Tracheal clinical outcomes

Clinical outcomes are broadly agreed, measurable changes in health or quality of life that result from our care. Constant review of our clinical outcomes establishes standards against which to continuously improve all aspects of our practice.

About the Tracheal Service

The Tracheal Team at GOSH was established in 2001 and is a group of health professionals brought together to provide the full range of expertise needed to treat conditions associated with the trachea (windpipe) and bronchi (branches of the windpipe to each lung). The team sees and treats a wide variety of serious conditions, some very rare, including:

  • long segment congenital tracheal stenosis
  • tracheo-broncho malacia
  • severe laryngo-tracheal clefts
  • tracheal tumours
  • cardiac problems causing bronchial and tracheal compression
  • post FETO (fetal endoscopic tracheal obstruction –used to treat congenital diaphragmatic hernia in some centres) 'mega trachea'

The team comprises specialists in nursing, ear, nose and throat (ENT), interventional radiology, intensive care, cardiothoracic surgery and physiotherapy. In 2006, the Tracheal Service received national recognition as the sole centre for the management of complex tracheal problems. The chart below shows the year on year growth in referrals to the team.

Referrals to the Tracheal Team 1996-2017

Referrals to the Tracheal Team 1996-2017

Clinical outcome measures

Long segment congenital tracheal stenosis (LSCTS) is the condition we see most often. The team established the slide tracheoplasty surgical technique as the gold standard approach to treat LSCTS, and has the world’s largest experience of this type of surgery. The technique involves dividing the narrowed part of the trachea, which can sometimes be only 1 or 2 millimetres wide, and sliding the two sections over each other until the part of the trachea that is normal width is reached.

Summary:

1. Early and late mortality

2. Actuarial survival

3. Complications

4. Length of stay

1. Early and late mortality for LSCTS

Table 1 below shows our results compared to other units around the world.

Recent results of slide tracheoplasty 2017

We have the world’s largest series, which means our team has seen the greatest number of patients, and thus we have had the opportunity to build our expertise in the treatment of this condition. We have produced the best outcomes internationally, with the lowest death rates for this serious condition, and our follow up, which extends to 288 months is also the longest available to judge the outcome of this treatment.

Ref: Butler CR, Speggiorin S, Rijnberg FM, Roebuck DJ, Muthialu N, Hewitt RJ, Elliott MJ. Outcomes of slide tracheoplasty in 101 children: a 17-year single-center experience. The Journal of Thoracic and Cardiovascular Surgery 2014; 147(6): 1783-9.

2. Actuarial survival

Actuarial survival is a way of measuring survival that counts the proportion of patients alive (in relation to the expectation of life in a normal population) at a certain point in time, in this case after a slide tracheoplasty. Actuarial survival counts all deaths for a selected population, so this means that patients whose death was unrelated to their tracheal disease would also be counted in this figure.

Between 1995 and the end of 2017, we performed a total of 154 slide tracheoplasties with an overall survival of 88 per cent. The figure below shows the increasing number of slide tracheoplasties and a significant improvement in survival over time despite increasing patient complexity.

Fig 2.1 Overall actuarial survival

Tracheal Overall actuarial survival 1995 to 2017

We are currently developing a risk score to inform preoperative decision making. The figure below that children with a risk score of five are at the highest risk of death after tracheoplasty (ie those ventilated preoperatively, with a weight below 5kg, and presence of coronary heart disease, complete bronchial risk, and a trifurcation anatomy (where the structure of the trachea has anomalies).

Fig 2.2 Predictive modelling of risk-adjusted survival

Fig 2.2 Predictive modelling of risk-adjusted survival 2017

3. Complications

One of the goals of an operation is to surgically correct the problem or improve function without causing problems associated with invasive procedures to the body. As our practice has evolved and our expertise has grown, we have seen a consistent reduction in surgical complications for slide tracheoplasty. During healing, it is expected that the trachea will narrow a little as part of normal scarring, and often the airway becomes a little soft or gets temporary obstruction with tissue called granulation tissue. These natural events are controlled by regular use of a small balloon in the airway for the first few weeks after surgery. A small minority of patients need a stent to keep the airway open. In the early days of our experience, we had to use metal stents that could not be removed once inserted. However, we have worked with a company in the Czech Republic (Ella CS) to make absorbable stents which are of great value in preventing the need for metal stents.

References:

Vondrys D, Elliott MJ, McLaren CA, Noctor C, Roebuck DJ. First experience with biodegradable airway stents in children. Annals of Thoracic Surgery 2011; 92(5):1870-4.

Rijnberg FM, Butler CR, Speggiorin S, Fierens A, Wallis C, Nouraei R, McLaren CA, Roebuck DJ, Hewitt R, Elliott MJ.  The influence of stents on microbial colonization of the airway in children after slide tracheoplasty: A 14-year single-center experience. Pediatric Pulmonology 2015; Jan;50(1):79-84.

The figure below shows since 1995 the increasing number of slide tracheoplasties performed while the proportion of patients experiencing any complication consistently reducing.

Fig 3. Cumulative slides and cumulative complications

Fig. 3 Tracheal Cumulative slides and cumulative complications

3.1 Post-operative deep wound infection rate

Infection is a risk with any operation. The number and rate of patients who have a 'deep wound' infection is reported here. A deep wound is one that involves the deep soft tissues (fascial and muscle layers).

Table 3.1 Post-operative deep wound infection rate, 1995-2017

Years Number of patients Number and percentage of deep wound infections
1995-2007 43 7 (16.3%)
2008-2012 51 2 (3.9%)
2013-2017 60 4 (6.7%)
Total 154 13 (8.4%)

3.2 Re-admission to Cardiac Intensive Care Unit (CICU)

A small number of patients may be readmitted to CICU due to complications. The number and rate of these occurring within 30 days of surgery is reported here.

Table 3.2 Rate of re-admission to CICU within 30 days, 1995-2017

Years Number of patients Readmissons to CICU within 30 days
1995-2007 43 6 (14.0%)
2008-2012 51 2 (3.9%)
2013-2017 60 4 (6.7%)
Total 154 12 (7.8%)

4. Length of stay

Another focus of the team’s commitment to delivering the best quality care has been to reduce the patients’ length of stay, with particular attention to the time spent on the intensive care units, and the time spent on a ventilator. The chart below shows our marked improvement over time in getting our patients well and fit for discharge after slide tracheoplasty.

Fig 4. Time spent in ICU and time to extubation

Fig. 4 Tracheal Time spent in ICU and time to extubation

This information was published in May 2018 and will be updated in June 2019.