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Zhao OS, Peterson A, Patel K, Wilcox L. Utility of chest x-ray for tracheostomy tube placement in pediatric patients. Laryngoscope Investig Otolaryngol 2024; 9:e1302. [PMID: 38984073 PMCID: PMC11231926 DOI: 10.1002/lio2.1302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 06/03/2024] [Accepted: 06/23/2024] [Indexed: 07/11/2024] Open
Abstract
Objective To evaluate the utility of ordering chest x-rays after pediatric tracheostomy tube placement in identifying acute, post-operative complications and how it impacts clinical decision-making. Methods In this retrospective cohort study, we identified tracheostomies performed in 139 pediatric patients through CPT codes over a 5-year period from 2013 to 2018. Manual chart review was performed for demographic and clinical characteristics, pre-procedure and post-procedure chest x-ray interpretations, and the presence of complications. Each complication was reviewed to see if action was taken due to post-procedure chest x-ray findings. Multivariable logistic regression was performed to determine associations with changes in pre-procedure versus post-procedure chest x-rays. Results In a cohort of 139 pediatric patients with pre-procedure and post-procedure chest x-rays, 40 (28.8%) of patients had new significant post-procedure chest x-ray findings compared to pre-procedure chest x-ray findings. Of these 40 instances of changes in pre-procedure versus post-procedure chest x-ray findings, only eight resulted in action being taken due to the observed findings. Among these eight instances of action being taken, only one instance involved in invasive action being taken with a bronchoscopy. With multivariable regression analysis, patient age, race, gender, and the presences of genetic syndromes, were not found to be significant risk factors in predicting changes in pre-procedure versus post-procedure chest x-ray. Conclusion In our study, post-procedure chest x-ray after tracheostomy tube placement did not significantly impact clinical decision making. It may be worth reconsidering the value in routine chest x-rays after tracheostomy tube placement in pediatric patients.
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Affiliation(s)
- Oliver S. Zhao
- Department of Otolaryngology: Head and Neck SurgeryVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - April Peterson
- Department of Otolaryngology: Head and Neck SurgeryVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kalpnaben Patel
- Department of Otolaryngology: Head and Neck SurgeryVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Lyndy Wilcox
- Department of Otolaryngology: Head and Neck SurgeryVanderbilt University Medical CenterNashvilleTennesseeUSA
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2
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Perez-Otero S, Cassidy MF, Morrison KA, Brydges HT, Tran D, Muller J, Flores RL, Ceradini DJ. Risk Factors for Acute-Level Hospital Course in Pediatric Craniofacial Fractures. J Craniofac Surg 2024; 35:1483-1487. [PMID: 39042070 DOI: 10.1097/scs.0000000000010164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 07/24/2024] Open
Abstract
PURPOSE The pediatric craniofacial trauma literature is limited to single institutions or short study periods. Herein, this study analyzes a national database over 10 years to delineate the epidemiology of pediatric craniofacial fractures and to identify risk factors for acute-level hospital course in the largest series to date. METHODS Utilizing the National Trauma Data Bank, pediatric craniofacial fractures admitted between 2010 and 2019 were identified. Descriptive analyses and multivariable regression were performed to identify risk factors for acute-level hospital course. RESULTS A total of 155,136 pediatric craniofacial fracture cases were reviewed, including cranial vault (49.0%), nasal (22.4%), midface (21.0%), mandibular (20.2%), and orbital floor fractures (13.7%). Midface and orbital floor fractures occurred commonly as multicraniofacial fractures. Cranial vault fractures were the most common among all age groups, but frequency declined with age. In contrast, facial fractures increased with age. Despite the inherent complexity of multicraniofacial trauma, isolated fractures remained a concern for acute-level hospital course.Cranial vault and midface fractures had an increased risk of intracranial injury and intensive care unit admission (P<0.001). Mandibular and midface fractures had an increased risk for cervical spine fracture and tracheostomy (P<0.001). Patient and injury-specific risk factors among the fractures with the strongest association for each outcome-cranial vault and mandible-were identified. CONCLUSIONS The inherent limitations of prior studies-geographical biases, small cohorts, and short-term study periods-were addressed. Describing the independent contribution of each craniofacial fracture to the risk of acute-level hospital course outcomes can be employed to better optimize risk stratification, counseling, and management.
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Affiliation(s)
- Sofia Perez-Otero
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
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Mitchell DN, Beams DR, Chorney SR, Kou YF, Liu P, Dabbous H, Johnson RF. Neighborhood Socioeconomic Disadvantage and Long-Term Outcomes After Pediatric Tracheostomy. Laryngoscope 2024; 134:2415-2421. [PMID: 37850858 DOI: 10.1002/lary.31117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/15/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
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.
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Affiliation(s)
- Dalia N Mitchell
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Dylan R Beams
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Pamila Liu
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Helene Dabbous
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
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4
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Song IG, Kim YS, Kim MS, Lee JW, Cho YM, Lim Y, Kwon SK, Suh DI, Park JD. Healthcare service use and medical outcomes of tracheostomy-dependent children: a nationwide study. BMJ Paediatr Open 2024; 8:e002377. [PMID: 38508660 PMCID: PMC10952918 DOI: 10.1136/bmjpo-2023-002377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024] Open
Abstract
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.
