Pediatric tracheotomy: indications and decannulation outcomes

Indications and Outcomes for Tracheostomies in Pediatric Oncology Patients-A Single Center Study

BACKGROUND

Children with cancer face a high risk of complications including prolonged mechanical ventilation requiring tracheostomies. While tracheostomies have been demonstrated to be a generally safe procedure, there remain significant rare complications and a paucity of literature addressing outcomes specifically for pediatric patients with cancer. The objective of this study was to characterize pediatric patients with cancer who underwent tracheostomies and describe their indications and outcomes for length of stay, decannulation, and complications.

PROCEDURES

At a single large volume children's hospital, retrospective medical record analysis was performed in all pediatric patients with cancer who received tracheostomies from 2004 to 2023.

RESULTS

Sixty-five patients were identified with a median follow-up time of 763 days (interquartile range 302-1687). Twenty-one (32%) patients had a tracheostomy placed due to complications from mass effect of the tumor, 16 (25%) due to complications from cancer treatment, and 14 (22%) had a tracheostomy placed for nononcologic reasons. Additionally, a distinct subgroup of 14 (22%) patients underwent tracheostomy perioperatively for elective airway management during surgical resection of their tumors. Twenty-nine (45%) were decannulated and 17 (26%) patients had a tracheostomy-associated complication, including tracheitis and tracheocutaneous fistula, and no patients had a tracheostomy-associated mortality.

CONCLUSIONS

The incidence of tracheostomy-associated complications and decannulation rates in pediatric patients with cancer was comparable with the general pediatric tracheostomy population. This study establishes a reference point for clinicians regarding the anticipated outcomes among pediatric patients with cancer requiring or having undergone a tracheostomy.

Percutaneous Tracheostomy Via Grigg's Technique in Children: Does Age and Size Matter?

OBJECTIVES

Percutaneous tracheostomy is rarely performed in children, especially in infants. In the present study, we aimed to evaluate the complications and outcomes of PT via the Griggs technique according to the age and size of pediatric patients.

METHODS

This study included 110 PICU patients who underwent PT using the Griggs technique between 2012 and 2020. The patients were divided into six groups according to their age, demographic data, primary disease, mean duration of intubation before PT, mean duration of PICU and hospitalization after PT, complications, and decannulation outcomes were compared between these groups.

RESULTS

The mean age and mean weight of the patients were 43.6 ± 58.9 months (1 month-207 months) and 14.6 ± 14.9 kg (2.6-65 kg), respectively. Mean intubation times before the procedures were 64.6 ± 40 days and 38.6 ± 37.9. Thirty-seven (33.6%) infants were under 6 months of age(Group 1). There were no intraoperative complications. Tracheostomy site stenosis was significantly greater in Group 1 than in the other age groups (p = 0.032). Granuloma formation and dermatitis incidence were similar in all age groups.

CONCLUSION

PT is a safe and feasible procedure even in small infants. The accidental decannulation risk is lower than standard tracheostomy. Interacting with rigid bronchoscopy guidance is essential to perform a safer procedure. The first tracheostomy change after PT in small infants under 6 months of age, the possibility of tracheostomy site (stoma) stenosis should be considered.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:416-422, 2025.

Preventing pediatric accidental decannulation events: A quality improvement initiative

OBJECTIVE

To describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3.

METHODS

A retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented: using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases.

RESULTS

Prior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases).

CONCLUSION

This data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.

Neighborhood Socioeconomic Disadvantage and Long-Term Outcomes After Pediatric Tracheostomy

OBJECTIVES

To determine whether long-term outcomes after pediatric tracheostomy are impacted by neighborhood socioeconomic disadvantage.

METHODS

A prospective cohort of children with tracheostomies was followed at an academic pediatric hospital between 2015 and 2020. Patients were grouped into low or high socioeconomic disadvantage using their neighborhood area deprivation index (ADI). Survival and logistic regression analyses determined the relationship between ADI group, decannulation, and mortality.

RESULTS

A total of 260 children were included with a median age at tracheostomy of 6.6 months (interquartile range [IQR], 3.9-42.3). The cohort was 53% male (N = 138), 55% White race (N = 143), and 35% Black or African American (N = 90). Tracheostomy was most frequently indicated for respiratory failure (N = 189, 73%). High neighborhood socioeconomic disadvantage was noted for 66% of children (N = 172) and 61% (N = 158) had severe neurocognitive disability. ADI was not associated with time to decannulation (HR = 0.90, 95% confidence interval [95% CI]: 0.53-1.53) or time to death (HR = 0.92, 95% CI: 0.49-1.72).

CONCLUSIONS

Neighborhood socioeconomic disadvantage was not associated with decannulation or mortality among children with a tracheostomy. These findings suggest that long-term outcomes after pediatric tracheostomy are less dependent on socioeconomic factors in an individual community.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2415-2421, 2024.

Time considerations and outcomes in pediatric tracheostomy decannulation

OBJECTIVE

The study objective is to identify factors that impact the time to decannulation in pediatric patients ages 0 through 18 years who are tracheostomy-dependent.

METHODS

This retrospective chart review from January 1, 2005 through December 31, 2020 identified pediatric tracheostomy patients at a single pediatric institution. Data extracted included demographic, socioeconomic factors, and clinical characteristics. Multivariate regression and survival analysis were used to identify factors associated with successful decannulation and decreased time with tracheostomy.

RESULTS

Of the 479 tracheostomy-dependent patients identified, 162 (33.8%) were decannulated. Time to decannulation ranged from 0.5 months to 189.2 months with median of 24 months (IQR 12.91-45.71). In the multivariate analysis, patients with bronchopulmonary dysplasia (p = 0.021) and those with Passy-Muir® Valve at discharge (p = 0.015) were significantly associated with decannulation. In contrast, neurologic comorbidities (p = 0.06), presence of gastrostomy tube (p < 0.001), or discharged on a home ventilator (p < 0.001) were associated with indefinite tracheostomy. When adjusting for age, sex, race, ethnicity, and insurance status, for every one month delay in establishment of outpatient otolaryngology care, time to decannulation was delayed by 0.5 months (p = 0.010). For each additional outpatient otolaryngology follow-up visit, time to decannulation increased by 3.36 months (p < 0.001).

CONCLUSIONS

Decannulation in pediatric tracheostomy patients is multifactorial. While timely establishment of outpatient care did correlate with quicker decannulation, factors related to medical complexity may have a greater impact on time to decannulation. Our results can help guide institutional decannulation protocols, as well as provide guidance when counseling families regarding tracheostomy expectations.

Perioperative and Long-Term Outcomes in Infants Undergoing a Tracheostomy from a Neonatal Intensive Care Unit

OBJECTIVE

The purpose of this study was to identify risk factors for perioperative complications and long-term morbidity in infants from the neonatal intensive care unit (NICU) presenting for a tracheostomy.

METHODS

This single-center retrospective cohort study included infants in the NICU presenting for a tracheostomy from August 2011 to December 2019. Primary outcomes were categorized as either a perioperative complication or long-term morbidity. A severe perioperative complication was defined as having either (1) an intraoperative cardiopulmonary arrest, (2) an intraoperative death, (3) a postoperative cardiopulmonary arrest within 30 days of the procedure, or (4) a postoperative death within 30 days of the procedure. Long-term morbidities included (1) the need for gastrostomy tube placement within the tracheostomy hospitalization and (2) the need for diuretic therapy, pulmonary hypertensive therapy, oxygen, or mechanical ventilation at 12 and 24 months following the tracheostomy.

RESULTS

One-hundred eighty-three children underwent a tracheostomy. The mean age at tracheostomy was 16.9 weeks while the mean post-conceptual age at tracheostomy was 49.7 weeks. The incidence of severe perioperative complications was 4.4% (n = 8) with the number of pulmonary hypertension medication classes preoperatively (OR: 3.64, 95% CI: (1.44-8.94), p = 0.005) as a significant risk factor. Approximately 81% of children additionally had a gastrostomy tube placed at the time of the tracheostomy, and 62% were ventilator-dependent 2 years following their tracheostomy.

CONCLUSION

Our study provides critical perioperative complications and long-term morbidity data to neonatologists, pediatricians, surgeons, anesthesiologists, and families in the expected course of infants from the NICU presenting for a tracheostomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1945-1954, 2024.

Healthcare service use and medical outcomes of tracheostomy-dependent children: a nationwide study

BACKGROUND

Despite the rising trend of tracheostomies in children, there is a lack of comprehensive resources for families to navigate the challenges of living with a tracheostomy, emphasising the need for evidence-based support in understanding postoperative care and long-term adjustments. This study aimed to examine the pattern of using healthcare services and nationwide medical outcomes in children who underwent a tracheotomy before the age of 2 years.

METHODS

This retrospective study used the National Health Insurance System database from 2008 to 2016 and included all children codified with tracheotomy procedure codes before their second birthday. Healthcare utilisation, such as medical costs, number of hospital visits, home healthcare nursing and medical diagnoses on readmission, in the first 2 years after tracheotomy was evaluated. Multivariable logistic regression analysis was used to determine the factors affecting mortality.

