Résumé :
|
Purpose : The care of the pediatric home mechanical ventilation (HMV) patient requires a multidisciplinary management approach. The medical literature regarding airway complications in children requiring long-term tracheostomy for HMV is scant, and there are no formal guidelines for how often a screening fiberoptic flexible bronchoscopy (FFB) should be performed in this population. The purpose of this study is to describe abnormalities identified on screening FFB in a large cohort of children on chronic HMV support and the interventions made as a result of the FFB findings. Methods : The medical records of children followed in our HMV clinic from January 2004 to September 2008 were reviewed. Age, sex, diagnosis, date of FFB, and FFB findings were recorded. Interventions (ventilator changes, tracheostomy tube changes,medication alterations and surgical interventions) that were implemented within one week as a result of pathology identified on FFB were identified. Analysis of data included an evaluation of calculation of frequency of diagnoses, FFB findings and the incidence of intervention after findings from a FFB. Results : Fifty-five pediatric HMV patients, 22 females and 33 males, were identified over a four year period at our institution received one hundred forty-three diagnostic FFBs. FFBs were performed by pediatric intensivists, pediatric pulmonologists and otolaryngologists. Median patient age was 7.5 years (range 1- 23 years). The most frequent underlying diagnoses requiring HMV were : Spinalmuscular atrophy type I (13%), bronchopulmonary dysplasia (11.5%), Duchenne's muscular dystrophy (11.5%), spinal cord injury (7%), and hypoxic-ischemic encephalopathy (7%). 76%of the FFBs revealed one or more abnormality. The most common findings were airway malacia (40%), stomal granulation (20%), mucosal inflammation (15%), upper airway edema (11%), other granulation tissue (6%), lymphoid hyperplasia (6%), and subglottic stenosis (5%). The incidence of interventions done after a FFB was 32%, in which the most common interventions were ventilator changes (22%) and tracheostomy tube changes (7%). Although seven patients had FFB findings that warranted otolaryngology consult, only one patient needed surgical intervention for a transcutaneous fistula identified on FFB. Conclusion : In our pediatric HMV population, there was a high incidence of unexpected airway abnormalities diagnosed by fiberoptic flexible bronchoscopy. The most prevalent findings were airway malacia and stomal granulation. Almost one third of our patients needed a clinical intervention as a result of unexpected findings identified on bronchoscopy. Clinical Implications : Because of the frequent airway abnormalities noted and the post-FFB interventions performed in our pediatric HMV patients, we recommend that at a minimum, annual flexible fiberoptic bronchoscopy should be performed in this population. Patients with airway pathology may benefit from even more frequent bronchoscopy evaluation.
|