP laser [6,7]. Most recently, use of resorbable mini-plates has been proposed to strengthen the trachea [8,9]. Despite the relatively common nature of this problem, SuStCo remains poorly understood and the management of this condition remains non-standardized.

Section snippets

Consensus objectives

Provide recommendations for the definition, classification and management of significant suprastomal collapse.

Target population

Infants and children with tracheostomies and severe suprastomal collapse.

Intended users

This manuscript and its recommendations are intended for pediatric otolaryngologists and airway surgeons who manage infants and children with pediatric tracheostomy.

Methods

Recommendations based on a systematic review of the literature and consensus expert opinion from members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG publication is to promote excellence in the care of children with otolaryngological conditions. This is achieved by collecting the opinions of experts in the field and condensing their recommendation into consensus documents which are disseminated through the literature.

An online survey was formulated by the

Disclaimer

Members of the International Pediatric Otolaryngology Group (IPOG) prepared this report. Consensus recommendations are based on the collective opinion of members of this group. Any person seeking to consult this report or apply its conclusions to patient care is expected to exercise independent medical judgment in the context of individual patient and institutional circumstances.

Definitions

In order to ensure total clarity in discussing suprastomal collapse, the authors sought to clearly define the terminology concerning the disease.

To grade suprastomal collapse as it relates to function, and assist in framing questions, we divided it into two main types:

  • Significant suprastomal collapse where the degree of collapse is major and prevents safe decannulation.

  • Insignificant suprastomal collapse where the degree of collapse is minor and decannulation is possible.

We also found that there

Conclusions

According to the group's experience, Significant Suprastomal Collapse is frequently encountered. All of the experts believe the gold standard for diagnosing SuStCo is airway endoscopy under general anesthesia with spontaneous respiration with the tracheostomy tube removed and the option of temporarily occluding the stoma. Suprastomal collapse can be classified as either anterior collapse or anterior and lateral collapse.

The type of tracheal incision or peristomal infection were not believed to

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Financial disclosure

No financial interests to disclose.

Declaration of competing interest

No conflicts of interest to disclose.

Acknowledgements

Drs Jaime Doody and John Russell were the lead authors. All remaining authors are listed in alphabetical order. The authorship list follows the agreement of the IPOG. All authors have contributed to the conception, and design of the work, drafting and revising the consensus recommendations for important intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work.

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