RESULTS

In total, 813 patients were included in this study. Their use of healthcare services and the accompanying expenses were higher than the national medians for similar age groups; however, both metrics decreased in the second year. The major causes of admission within 2 years of surgery were respiratory and neurological diseases. The mortality rate within 2 years was 37.8%. Higher risks of mortality were associated with having two or more complex chronic conditions. Use of home healthcare nursing services was associated with a lower mortality risk.

CONCLUSION

Paediatric patients with more complex chronic conditions tended to have higher mortality rates within 2 years after surgery. However, receiving home healthcare nursing was significantly associated with a reduced risk of death. Many causes of hospitalisation may be preventable with education and supportive care. Therefore, further research for establishing an integrated care system for these patients and their caregivers is required.

A systematic review of antimicrobial therapy in children with tracheostomies

Tracheostomies are indicated in children to facilitate long-term ventilatory support, aid in the management of secretions, or manage upper airway obstruction. Children with tracheostomies often experience ongoing airway complications, of which respiratory tract infections are common. They subsequently receive frequent courses of broad-spectrum antimicrobials for the prevention or treatment of respiratory tract infections. However, there is little consensus in practice with regard to the indication for treatment/prophylactic antimicrobial use, choice of antimicrobial, route of administration, or duration of treatment between different centers. Routine antibiotic use is associated with adverse effects and an increased risk of antimicrobial resistance. Tracheal cultures are commonly obtained from pediatric tracheostomy patients, with the aim of helping guide antimicrobial therapy choice. However, a positive culture alone is not diagnostic of infection and the role of routine surveillance cultures remains contentious. Inhaled antimicrobial use is also widespread in the management of tracheostomy-associated infections; this is largely based on the theoretical benefits of higher airway antibiotic concentrations. The role of prophylactic inhaled antimicrobial use for tracheostomy-associated infections remains largely unproven. This systematic review summarizes the current evidence base for antimicrobial selection, duration, and administration route in pediatric tracheostomy-associated infections. It also highlights significant variation in practice between centers and the urgent need for further prospective evidence to guide the management of these vulnerable patients.

Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis

Objective

This study aimed to determine the direct costs of pediatric tracheostomy care within a health care system.

Study Design

Prospective analysis.

Setting

Academic children's hospital.

Methods

Costs associated with caring for pediatric tracheostomy patients under 18 years were analyzed between 2015 and 2021. Direct costs were calculated using the Medicare/Medicaid charges-to-costs ratio for various visit types. Costs were estimated using generalized linear equations, accounting for confounders.

Results

A total of 297 children underwent tracheostomy at a median age of 0.94 years. The median follow-up was 2.5 years, resulting in 13,966 visits (mean = 41). The total cost was $321 million. The initial admission accounted for 72% ($231 million) of costs while other inpatient admissions added 24% ($78 million). Emergency department, observation, and outpatient visits comprised 4% of costs. The length of stay (LOS) was the primary cost driver for inpatient visits. Each additional hospital day increased costs by roughly $1195, and each extra admission added about $130,223 after adjusting for confounders. Respiratory failure and infections were the primary reasons for 67% of subsequent admissions.

Conclusion

Pediatric tracheostomy care generated over $300 million in direct costs over 5 years. Inpatient stays constituted 96% of these costs, with the LOS being a major factor. To reduce direct health expenditures for these patients, the focus should be on minimizing admissions.

Revisiting the Great Ormond Street Hospital protocol for ward decannulation of children with tracheostomy

INTRODUCTION

Tracheostomy decannulation is an important and final step in managing patients once the underlying issue requiring a tracheostomy resolves. However, no consensus exists on the optimal method to decannulate a paediatric patient. We revisit the Great Ormond Street Hospital (GOSH) tracheostomy decannulation protocol, a 5-day process involving downsizing the tracheostomy tube, capping, and observation, to evaluate its effectiveness and assess if changes to the protocol are required.

METHOD

This is a retrospective study, reviewing patient records between April 2018 and April 2023 from a single quaternary care centre. Data extracted include comorbidities, age at the time of decannulation, duration of tracheostomy, reason for tracheostomy insertion, whether a decannulation attempt was successful or not, and the timings of decannulation failure.

RESULTS

66 patients that met the selection criteria underwent a decannulation trial between April 2018 and April 2023. 32 patients were male, and 34 patients were female. Age at attempted decannulations ranged from 1 year to 18 years, with an average age of 6.1 years. There were a total of 93 attempts at decannulation, with 51 (54.8%) successful attempts, 35 (56.5%) first decannulation attempt successes, and 42 (45.2%) unsuccessful attempts. 17 patients had 2 attempts at decannulation, and 4 patients had 3 or more attempts at decannulation. Of the unsuccessful attempts, patients mostly failed on capping of the tracheostomy tube with 33 failures (35.5%).

CONCLUSION

The GOSH protocol achieved similar success rates to comparable protocols. The protocol's multi-step approach provides thorough evaluation and support for patients during the decannulation process, and its success on a complex patient cohort supports its continued use.

Tracheotomy in children older than two years: Analysis of discharge trends from 2015 to 2020

OBJECTIVE

In light of increasingly complex patients being discharged with tracheostomies, we aimed to evaluate discharge trends over time in pediatric tracheotomy patients. We hypothesized that there would be delays in discharge from increased focus on preparing families for at-home care of critically ill pediatric patients.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of pediatric patients who underwent tracheotomy (Current Procedural Terminology code 31600) between 2015 and 2020 using the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIP-P). Univariate and multivariate regression analyses were performed to assess patient demographics, comorbidities, perioperative factors, postoperative complications, and discharge information. Data were analyzed using Stata 15.

RESULTS

A total of 1552 patients were identified. There were 868 (56 %) males and 684 (44 %) females with a mean age of 7.3 ± 5.7 years. At least one comorbidity was seen in 1282 (83 %) patients, with 907 (58 %) having impaired cognitive status or developmental delay. Thirty-six (2.3 %) patients experienced mortality within 30 days, while 710 (46 %) were still in the hospital at 30 days. The odds of remaining in the hospital after 30 days were positively correlated with the year (p=.001). Other factors associated with an increased likelihood of remaining in the hospital after 30 days included younger patient age (p <.001), any complication (p <.001), and a higher American Society of Anesthesiologists classification (p <.001).

CONCLUSION

As years have progressed, fewer children were discharged from the hospital after 30 days following tracheotomy. Further research may identify socioeconomic factors contributing to the increasing length of hospital stays associated with a need for tracheotomy.

Effect of Speaking Valves on Tracheostomy Decannulation

Introduction  Despite several pediatric tracheostomy decannulation protocols there remains tremendous variability in practice. The effect of tracheostomy capping on decannulation has been studied but the role of speaking valves (SVs) is unknown. Objective  Given the positive benefits SVs have on rehabilitation, we hypothesized that SVs would decrease time to tracheostomy decannulation. The purpose of the present study was to evaluate this in a subset of patients with chronic lung disease of prematurity (CLD). Methods  A retrospective chart review was performed at a tertiary care children's hospital. A total of 105 patients with tracheostomies and CLD were identified. Data collected included demographics, gestational age, congenital cardiac disease, airway surgeries, granulation tissue excisions, SV and capping trials, tracheitis episodes, and clinic visits. Statistics were performed with logistic and linear regression. Results  A total of 75 patients were included. The mean gestational age was 27 weeks (standard deviation [SD] = 3.6) and the average birthweight was 1.1 kg (SD = 0.6). The average age at tracheostomy was 122 days (SD = 63). A total of 70.7% of the patients underwent decannulation and the mean time to decannulation (TTD) was 37 months (SD = 19). A total of 77.3% of the patients had SVs. Those with an SV had a longer TTD compared to those without (52 versus 35 months; p  = 0.008). Decannulation was increased by 2 months for every increase in the number of hospital presentations for tracheitis ( p  = 0.011). Conclusion  The present study is the first, to our knowledge, to assess the effect of SVs on tracheostomy decannulation in patients with CLD showing a longer TTD when SVs are used.

Laryngotracheal Reconstruction Outcomes in Children Born Extremely Premature

INTRODUCTION

There has been a notable increase in the number of neonates born 28 weeks gestational age or younger in the United States. Many of these patients require tracheostomy early in life and subsequent laryngotracheal reconstruction (LTR). Although extremely premature infants often undergo LTR, there is no known study to date examining their post-surgical outcomes.

OBJECTIVES

To compare decannulation rates, time to decannulation and complication rates between LTR patients born extremely premature to those born preterm and term.

METHODS

We identified 179 patients treated at a stand-alone tertiary children's hospital who underwent open airway reconstruction from 2008 to 2021. A Chi Squared test was used to detect differences in categorical clinical data between the groups of patients. A Mann-Whitney test was used to analyze continuous data within these same groups. Time to decannulation analysis was performed using Kaplan Meier analysis and evaluated with log-rank and Cox proportional hazards regression.

RESULTS

Children born extremely premature were more likely to incur complications following LTR (OR = 2.363, p = 0.005, CI 1.295-4.247). There was no difference in time to decannulation (p = 0.0543, Log-rank) or rate of decannulation (OR = 0.4985, p = 0.05, CI 0.2511-1.008). Extremely premature infants were more likely to be treated with an anterior and posterior grafts (OR = 2.471, p = 0.004, CI 1.297-4.535) and/or an airway stent (OR = 3.112, p < 0.001, CI 1.539-5.987).