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Affiliation(s)
- In Gyu Song
- Pediatrics, Yonsei University College of Medicine, Seodaemun-gu, Korea (the Republic of)
| | - You Sun Kim
- Department of Paediatrics, National Medical Center, Jung, Korea (the Republic of)
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Min Sun Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
- Seoul National University Children's Hospital Integrated Care Center, Seoul, Korea (the Republic of)
| | - Ji Weon Lee
- Seoul National University Children's Hospital Integrated Care Center, Seoul, Korea (the Republic of)
| | - Yoon-Min Cho
- National Health Insurance Service, Wonju, Korea (the Republic of)
| | - Youna Lim
- Seoul National University, Gwanak-gu, Korea (the Republic of)
| | - Seong Keun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Dong In Suh
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - June Dong Park
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
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Pearce H, Talks BJ, Powell S, Brodlie M, Powell J. A systematic review of antimicrobial therapy in children with tracheostomies. Pediatr Pulmonol 2024; 59:251-259. [PMID: 38010838 DOI: 10.1002/ppul.26766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/05/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
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.
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Affiliation(s)
- Helen Pearce
- Biosciences Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Benjamin James Talks
- Biosciences Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Malcolm Brodlie
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE1 4LP
- Translational and Clinical Research Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
| | - Jason Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, William Leech Building, Newcastle University, Newcastle Upon Tyne, UK
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Namavarian A, Levy BB, Tepsich M, McKinnon NK, Siu JM, Propst EJ, Wolter NE. Percutaneous tracheostomy in the pediatric population: A systematic review. Int J Pediatr Otorhinolaryngol 2024; 177:111856. [PMID: 38185003 DOI: 10.1016/j.ijporl.2024.111856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/25/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Percutaneous tracheostomy is routinely performed in adult patients but is seldomly used in the pediatric population due to concerns regarding safety and limited available evidence. This study aims to consolidate the current literature on percutaneous tracheostomy in the pediatric population. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted. MEDLINE, EMBASE, CINAHL, and Web of Science were searched for studies on pediatric percutaneous tracheostomy (age ≤18). The Joanna Briggs Institute and ROBINS-I tools were used for quality appraisal. RESULTS Twenty-one articles were included resulting in 143 patients. Patient age ranged from 2 days to 17 years, with the largest subpopulation of patients (n = 57, 40 %) being adolescents (age between 12 and 17 years old). Main indications for percutaneous tracheostomy included prolonged ventilation (n = 6), respiratory insufficiency (n = 5), and upper airway obstruction (n = 5). One-third (n = 47) of percutaneous tracheostomies were completed at the bedside in an intensive care unit. Select studies reported on surgical time and time from intubation to tracheostomy with a mean of 13.8 (SD = 7.8) minutes (n = 27) and 8.9 (SD = 2.8) days (n = 35), respectively. Major postoperative complications included tracheoesophageal fistula (n = 4, 2.8 %) and pneumothorax (n = 3, 2.1 %). There were four conversions to open tracheostomy. CONCLUSION Percutaneous tracheostomy had a similar risk of complications to open surgical tracheostomy in children and adolescents and can be performed at the bedside in a select group of patients if necessary. However, we feel that consideration must be given to the varying anatomical considerations in children and adolescents compared with adults, and therefore suggest that this procedure be reserved for adolescent patients with a thin body habitus and clearly demarcated and palpable anatomical landmarks who require a tracheostomy. When performed, we strongly support using endoscopic guidance and a surgeon who has the ability to convert to an open tracheostomy if required.
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Affiliation(s)
- Amirpouyan Namavarian
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Ben B Levy
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Nicole K McKinnon
- Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada
| | - Jennifer M Siu
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada; Hospital for Sick Children, Toronto, ON, Canada.