CONCLUSION

Compared with all other patients, extremely premature infants have equivalent decannulation success, but are at an increased risk for complications following LTR.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3608-3614, 2023.

Pediatric tracheostomy decannulation: what's the evidence?

PURPOSE OF REVIEW

Pediatric decannulation failure can be associated with large morbidity and mortality, yet there are no published evidence-based guidelines for pediatric tracheostomy decannulation. Tracheostomy is frequently performed in medically complex children in whom it can be difficult to predict when and how to safely decannulate.

RECENT FINDINGS

Published studies regarding pediatric decannulation are limited to reviews and case series from single institutions, with varying populations, indications for tracheostomy, and institutional resources. This article will provide a review of published decannulation protocols over the past 10 years. Endoscopic airway evaluation is required to assess the patency of the airway and address any airway obstruction prior to decannulation. There is considerable variability in tracheostomy tube modification between published protocols, though the majority support a capping trial and downsizing of the tracheostomy tube to facilitate capping. Most protocols include overnight capping in a monitored setting prior to decannulation with observation ranging from 24 to 48 h after decannulation. There is debate regarding which patients should have capped polysomnography (PSG) prior to decannulation, as this exam is resource-intensive and may not be widely available. Persistent tracheocutaneous fistulae are common following decannulation. Excision of the fistula tract with healing by secondary intention has a lower reported operative time, overall complication rate, and postoperative length of stay.

SUMMARY

Pediatric decannulation should occur in a stepwise process. The ideal decannulation protocol should be safe and expedient, without utilizing excessive healthcare resources. There may be variability in protocols based on patient population or institutional resources, but an explicitly described protocol within each institution is critical to consistent care and quality improvement over time. Further research is needed to identify selection criteria for who would most benefit from PSG prior to decannulation to guide allocation of this limited resource.

Effectiveness of Training: Airway Management of Tracheostomized Pediatric Patients by Pediatric Residents and Anesthesiology Residents

To evaluate the effect of training on increasing baseline knowledge of pediatrics and anesthesia residents about airway management of pediatric patients with tracheostomy. It is a prospective, descriptive, before and after survey study. A questionnaire was conducted to measure the baseline knowledge of pediatrics and anesthesia residents about airway management in patients with pediatric tracheotomy. The same questionnaire was repeated after the education. Of the 63 participants, 42 were pediatric residents and 21 were anesthesiology residents. While the number of participants who answered the cuff part, inner cannula part, obturator part and balloon part of the tracheostomy tube correctly before the training was 27, 4, 10, and 12, respectively, these numbers increased to 53, 52, 57, and 55 after the training. There was a statistically significant improvement after the training in the correct response of the cuff, inner cannula, obturator, and balloon sections. A statistically significant improvement was observed in the answers received after the training for all 7 questions regarding the clinical scenario of accidental decannulation and tracheostomy bleeding compared to the pre-training. There was a statistical improvement in part where the participants rated themselves. In conclusion, training increases the ability of healthcare professionals to cope with life-threatening complications related to pediatric tracheotomy. A standardized education program on pediatric tracheostomy should be included in the routine programs of associated departments such as emergency medicine, anesthesia, and pediatrics residencies.

Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series

OBJECTIVE

Medical advances have resulted in increased survival rates of neurologically impaired children who may require mechanical ventilation and subsequent tracheostomy as a surgical airway. However, at present, there is no definite consensus regarding the timing and methods for placement of a surgical airway in a neurologically impaired intubated child who needs to be cared for over a long-term period. We therefore created a flowchart for the selection of a surgical airway for Neurologically Impaired Pediatric Patients (NIPPs).

METHODS

The flowchart includes information on the patients' backgrounds, such as intubation period, prognosis related to reversibility, and history of aspiration pneumonia. To evaluate the importance of the flowchart, first we conducted a survey of pediatricians regarding selection of a surgical airway, and we also evaluated the appropriateness of the flowchart among pediatricians and caregivers through questionnaire surveys which include satisfaction with the decision-making process, and postoperative course after discharge.

RESULTS

A total of 21 NIPPs with intubation underwent surgery and a total of 24 participants (14 pediatricians and 10 caregivers) completed the survey. The answers regarding the importance of the flowchart showed that eleven pediatricians had experience selecting of surgical airways, nine of whom had had experiences in which they had to make a difficult decision. The answers regarding the appropriateness of the flowchart revealed that all pediatricians and caregivers were satisfied with the decision-making process and postoperative course after discharge using the flowchart.

CONCLUSIONS

The present study demonstrated the effectiveness of our flowchart for selecting an appropriate surgical airway in NIPP. By referring to our flowchart, pediatricians and caregivers are likely to be able to select an appropriate surgical airway, leading to increased satisfaction with the decision-making process and postoperative course.

LEVEL OF EVIDENCE: 4

Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation

OBJECTIVES

To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence.

STUDY DESIGN

Prospective cohort.

METHODS

All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation.

RESULTS

A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p = 0.049) with failure to spontaneously close.

CONCLUSIONS

Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:417-422, 2023.

Effect of tracheostomy timing in pediatric patients with traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established.

OBJECTIVE

This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes.

DESIGN/METHODS

The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median = 9 days).

RESULTS

Of the 68,793 patients (mean age = 14, IQR 4-18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age = 16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p < 0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence.

CONCLUSIONS

Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.

Pediatric Tracheostomy at a Tertiary Healthcare Institution: A Retrospective Study Focused on Outcomes

The aim of this study was to retrospectively evaluate all pediatric tracheotomies that had been performed at Sanliurfa Training and Research Hospital From September 2016 to July 2019. A retrospective study was performed on pediatric patients who had undergone tracheostomy during the three-year study period. Patient data were reviewed for the following variables: age, gender, age at the time of tracheostomy, primary indication for tracheostomy, length of stay in intensive care unit before and after tracheostomy, complications, mortality and cause of death. The primary indication for tracheostomy was categorized into 4 separate groups: congenital disease, traumatic injury, prolonged intubation and other causes. The study group consisted of 138 children. Seventy-one (51.4%) of the children were male, 67 (48.6%) were female and the mean age of tracheostomy was 13.30 (0.03-192.27) months, and 44.2% were younger than 1 year when tracheotomy was performed. The median age at the time of tracheostomy was highest in children who underwent tracheostomy for traumatic injury. The indication for tracheostomy was prolonged intubation in 73.2% of the children. Complications were observed in 13 (9%) children; bleeding (69.2%) was the most common. Complications were most frequent in children who underwent tracheostomy for prolonged intubation. The overall mortality ratewas 30.4% with cardiac arrest being the most common cause. At our center, the most common indication for tracheostomy in children was long-term intubation, possibly due to our center being a tertiary healthcare institute. Bleeding was the most common complication, while cardiac arrest was the most common cause of death.

Reduction in inpatient readmissions following implementation of a dedicated tracheostomy care team

OBJECTIVE

Pediatric tracheostomy patients are at risk for lengthy hospitalizations and multiple readmissions with rare but potentially disastrous tracheostomy-related complications. Several centers have formed multidisciplinary teams for pediatric tracheostomy patients to coordinate care and enhance caregiver education to aid in safe care delivery. Current literature has shown encouraging change in pediatric tracheostomy care with these interventions, but there remains an opportunity to better gauge alterations of morbidity. We aimed to review our institution's experience before and after development of a pediatric tracheostomy care team.

METHODS

Pediatric tracheostomy patients (<19 years) who underwent tracheostomy between January 2010 and June 2020 were included. A pediatric tracheostomy care team including a nurse practitioner and registered nurse was established in July 2017. Rates of readmission, outpatient visits, decannulation rates, and mortality are examined before and after implementation of the care team. Bivariate and multivariable analyses were utilized.

RESULTS

296 patients were included with 128 patients in the pre-intervention group, 82 in the post-intervention group, and 86 completing cross-over care. The groups were comparable in age at tracheostomy, tracheostomy indication, and underlying comorbidities. Mean outpatient visits per tracheostomy-year in the post-intervention group were higher than the pre-intervention group (2.3 vs. 2.2, p = .02). Fewer mean inpatient admissions per tracheostomy-year (0.02 vs. 0.11, p = .03) were observed after intervention. Time to decannulation did not differ significantly between the two groups (p = .57).

CONCLUSION

Implementation of a dedicated tracheostomy care team may help decrease inpatient admissions for tracheostomy-specific complications.

Indication-based timing of tracheostomy and its effects on outcome in the pediatric intensive care unit

OBJECTIVES

The objective of study was to find an association between the timing of tracheostomy with duration of mechanical ventilation (MV) and length of stay (LOS) in pediatric intensive care unit (PICU) and hospital.

METHODS

The data were collected prospectively from 2000 to 2018 and were analyzed retrospectively. Data included clinical diagnosis, indication, and duration (days) of MV, LOS in PICU and hospital before and after tracheostomy. Patients who did not receive MV or underwent MV for <24 h were excluded. According to the indication of tracheostomy enrolled patients were divided into four groups-airways anomalies (AA), central neurological impairment (CNI), cardiopulmonary insufficiency (CPI), and neuromuscular disorders (NMD). Patients in each group were divided into early (ET) and late tracheostomy (LT) category based on the median (interquartile range interquartile range [IQR]) days of pretracheostomy MV.

RESULTS

Two hundred and fifty six patients were analyzed. The frequency and median [IQR] days of pretracheostomy MV were -AA 54 [7(3,16)], CNI 120 [12(9,16)], CPI 51 [25(16.5,30.5)], and NMD 31[12(8,16.5)]. In AA patients, median (IQR) durations of posttracheostomy MV [2(1,5.2) versus 3.5(2,12); p = 0.032], PICU [7(5,8.2) versus11(7,18); p = 0.004] and hospital [12(9.7,21) versus 21.5(12,28); p = 0.027] stays were lower in ET as compared with LT group. Posttracheostomy MV duration was significantly short in ET patients with CNI and NMD (p < 0.005). The total days of MV, PICU and hospital stay were significantly lower in ET as compared with LT patients in all four groups (p < 0.01).

CONCLUSION

As compared with LT, ET patient had shorter durations of total MV and PICU and hospital stay.

Tracheostomy practices in children on mechanical ventilation: a systematic review and meta-analysis

OBJECTIVE

To evaluate current practices of tracheostomy in children regarding the ideal timing of tracheostomy placement, complications, indications, mortality, and success in decannulation.

SOURCE OF DATA

The authors searched PubMed, Embase, Cochrane Library, Google Scholar, and complemented by manual search. The guidelines of PRISMA and MOOSE were applied. The quality of the included studies was evaluated with the Newcastle-Ottawa Scale. Information extracted included patients' characteristics, outcomes, time to tracheostomy, and associated complications. Odds ratios (ORs) with 95% CIs were computed using the Mantel-Haenszel method.

SYNTHESIS OF DATA

Sixty-six articles were included in the qualitative analysis, and 8 were included in the meta-analysis about timing for tracheostomy placement. The risk ratio for "death in hospital outcome" did not show any benefit from performing a tracheostomy before or after 14 days of mechanical ventilation (p = 0.49). The early tracheostomy before 14 days had a great impact on the days of mechanical ventilation (-26 days in mean difference, p < 0.00001). The authors also found a great reduction in hospital length of stay (-31.4 days, p < 0.008). For the days in PICU, the mean reduction was of 14.7 days (p < 0.007).

CONCLUSIONS

The meta-analysis suggests that tracheostomy performed in the first 14 days of ventilation can reduce the time spent on the ventilator, and the length of stay in the hospital, with no effect on mortality. The decision to perform a tracheostomy early or late may be more dependent on the baseline disease than on the time spent on ventilation .

Decannulation protocol for short term tracheostomy in pediatric head and neck tumor patients

BACKGROUND

While the majority of pediatric tracheostomies are performed in the setting of chronic and complex medical comorbidities, perioperative tracheostomies following head and neck tumor ablation are generally short-term. Deliberate planning is required for decannulation in this setting and no published protocols currently exist. Our study outlines a management strategy for short-term tracheostomy in pediatric patients following head and neck surgery.

METHODS

A retrospective study of pediatric head and neck tumor patients undergoing tracheostomy was performed at a quaternary children's hospital from February 1, 2016 to December 31, 2018. Charts were reviewed for demographics, surgical operation, relevant tracheostomy-related complications, and time to decannulation.

RESULTS

Eleven patients with a mean age of 10.4 years (st.dev. 6.7, range: 0.5-23) underwent tracheostomy during their primary ablative/reconstructive surgery. Trans-tracheal pressure monitoring helped direct the need for tracheostomy downsizing and readiness for capping trials. All patients were decannulated before hospital discharge after a mean of 12.8 days (st.dev. 2.5, range: 9-18) and were discharged after a mean of 14.8 days (st.dev. 2.5, range: 11-20).

CONCLUSION

Pediatric head and neck surgery patients can be quickly and safely decannulated with an instructive protocol and multidisciplinary care.

Survival and decannulation across indications for infant tracheostomy: a twelve-year single-center cohort study

OBJECTIVE

Describe survival and decannulation following infant tracheostomy based on indication for tracheostomy placement.

STUDY DESIGN

Retrospective cohort study of infants who received tracheostomy at a single pediatric hospital over a twelve-year period. Primary and secondary indications were categorized into pulmonary, anatomic, cardiac, neurologic/musculoskeletal, and others.

RESULTS

A total of 378 infants underwent tracheostomy; 323 had sufficient data to be included in analyses of post-discharge outcomes. Overall mortality was 26.3%; post-operative and post-discharge mortality differed across primary indications (P = 0.03 and P = 0.005). Among survivors, 69.3% decannulated at a median age of 3.0 years (IQR 2.3, 4.5 years). Decannulation among survivors varied across primary indications (P = 0.002), ranging from 17% to 75%. In multivariable analysis, presence of a neurologic or musculoskeletal indication for tracheostomy was a significant negative predictor of future decannulation (aOR 0.10 [95% CI 0.02-0.44], P = 0.003).

CONCLUSIONS

Early childhood outcomes vary across indications for infant tracheostomy.

Outpatient healthcare use and outcomes after pediatric tracheostomy

OBJECTIVES

To 1) describe health outcomes and outpatient healthcare use after pediatric tracheostomy, and 2) identify populations with higher morbidity that may benefit from improved post-operative monitoring.

METHODS

Optum's commercial insurance database was queried from 2003 to 2019. Children aged 0-18 who received tracheostomy identified. Mortality, decannulation, tracheostomy complications, and home ventilator dependence were determined, as well as physician office visits and specialty type. The effect that patient characteristics (age, sex, ethnicity, prematurity, and presence versus absence of chronic lung disease [CLD], congenital heart disease [CHD], neurologic impairment [NI], and upper airway obstruction [UAO]) had on outcomes were compared.

RESULTS

1231 children were identified. Infants accounted for 33% of patients and 40% of the cohort was premature. The most common comorbid conditions were NI (76%), UAO (69%), CLD (48%), and CHD (35%). Within 5 years postoperatively, 25% died, 45% had home ventilator dependence, 53% had a complication, and 10% were decannulated. CHD was associated with higher risk of death (HR,1.98; 95% CI 1.22, 3.21), while UAO was associated with lower risk of death (HR,0.51; 95% CI 0.32, 0.83) and higher probability of decannulation (HR,3.56, 95% CI 1.08, 11.74). The median number of physician office visits was 6 per year (IQR 3,10). The most common specialty types were pediatrics (32%), pulmonary medicine (10%), and otolaryngology (8%). NI was associated with greater number of office visits (mean difference/year, 4.10; 95% CI 2.00, 6.19) while Hispanic ethnicity was associated with fewer visits (mean difference/year, -2.94; 95%CI -5.42, -0.45).

CONCLUSIONS

UAO was associated with lower risk of mortality and higher probability of decannulation, while NI was associated with greater outpatient healthcare utilization. Social disparities in outpatient tracheostomy care were observed.

Indications and clinical outcome in pediatric tracheostomy: Lessons learned

OBJECTIVE

Indications for tracheostomy have changed over the last decades and clinical outcome varies depending on the indication for tracheostomy. By gaining more insight in the characteristics and outcome of the tracheostomized pediatric population, clinical care can be improved and a better individual prognosis can be given. Therefore, we studied the outcome of our pediatric tracheostomy population in relation to the primary indication over the last 16 years.

METHODS

We retrospectively included children younger than 18 years of age with a tracheostomy tube in the Erasmus Medical Center, Sophia children's hospital. The primary indication for tracheostomy, gender, age at tracheostomy, age at decannulation, comorbidity, mortality, closure of a persisting tracheocutaneous fistula after decannulation, surgery prior to decannulation and the use of polysomnography were recorded and analyzed.

RESULTS

Our research group consisted of 225 children. Reasons for a tracheostomy were first divided in two major diagnostic groups: 1) airway obstruction group (subgroups: laryngotracheal obstruction and craniofacial anomalies) and 2) pulmonary support group (subgroups: cardio-pulmonary diseases and neurological diseases). Children in the airway obstruction group were younger when receiving a tracheostomy (3.0 months vs. 31.0 months, p < 0.05), they were tracheostomy dependent for a longer time (median 21.5 months vs. 2.0 months, p < 0.05) and they required surgery more often (74.5% vs. 8.3%, p < 0.05) than the children in the pulmonary support group. The decannulation rate of children with a laryngotracheal obstruction is high (74.8%), but low in all other subgroups (craniofacial anomalies; 38.5%, cardio-pulmonary diseases; 34.6% and neurological diseases; 52.9%). Significantly more children (36.7%) died in the pulmonary support group due to underlying comorbidity, mainly in the cardio-pulmonary diseases subgroup. Surgery for a persisting tracheocutaneous fistula was performed in 34 (37.8%) children, with a significant relationship between the duration of the tracheostomy and the persistence of a tracheocutaneous fistula. No cannula related death occurred during this study period.

CONCLUSION

Main indications for a tracheostomy were airway obstruction and pulmonary support. Children in the airway obstruction group were younger when receiving a tracheostomy and they were tracheostomy dependent for a longer period. Within the airway obstruction group, the decannulation rate for children with laryngotracheal stenosis was high, but low for children with craniofacial anomalies. In the pulmonary support group, the decannulation rate was low and the mortality rate was high. Surgery for a persisting tracheocutaneous fistula was frequently needed.

Racial Influences on Pediatric Tracheostomy Outcomes

OBJECTIVES/HYPOTHESIS

To determine the impact of race on outcomes after pediatric tracheostomy.

STUDY DESIGN

Retrospective case series.

METHODS

A case series of tracheostomies at an urban, tertiary care children's hospital between 2014 and 2019 was conducted. Children were grouped by race to compare neurocognition, mortality, and decannulation rate.

RESULTS

A total of 445 children with a median age at tracheostomy of 0.46 (interquartile range [IQR]: 0.97) years were studied. The cohort was 32% Hispanic, 31% White, 30% Black, 2.9% Asian, and 4.3% other race. Black compared to White children had a lower median birth weight (2,022 vs. 2,449 g, P = .005), were more often extremely premature (≤28 weeks gestation: 62% vs. 57%, P = .007), and more frequently had bronchopulmonary dysplasia (BPD) (35% vs. 17%, P = .002). Hispanic compared to Black children had higher median birth weight (2,529 g, P < .001), less extreme prematurity (44%, P < .001), and less BPD (21%, P = .04). The proportion of Black children was higher (30% vs. 19%, P < .001), while the proportion of Hispanic children with a tracheostomy was lower (32% vs. 42%, P = .003) compared to the racial distribution of all pediatric admissions. Racial differences were not seen for rates of severe neurocognitive disability (P = .51), decannulation (P = .17), or death (P = .92) after controlling for age, sex, prematurity, and ventilator dependence.

CONCLUSION

Black children disproportionately underwent tracheostomy and had a higher comorbidity burden than White or Hispanic children. Hispanic children had proportionally fewer tracheostomies. Neurocognitive ability, decannulation, and mortality were similar for all races implying that health disparities by race may not change long-term outcomes after pediatric tracheostomy. Laryngoscope, 2021.

Comparing decannulation failures and successes in pediatric tracheostomy: An 18-year experience

OBJECTIVES

There is a paucity of published literature identifying patients at higher risk of decannulation failure. The purpose of this study is to evaluate patient factors that may predict successful decannulation of pediatric tracheostomy patients and analyze factors contributing to tracheostomy decannulation failures.

METHODS

A retrospective chart review of tracheostomy outcomes was conducted at a pediatric referral hospital. Successful and failed decannulations were compared using the following patient variables: age at tracheostomy, sex, ethnicity, gestational age and weight, the primary indication for tracheostomy, comorbidities, age at decannulation attempt, polysomnography data, and status of airway before decannulation as assessed endoscopically by airway team.

RESULTS

Four hundred thirty-nine tracheostomies were performed over the 18-year period with 173 decannulation attempts. The overall rate of successful decannulation on the first attempt was 91.9% (159 of 173), with an eventual decannulation success rate of 97.1% (168 of 173). Compared with failed decannulations, the patients with successful decannulations had a shorter duration of tracheostomy and no medical comorbidities. Gestational age and weight approached, but did not achieve, statistical significance. After 25 months with a tracheostomy, approximately 50% of patients are decannulated with very few decannulations occurring after 75 months. The overall mortality rate in this cohort was 18.6% (78 of 420) with a tracheostomy-related mortality rate of 0.95% (4 of 420).

CONCLUSIONS

The decannulation protocol at this institution is successful nearly 92% of the time. Fewer medical comorbidities, shorter duration of tracheostomy placement, and older gestational age may improve the likelihood of successful decannulation. Future studies are needed to determine the optimal timing and workup to evaluate patients for decannulation.

Decannulation following tracheostomy in children: A systematic review of decannulation protocols

OBJECTIVE

To provide a systematic review of the existing pediatric decannulation protocols, including the role of polysomnography, and their clinical outcomes.

METHODS

Five online databases were searched from database inception to May 29, 2020. Study inclusion was limited to publications that evaluated tracheostomy decannulation in children 18 years of age and younger. Data extracted included patient demographics and primary indication for tracheostomy. Methods used to assess readiness for decannulation were noted including the use of bronchoscopy, tracheostomy tube modifications, and gas exchange measurements. After decannulation, details regarding mode of ventilation, location, and length of observation period, and clinical outcomes were also collected. Descriptive statistical analyses were performed.

RESULTS

A total of 24 studies including 1395 children were reviewed. Tracheostomy indications included upper airway obstruction at a well-defined anatomic site (35%), upper airway obstruction not at a well-defined site (12%) and need for long-term ventilation and pulmonary care (53%). Bronchoscopy was routinely used in 23 of 24 (96%) protocols. Tracheostomy tube modifications in the protocols included capping (n = 20, 83%), downsizing (n = 14, 58%), and fenestrations (n = 2, 8%). Measurements of gas exchange included polysomnography (n = 13/18, 72%), oximetry (n = 10/18, 56%), blood gases (n = 3,17%), and capnography (n = 3, 17%). After decannulation, children in 92% of protocols were transitioned to room air. Observation period of 48 h or less was used in 76% of children.

CONCLUSIONS

There exists large variability in pediatric decannulation protocols. Polysomnography plays an integral role in assessing most children for tracheostomy removal. Evidence-based guidelines to standardize pediatric tracheostomy care remain an urgent priority.

The low value of pre-decannulation capped overnight ICU monitoring for pediatric patients

OBJECTIVE

To determine the value of pre-decannulation capped overnight ICU monitoring for assessing decannulation-readiness in pediatric patients.

METHODS

This study included all pediatric patients, age 18 and under, with a tracheostomy attempting decannulation at the University of Michigan between 2013 and 2018. Patients who underwent major airway reconstruction immediately prior to decannulation were excluded. Descriptive and comparative statistics were calculated to compare the sub-group of patients who underwent pre-decannulation capped overnight ICU monitoring to those who did not.

RESULTS

125 pediatric patients attempted decannulation for a total of 126 attempts with 105 attempts being eligible for inclusion. 75 eligible attempts included pre-decannulation capped overnight ICU monitoring, while 30 did not. Subsequent rates of successful decannulation were 97.33% (73/75) and 100.00% (30/30), respectively (P = 0.366; 95% CI -8.818-9.260). The pre-decannulation capped overnight ICU monitoring passing rate was 98.67% (74/75) despite a complication rate of 5.33% (4/75). Post-decannulation, 98.08% (102/104) of decannulated patients were monitored inpatient for a minimum of 24 h DISCUSSION: With similar rates of successful decannulation among both sub-groups and previous research demonstrating sufficient ambulatory testing accurately predicts successful decannulation, pre-decannulation capped overnight ICU monitoring is a low-value, high-cost test that can be safely discontinued without compromising patient care. Notably, our study excluded patients undergoing open airway reconstruction immediately prior to decannulation. The 24-h monitoring post-decannulation serves as a safety net for individuals who ultimately fail decannulation.

[Modern causes of tracheostomy in children]

The purpose of work is to analyze the causes of tracheostomy in children hospitalized in a large multidisciplinary pediatric hospital.

MATERIAL AND METHODS

Retrospective analysis of case of children treated in a multidisciplinary urgent hospital - GBUZ «Morozovskaya CCCH of MDH», which in the period from 01.01.16 to 31.12.18 was made operation «tracheostomy» was conducted.

RESULTS

Tracheostomy was performed in 138 (0.064%) among 216 469 hospitalized children. Age at the time of tracheostomy ranged from 2 weeks to 17.5 years (on average 67.9±59.84 months, Me=47.5 months), and 36.2% of children had tracheostomy was done on the 1^st year of life. 126 (91.3%) patients required prolonged tracheal intubation prior to tracheostomy placement; the duration of intubation ranged from 1 to 95 days (on average 19.9±13.42 days, Me=14 days). The main reasons of tracheostomy were the need for long-term mechanical ventilation/respiratory support; the need for constant sanitation of the lower respiratory tract with bulbar/pseudobulbar disorders; upper respiratory paths obstruction. The diseases that led to this condition can be grouped into 4 categories: CNS pathology - 76 (55.1%) patients; brain / spinal cord tumors - 36 (26.1%); neurodystrophy and stenosis of the upper respiratory tract of various etiology - 13 (9.4% each) patients. 68.1% of patients were found incurable and required palliative care. Mortality among patients with a known catamnesis was 39.1%, mainly due to progression of the underlying disease; the lethality associated with tracheal cannulation was 1.4%.

CONCLUSION

Currently, pediatric tracheostomy is moving into the category of predominantly planned surgical interventions. More than 2/3 of children requiring tracheostomy are patients in need of palliative care with severe pathology of the central nervous system; in which the main indications for surgery are the need for respiration support and regular tracheobronchial care..

Using Narratives to Correct Forecasting Errors in Pediatric Tracheostomy Decision Making

PURPOSE

Parents who face goals-of-care tracheostomy decisions may lack an understanding of challenges affecting their child's and family's long-term quality of life (QOL) to accurately forecast possible outcomes for decision making. We sought to examine whether and how parents' narratives of the child's and family's long-term QOL influence parental tracheostomy decisions and forecasting.

METHOD

We recruited US adult Amazon Mechanical Turk participants (N = 1966) who self-reported having a child (<6 y old) or planning a pregnancy within 5 y. Participants read a vignette about making a tracheostomy decision for their hypothetical neurologically impaired baby. They were randomized to 1 of the following 4 conditions: 1) Baby QOL narratives, 2) Family QOL narratives, 3) Baby QOL + Family QOL narratives, and 4) control: no narratives. They then made a decision about whether or not to pursue tracheostomy, forecasted their concerns about the baby's and family's QOL, reported their values and social norm beliefs about tracheostomy, comfort care, and parental medical decision making, and completed individual differences scales and demographics.

RESULTS

Controlling for individual characteristics, participants in the Baby QOL and Baby QOL + Family QOL conditions were less likely to choose tracheostomy as compared with the control (odds ratio [OR] = 0.38 and 0.25, respectively, P < 0.001). Fewer participants in the Family QOL condition chose tracheostomy compared with the control, but this difference was not statistically significant (OR = 0.70, P = 0.11). Moreover, narratives increased pessimistic forecasting, which was associated with less interest in tracheostomy.

CONCLUSION

Narratives clarifying long-term implications of pursuing tracheostomy have the potential to influence forecasting and decisions. Narrative-based interventions may be valuable in other situations in which forecasting errors are common.

Tracheocutaneous Fistula After Pediatric Open Airway Reconstruction

OBJECTIVES

Tracheocutaneous fistula (TCF) is a common occurrence after pediatric tracheostomy decannulation. However, the persistence of TCF after staged reconstruction of the pediatric airway is not well-described. The primary objective was to determine the rate of persistent TCF after successful decannulation in children with staged open airway reconstruction.

METHODS

A case series with chart review of children who underwent decannulation after double-stage laryngotracheal reconstruction between 2017 and 2019.

RESULTS

A total of 26 children were included. The most common open airway procedure was anterior and posterior costal cartilage grafting (84.6%, 22/26). Median age at decannulation was 3.4 years (IQR: 2.8-4.3) and occurred 7.0 months (IQR: 4.3-10.4) after airway reconstruction. TCF persisted in 84.6% (22/26) of children while 15.4% (4/26) of stomas closed spontaneously. All closures were identified by the one-month follow-up visit. There was no difference in age at tracheostomy (P = .86), age at decannulation (P = .97), duration of tracheostomy (P = .43), or gestational age (P = .23) between stomas that persisted or closed. Median diameter of stent used at reconstruction was larger in TCFs that persisted (7.0 mm vs 6.5 mm, P = .03). Tracheostomy tube diameter (P = .02) and stent size (P < .01) correlated with persistence of TCF on multivariable logistic regression analysis. There were 16 surgical closure procedures, which occurred at a median of 14.4 months (IQR: 11.4-15.4) after decannulation. Techniques included 56.3% (9/16) by primary closure, 18.8% (3/16) by secondary intention and 25% (4/16) by cartilage tracheoplasty. The overall success of closure was 93.8% (15/16) at latest follow-up.

CONCLUSIONS

Persistent TCF occurs in 85% of children who are successfully decannulated after staged open airway reconstruction. Spontaneous closure could be identified by 1 month after decannulation and was more likely when smaller stents and tracheostomy tubes were utilized. Surgeons should counsel families on the frequency of TCF and the potential for additional procedures needed for closure.

Tracheostomy in the pediatric trisomy 21 population

INTRODUCTION

Tracheostomy in children is often performed to alleviate airway obstruction (AO) or to facilitate long-term ventilator support due to respiratory failure of various etiologies, such as heart failure, and postoperative respiratory failure. Although many of these pathologies are common among trisomy 21 patients, tracheostomy rates among this population have not previously been reported. The aim of our study was to determine the incidence of trisomy 21 patients undergoing tracheostomy. Secondary objectives include decannulation rates and mortality associated with tracheostomy.

MATERIALS AND METHODS

A retrospective cohort study was conducted on pediatric trisomy 21 patients undergoing tracheostomy between 2004 and 2013.

RESULTS

Twenty patients underwent tracheostomy at a median age of 7.1 months (interquartile range [IQR] = 3.5,21.3). The estimated incidence of tracheostomy in trisomy 21 patients among our tracheostomy population was 1.7% (20/1173) over 10 years. The most common indications were airway obstruction (AO) (55%), cardiac/pulmonary respiratory failure (CRF) (25%), or both (20%). Overall mortality was 30%, much lower among AO patients (9%) than CRF (40%) or both (60%), (P = 0.029). Nine patients (45%) were successfully decannulated, with median duration of cannulation of 2.2 years (IQR = 1.7,3).

CONCLUSIONS

This study suggests a rate of tracheostomy in the pediatric trisomy 21 population approximately 3 times that of the general pediatric population. Over half in this cohort underwent tracheostomy for isolated AO, while the general pediatric tracheostomy population demonstrates a much higher prevalence of prematurity-related CRF. Overall mortality rate and decannulation rate approximated that of the general pediatric tracheostomy population, although outcomes were significantly poorer among patients trisomy 21 patients undergoing tracheostomy for CRF.

Tracheostomy in Pediatric Intensive Care Unit-A Two Decades of Experience

Aim and objective

To study the profile, indications, related complications, and predictors of decannulation and mortality in patients who underwent tracheostomy in the pediatric intensive care unit (PICU).

Materials and methods

Retrospective analysis of prospectively collected data of tracheostomies was done on patients admitted at PICU. Demographics, primary diagnosis, indication of tracheostomy, and durations of endotracheal intubation, mechanical ventilation, and tracheostomy cannulation were recorded. The indication was recorded in one of the four categories—upper airway obstruction (UAO), central neurological impairment (CNI), prolonged mechanical ventilation, and peripheral neuromuscular disorders).

Results

Two hundred ninety cases were analyzed. UAO (42%) and CNI (48.2%) were main indications in the halves of the study period, respectively. Decannulation was successful in 188 (64.8%) patients. Seventy-seven percentage UAO patients were decannulated successfully [OR (odds ratio); 95% CI (confidence interval), 2.647; 1.182–5.924, p = 0.018]. Age <1 year (0.378; 0.187–0.764; p = 0.007), nontraumatic, noninfectious central neurological diseases (0.398; 0.186–0.855; p = 0.018), and malignancy (0.078; 0.021–0.298; p <0.001), durations of posttracheostomy ventilation (0.937; 0.893–0.983; p = 0.008), and stay in the PICU (0.989; 0.979–0.999; p = 0.029) were predictors of unsuccessful decannulation. There were 91 (31.4%) deaths. Age <1 year (2.39 (1.13–5.05; p = 0.02), malignancy (17.55; 4.10–75.11; p <0.001), durations of posttracheostomy ventilation (1.06; 1.006–1.10; p = 0.028), and hospital stay (1.007; 1.0–1.013; p = 0.043) were independent predictors of mortality. Indication of UAO favored survivor (0.24; 0.09–0.57; p <0.001).

Conclusion

The indications for tracheostomy in children had changed over the years. Infancy, primary diagnosis, length of posttracheostomy ventilation, and stay in the PICU and hospital were independent predictors of decannulation and mortality.

What This Adds

Similar to developed countries, the age at the time of tracheostomy and indication are changing. Inability to decannulate and mortality were associated with the age of a child at the time of tracheostomy, indication, medical diagnosis, and duration of postprocedure mechanical ventilation and stay in the hospital.

How to cite this article

Sachdev A, Chaudhari ND, Singh BP, Sharma N, Gupta D, Gupta N, et al. Tracheostomy in Pediatric Intensive Care Unit—A Two Decades of Experience. Indian J Crit Care Med 2021;25(7):803–811.

Respiratory, growth, and survival outcomes of infants with tracheostomy and ventilator dependence

BACKGROUND

Outcome of infants with tracheostomy have not been well described in the literature. Our objective was to describe the respiratory, growth, and survival outcomes of infants with tracheostomy.

METHODS

A retrospective study was conducted on 204 infants born between 2005 and 2015 with tracheostomy at <1 year of age and follow-up in the Infant Tracheostomy and Home Ventilator Clinic up to 4 years of age.

RESULTS

The mean age at tracheostomy was 4.5 months with median age of 3 months. Median age of decannulation was 32 months. The time from tracheostomy placement to complete discontinuation of mechanical ventilation was 15.4 months and from tracheostomy to decannulation was 33.8 months. Mortality rate was 21% and median age of death was 18 months. Preterm infants with acquired airway and lung disease (BPD) and born at <28 weeks' gestation had a significantly higher survival rate compared to term infants. The z-scores for weight and weight for length improved from the time of discharge (mean chronological age 6.5 months) to first year and remained consistent through 3 years.

CONCLUSIONS

Premature infants had a higher rate of discontinuation of mechanical ventilation and decannulation compared to term infants. These infants showed consistent growth and comparable survival rate.

IMPACT

Infants with tracheostomy and ventilator dependence followed in a multidisciplinary clinic model may have improved survival, growth, and earlier time to decannulation. Preterm infants with acquired airway and lung disease (BPD) with tracheostomy had a higher survival rate compared to term infants with various tracheostomy indications. The age at tracheostomy in infants was 4.5 months and of decannulation was 37 months. Time from tracheostomy to complete discontinuation of mechanical ventilation was 15.4 months. Addition of this data to the sparse literature will be crucial in counseling the families and education of medical staff.

Mortality and Outcomes of Pediatric Tracheostomy Dependent Patients

Objective: To describe clinical factors associated with mortality and causes of death in tracheostomy-dependent (TD) children. Methods: A retrospective study of patients with a new or established tracheostomy requiring hospitalization at a large tertiary children's hospital between 2009 and 2015 was conducted. Patient groups were developed based on indication for tracheostomy: pulmonary, anatomic/airway obstruction, and neurologic causes. The outcome measures were overall mortality rate, mortality risk factors, and causes of death. Results: A total of 187 patients were identified as TD with complete data available for 164 patients. Primary indications for tracheostomy included pulmonary (40%), anatomic/airway obstruction (36%), and neurologic (24%). The median age at tracheostomy and duration of follow up were 6.6 months (IQR 3.5-19.5 months) and 23.8 months (IQR 9.9-46.7 months), respectively. Overall, 45 (27%) patients died during the study period and the median time to death following tracheostomy was 9.8 months (IQR 6.1-29.7 months). Overall survival at 1- and 5-years following tracheostomy was 83% (95% CI: 76-88%) and 68% (95% CI: 57-76%), respectively. There was no significant difference in mortality based on indication for tracheostomy (p = 0.35), however pulmonary indication for tracheostomy was associated with a shorter time to death (HR: 1.9; 95% CI: 1.04-3.4; p = 0.04). Among the co-morbid medical conditions, children with seizure disorder had higher mortality (p = 0.04). Conclusion: In this study, TD children had a high mortality rate with no significant difference in mortality based on indication for tracheostomy. Pulmonary indication for tracheostomy was associated with a shorter time to death and neurologic indication was associated with lower decannulation rates.

Patient and caregiver experiences at a Multidisciplinary Tracheostomy Clinic

INTRODUCTION

Children with tracheostomy are a heterogeneous population requiring care from multiple specialties. Multidisciplinary approaches to treating such patients helps to improve the quality of care they receive. Our institution established a Multidisciplinary Tracheostomy Clinics (MDTC) to address outpatient care coordination for tracheostomy patients by providing care from multiple disciplines at a single visit. We report patient/caregivers' experiences of our MDTC.

METHODS

Patients with tracheostomy or their caregivers were prospectively recruited between Dec 2017-Oct 2019 to complete surveys assessing their experience at the MDTC. Demographic and satisfaction questionnaires were sent electronically by a REDCap survey distribution tool. Demographic data were collected, such as patient's residence and education level. Medical care variables assessed included history of MDTC attendance, commute time, medical specialties seen, tracheostomy "Go-Bag" use, home-care nursing, and MDTC satisfaction ratings.

RESULTS

Twenty-nine patients/caregivers completed the satisfaction survey and 22 completed both the satisfaction survey and demographics questionnaire. Patient ages ranged from 11 months to 36 years. Twenty-three (79%) participants commuted for up to 2 h to the MDTC, and 6 (21%) commuted for more than 2 h. The median number of medical specialties seen at the MDTC was 3. All participants were satisfied that they saw all requested specialties. Tracheostomy supplies were checked for 25 of 28 patients. Twenty-three of 28 subjects rated staff teamwork as "excellent." Twenty-four of 28 patients were "highly likely" to recommend the MDTC. Twenty-three of 28 participants were "highly likely" to return, and 4 were "somewhat likely" to return.

CONCLUSION

This study demonstrates that patients with tracheostomy and caregivers were satisfied with the improved coordination and facilitation of care through a Multidisciplinary Tracheostomy Clinic.

The Incidence of Pediatric Tracheostomy and Its Association Among Black Children

OBJECTIVE

In 2012, Black or African American children constituted 21% of pediatric tracheostomies while representing approximately 15% of the US population. It is unclear if this discrepancy is due to differences in associated diagnoses. This study aimed to analyze the incidence of pediatric tracheostomy in the United States from 2003 to 2016 and to determine the odds of placement among Black children when compared with other children.

STUDY DESIGN

Retrospective.

SETTING

Academic hospital.

SUBJECTS AND METHODS

We used the 2003 to 2016 Kid Inpatient Database to determine the incidence of pediatric tracheostomy in the United States and determine the odds of tracheostomy placement in Black children when compared with other children.

RESULTS

A total of 26,034 pediatric tracheostomies were performed between 2003 and 2016, among which, 21% were Black children. The median age was 7 years (interquartile range [IQR] = 0 to 17); 43% were ≤2 years old, and 62% were male. The most common principal diagnosis was respiratory failure (72%). When compared with other children, Black children were more likely to undergo tracheostomy (odds ratio [OR] = 1.2; 95% CI, 1.1-1.3), which increased among children younger than 2 years old (OR = 1.5; 95% CI, 1.4-1.5). Black children with tracheostomies were also more likely to be diagnosed with laryngeal stenosis and bronchopulmonary dysplasia and to have an extended length of stay (P < .001).

CONCLUSION

Black children are 1.2 times more likely to undergo tracheostomy in the United States compared with other children. Further investigation is warranted to evaluate if there are underlying anatomical, environmental, or psychosocial factors that contribute to this discrepancy.

Guidelines for Tracheostomy From the Korean Bronchoesophagological Society

The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.

A Longitudinal Analysis of Outcomes in Tracheostomy Placement Among Preterm Infants

OBJECTIVES

To study a case series of preterm and extremely preterm infants, comparing their decannulation and survival rates after tracheostomy.

METHODS

We performed a single-institution longitudinal study of preterm infants with a tracheostomy. Infants were categorized as premature (born > 28 weeks and < 37 weeks) and extremely premature (born ≤ 28 weeks). Decannulation and survival rates were determined using the Kaplan-Meier method. Neurocognitive quality of life (QOL) was reported as normal, mild/moderately, and severely impaired. Statistical significance was set at P < .05.

RESULTS

This study included 240 patients. Of those, 111 were premature and 129 were extremely preterm. The median age (interquartile range) at tracheostomy was 4.8 months (0.4). Premature infants were more likely than extremely preterm to have airway obstruction (54% vs. 32%, P < .001); whereas extremely preterm infants were more likely to have bronchopulmonary dysplasia (68% vs. 15%, P < .001) and to be ventilation-dependent (68% vs. 54%, P < .001). The 5-year decannulation rate for premature infants was 46% and for extremely preterm was 64%. The 5-year survival rate post-tracheostomy for preterm was 79% and for extremely preterm was 73%. The log-rank test of equality showed that decannulation and survival were similar (P > .05) for both groups, even after controlling for potentially confounding factors like race, age, gender, birth weight, and age at tracheostomy. For neurocognitive QOL, 47% of patients survived with severely impaired QOL after tracheostomy. Preterm had 56% with severely impaired QOL and extremely preterm had 40% with severely impaired QOL (P = .03).

CONCLUSION

This study demonstrated that the time to decannulation and the likelihood of survival did not vary among premature and extremely premature infants even when controlling for other confounding variables.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:417-422, 2021.

Investigation of the Paediatric Tracheostomy Decannulation: Factors Affecting Outcome

Introduction:

Evidence for factors determining paediatric tracheostomy decannulation vary extensively; therefore, this prospective observational study aimed to investigate these factors.

Materials and Methods:

In total, 67 consecutive paediatric patients (<12 years old) who referred to the Department of Otolaryngology, (Postgraduate Institute Medical Education and Research),(Chandigarh), India, for decannulation were included and evaluated for contributing factors in this study. Parental counselling was performed, and informed consents were obtained from them. The patients underwent detailed work up including X-rays of airway/soft tissue neck (STN) and endoscopic assessment under anaesthesia for evaluating airway patency. Decannulations were attempted post assessment and followed up one month to classify decannulation as success or failure regarding the removal of the tracheostomy tube.

Results:

Totally, 61 patients out of 67 cases were successfully decannulated, whereas six children failed the decannulation. Moreover, the duration of tracheostomy (Pearson’s Chi-square 35.330, P=0.013), indication of tracheostomy (Pearson’s Chi-square 21.211, P=0.000), STN X-Ray (Chi-square 43.249, P=0.000), and bronchoscopic findings (Chi-square 67.000, P=0.000) were significantly associated with the outcome of decannulation. However, decannulation outcome had no significant correlation with various factors, such as the duration of intubation preceding tracheostomy, duration of ventilation, tracheal swabs, and antibiotic therapy.

Conclusion:

The STN X-ray is an independent predictor, and it is recommended for paediatric tracheostomy decannulation. Moreover, bronchoscopic assessment should be performed in children having doubtful infra-stomal airway. Duration of tracheostomy significantly affects decannulation outcome. However, intubation duration preceding tracheostomy and duration of assistive ventilation have no direct effects on the outcome of decannulation. In children, gradual decannulation should be preferred and one month follow up is adequate for deciding decannulation outcome.

Long-Term Outcomes After Pediatric Tracheostomy-Candidates for and Timing of Decannulation

BACKGROUND

Although pediatric tracheostomy has been a widely performed, life-saving procedure, its long-term outcomes have remained unclear. This study aimed to review outcomes after tracheostomy at a Japanese tertiary hospital and clarify candidates for and timing of decannulation.

MATERIALS AND METHODS

Hospital records of critically ill children who underwent tracheostomy from 2001 to 2014 were retrospectively reviewed, subsequently analyzing outcomes according to demographics, complications, and decannulation. After excluding those who were lost to follow-up or had irreversible neuromuscular impairment, the remaining patients were divided into the decannulation (D group) and nondecannulation (ND group) groups and compared.

RESULTS

In total, 184 patients who underwent tracheostomy were analyzed (median age at operation: 0.5 y). The major indication for tracheostomy was irreversible neuromuscular impairment (46%). Surgery-related and overall mortality rates were 1% and 25%, respectively, while the successful decannulation rate was 21%. No significant difference in surgical indications or comorbidities was observed between the D (n = 39) and ND (n = 50) groups, except for infection (7 in D group versus 0 in ND group; P = 0.002) and chromosome-gene disorder (15% versus 34%; P = 0.04). The ND group had a significantly higher mortality rate than the D group (46% versus 3%; P < 0.0001). The median time to decannulation was 3.6 years, while that for infection was 0.7 y.

CONCLUSIONS

Patients who underwent tracheostomy at our institution due to temporary infections achieved more successful and earlier decannulation compared to other indications. Chromosome-gene disorder as a comorbidity can negatively affect decannulation.

Tracheostomy in Infants in the Neonatal Intensive Care Unit

Approximately half of all pediatric tracheostomies are performed in infants younger than 1 year. Most tracheostomies in patients in the NICU are performed in cases of chronic respiratory failure requiring prolonged mechanical ventilation or upper airway obstruction. With improvements in ventilation and management of long-term intubation, indications for tracheostomy and perioperative management in this population continue to evolve. Evidence-based protocols to guide routine postoperative care, prevent and manage tracheostomy emergencies including accidental decannulation and tube obstruction, and attempt elective decannulation are sparse. Clinician awareness of safe tracheostomy practices and larger, prospective studies in infants are needed to improve clinical care of this vulnerable population.

Tracheostomy in Very Low Birth Weight Infants: A Prospective Multicenter Study

OBJECTIVES

In this study, we benchmark outcomes and identify factors associated with tracheostomy placement in infants of very low birth weight (VLBW).

METHODS

Data were prospectively collected on infants of VLBW (401-1500 g or gestational age of 22-29 weeks) born between 2006 and 2016 and admitted to 796 North American centers. Length of stay (LOS), mortality, associated surgical procedures, and comorbidities were assessed, and infants who received tracheostomy were compared with those who did not. Multivariable logistic regressions were performed to identify risk factors for tracheostomy placement and for mortality in those receiving tracheostomy.

RESULTS

Of 458 624 infants of VLBW studied, 3442 (0.75%) received tracheostomy. Infants with tracheostomy had a median (interquartile range) LOS of 226 (168-304) days and a mortality rate of 18.8%, compared with 58 (39-86) days and 8.3% for infants without tracheostomy. Independent risk factors associated with tracheostomy placement included male sex, birth weight <1001 g, African American non-Hispanic maternal race, chronic lung disease (CLD), intraventricular hemorrhage, patent ductus arteriosus ligation, and congenital neurologic, cardiac, and chromosomal anomalies. Among infants who received tracheostomy, male sex, birth weight <751 g, CLD, and congenital anomalies were independent predictors of mortality.

CONCLUSIONS

Infants of VLBW receiving tracheostomy had twice the risk of mortality and nearly 4 times the initial LOS of those without tracheostomy. CLD and congenital anomalies were the strongest predictors of tracheostomy placement and mortality. These benchmark data on tracheostomy in infants of VLBW should guide discussions with patient families and inform future studies and interventions.

Indications and outcomes of paediatric tracheotomy: a descriptive study using a Japanese claims database

OBJECTIVE

To examine the incidence of and indications for paediatric tracheotomy to clarify the disease burden relevant to tracheotomy in a population-based context.

DESIGN

A descriptive analysis of a retrospective cohort.

SETTING

This study utilised a nationwide claims database in Japan constructed by JMDC (Tokyo, Japan). The database includes claims data for approximately 3.75 million insured persons (approximately 3.1% of the population of Japan) comprising mainly company employees and their family members.

PARTICIPANTS

We identified children registered to have undergone tracheotomy from 2005 to 2017 among about 1.2 million children aged 0-15 years.

MAIN OUTCOME MEASURES

The characteristics of the study population, and indications for tracheotomy, duration of hospital stay, duration of mechanical ventilation, duration of tracheotomy dependence, complications related to tracheotomy and death were assessed. When there were multiple indications, classification for a child into multiple groups was allowed.

RESULTS

The study included 215 children (120 males, 56%). The median age at tracheotomy was 0.8 years. The most common age at tracheotomy was less than 12 months (n=127, 59.1%). The most common indications for tracheotomy were chronic lung disease (n=79, 36.7%), followed by neuromuscular disease (n=77, 35.8%), cardiovascular disease (n=53, 24.3%), upper airway obstruction (n=43, 20%), premature birth and related conditions (n=34, 15.8%), trauma (n=16, 7.4%), prolonged ventilation due to other causes (n=12, 5.6%) and malignancy (n=9, 4.2%). The median duration of tracheotomy dependence was 17.2 months. During the follow-up period, decannulation was achieved in 84 children (39.1%), and the median time from tracheotomy to decannulation was 12.0 months.

CONCLUSIONS

Most paediatric tracheotomies were performed due to chronic underlying diseases, and the mean duration of tracheotomy dependence was nearly 1-½ years. The long-term duration of tracheotomy dependence might have some impacts on patients' physical and mental development and the quality of life.

Epidemiology of Pediatric Tracheostomy and Risk Factors for Poor Outcomes: An 11-Year Single-Center Experience

OBJECTIVE

Children with long-term tracheostomies are at higher risk of complications. This study aims to describe the epidemiology, outcomes, and factors associated with successful decannulation in children undergoing tracheostomy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary hospital.

SUBJECTS AND METHODS

A retrospective analysis was conducted on pediatric tracheostomies performed from 2006 to 2016. Demographics, preexisting comorbidities, indications for tracheostomy, and pretracheostomy ventilatory requirements were collected. A multivariate regression model with covariates of age, failure to thrive (FTT), and comorbidities was used to identify factors associated with successful decannulation. Secondary outcomes were ventilation and oxygen requirements at hospital discharge, hospital and intensive care unit length of stay, and complications.

RESULTS

In total, 105 patients received a tracheostomy at a median age of 8.0 months (interquartile range, 2.0-45.0). The most common indication was anatomic airway obstruction (55 of 105, 52.5%). Forty-four (41.9%) patients had preexisting FTT. In-hospital mortality was 14 of 105 (13.3%). None were directly related to tracheostomy. At discharge, 40 of 91 (44.0%) and 12 of 91 (13.2%) required home mechanical ventilation and supplemental oxygen, respectively. Forty-one (39%) patients underwent successful decannulation at a median 408 days (interquartile range, 170-1153) posttracheostomy. On adjusted analysis, unsuccessful decannulation was more common in patients with FTT and neurologic comorbidities. Postoperative complications were more common in younger patients and those with a longer time to decannulation.

CONCLUSION

Neurologic comorbidities and FTT were risk factors for unsuccessful decannulation after pediatric tracheostomy. Nutritional interventions may have a role in improving long-term outcomes following pediatric tracheostomies and should be investigated in future studies.

Pediatric tracheocutaneous fistula closure following tracheostomy decannulation

OBJECTIVE

To determine the frequency and risk factors that lead to the development of persistent TCF (tracheocutaneous fistula) formation in children following tracheostomy decannulation at our institution.

METHODS

A retrospective chart review of all pediatric patients at Children's Hospital Colorado who underwent tracheostomy decannulation and were being followed between January 1, 2007 and December 31, 2013. TCF was defined as a persistent fistula six months following decannulation. We determined patient demographics, age at tracheotomy, primary indication for tracheotomy, tracheostomy-tube size, medical comorbidities, age at decannulation, date of TCF closure, and method of TCF closure.

RESULTS

One hundred twenty-nine patients ranging from 51 days to 19 years of age underwent tracheostomy decannulation. 63 (49%) patients underwent surgical closure of TCF. Compared to those with spontaneous closure by multivariable analysis, those with surgical closure were younger at tracheostomy placement (p = 0.0002), had a tracheostomy for a longer duration (p = 0.0025), and were diagnosed with tracheobronchomalacia (p = 0.0051). The likelihood of spontaneous closure decreased over time. Tracheostomy tube internal diameter correlated with age (R = 0.64, p < 0.0001).

CONCLUSIONS

Approximately 50% of pediatric tracheostomy stoma sites will close spontaneously. Development of a persistent TCF was associated with younger age at placement, longer duration of tracheostomy, and the presence of tracheobronchomalacia. These observations may help clinicians anticipate outcomes following tracheostomy decannulation in children.

Tracheostomy decision making: From placement to decannulation

Over the last few decades, greater numbers of tracheostomies have been performed in medically complex and fragile children to manage upper airway obstruction, progressive neuromuscular disorders, abnormal ventilatory drive and to facilitate airway clearance. The optimal timing of tracheostomy tube placement and methods to determine suitable patients for the procedure remain unclear. Caring for children with tracheostomies can have a considerable financial and psychosocial impact on a family. Pediatric patients with tracheostomies have a 2-3 fold greater morbidity and mortality compared to adult patients. Clinicians should provide as much clarity as possible for families on the positive and negative aspects of pediatric tracheotomies and long term mechanical ventilation prior to tracheostomy placement. Tracheostomies are often placed as a bridge, whilst time for healing, growth and other therapies are needed to help overcome the indication for tracheostomy. Suitable investigations used to determine the optimal timing of decannulation remain physician and institution dependent.