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7
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Steuart R, Pan AY, Woolums A, Benscoter D, Russell CJ, Henningfeld J, Thomson J. Respiratory culture growth and 3-years lung health outcomes in children with bronchopulmonary dysplasia and tracheostomies. Pediatr Pulmonol 2024; 59:300-313. [PMID: 37937895 DOI: 10.1002/ppul.26746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/22/2023] [Accepted: 10/25/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND While bacteria identification on respiratory cultures is associated with poor short-term outcomes in children with bronchopulmonary dysplasia (BPD) and tracheostomies, the influence on longer-term respiratory support needs remains unknown. OBJECTIVE To determine if respiratory culture growth of pathogenic organisms is associated with ongoing need for respiratory support, decannulation, and death at 3 years posttracheostomy placement in children with BPD and tracheostomies. METHODS This single center, retrospective cohort study included infants and children with BPD and tracheostomies placed 2010-2018 and ≥1 respiratory culture obtained in 36 months posttracheostomy. Primary predictor was any pathogen identified on respiratory culture. Additional predictors were any Pseudomonas aeruginosa and chronic P. aeruginosa identification. Outcomes included continued use of respiratory support (e.g., oxygen, positive pressure), decannulation, and death at 3 years posttracheostomy. We used Poisson regression models to examine the relationship between respiratory organisms and outcomes, controlling for patient-level covariates and within-patient clustering. RESULTS Among 170 children, 59.4% had a pathogen identified, 28.8% ever had P. aeruginosa, and 3.5% had chronic P. aeruginosa. At 3 years, 33.1% of alive children required ongoing respiratory support and 24.8% achieved decannulation; 18.9% were deceased. In adjusted analysis, any pathogen and P. aeruginosa were not associated with ongoing respiratory support or mortality. However, P. aeruginosa was associated with decreased decannulation probability (adjusted risk ratio 0.48, 95% CI 0.23-0.98). Chronic P. aeruginosa was associated with lower survival probability. CONCLUSION Our findings suggest that respiratory pathogens including P. aeruginosa may not promote long-term respiratory dysfunction, but identification of P. aeruginosa may delay decannulation.
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Affiliation(s)
- Rebecca Steuart
- Section of Special Needs, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Complex Care Program, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Amy Y Pan
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Abigail Woolums
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer Henningfeld
- Department of Pediatrics, Section of Pulmonary Medicine, Milwaukee, Wisconsin, USA
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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8
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Redmann AJ, Hart CK, Smith MM, Martin C, Borschuk AP, Cortezzo DE, Benscoter D. Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation. Pediatr Pulmonol 2024. [PMID: 38165151 DOI: 10.1002/ppul.26839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 11/22/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence. HYPOTHESIS Moral distress will be significant in a dedicated pediatric trach/vent unit. METHODS The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy (MD/DOs), advanced practice practitioners (APPs), registered nurses (RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed. RESULTS Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartile range [IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively). CONCLUSIONS Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs. APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.
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Affiliation(s)
- Andrew J Redmann
- Children's Minnesota, Pediatric ENT and Facial Plastic Surgery, Minneapolis, Minnesota, USA
- Department of Otolaryngology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Catherine K Hart
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew M Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carrie Martin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adrienne P Borschuk
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, Division of Behavioral Medicine and Clinical Psychology, Cincinnati, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - DonnaMaria E Cortezzo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Neonatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pain and Palliative Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut, USA
- Division of Neonatology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
- Division of Pain and Palliative Care, Connecticut Children's Medical Center, Hartford, Connecticut, USA
- Fetal Care Program, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Dan Benscoter
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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9
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Zhang J, Liu P, Narayanan AM, Chorney SR, Kou Y, Johnson RF. Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis. OTO Open 2024; 8:e108. [PMID: 38235054 PMCID: PMC10792475 DOI: 10.1002/oto2.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/19/2024] Open
Abstract
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.
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Affiliation(s)
- Jinghan Zhang
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Palmila Liu
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Ajay M. Narayanan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Stephen R. Chorney
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Children's Health Airway Management ProgramChildren's Medical Center DallasDallasTexasUSA
| | - Yann‐Fuu Kou
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Children's Health Airway Management ProgramChildren's Medical Center DallasDallasTexasUSA
| | - Romaine F. Johnson
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Children's Health Airway Management ProgramChildren's Medical Center DallasDallasTexasUSA
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10
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Bergman M, Harwood J, Liu L, Shontz KM, Chan C, Chiang T. Long-Term Chondrocyte Retention in Partially Decellularized Tracheal Grafts. Otolaryngol Head Neck Surg 2024; 170:239-244. [PMID: 37365963 PMCID: PMC10782834 DOI: 10.1002/ohn.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 05/18/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Decellularized tracheal grafts possess the biological cues necessary for tissue regeneration. However, conventional decellularization approaches to target the removal of all cell populations including chondrocytes lead to a loss of mechanical support. We have created a partially decellularized tracheal graft (PDTG) that preserves donor chondrocytes and the mechanical properties of the trachea. In this study, we measured PDTG chondrocyte retention with a murine microsurgical model. STUDY DESIGN Murine in vivo time-point study. SETTING Research Institute affiliated with Tertiary Pediatric Hospital. METHODS PDTG was created using a sodium dodecyl sulfate protocol. Partially decellularized and syngeneic grafts were orthotopically implanted into female C57BL/6J mice. Grafts were recovered at 1, 3, and 6 months postimplant. Pre- and postimplant grafts were processed and analyzed via quantitative immunofluorescence. Chondrocytes (SOX9+, DAPI+) present in the host and graft cartilage was evaluated using ImageJ. RESULTS Partial decellularization resulted in the maintenance of gross tracheal architecture with the removal of epithelial and submucosal structures on histology. All grafts demonstrated SOX9+ chondrocytes throughout the study time points. Chondrocytes in PDTG were lower at 6 months compared to preimplant and syngeneic controls. CONCLUSION PDTG retained donor graft chondrocytes at all time points. However, PDTG exhibits a reduction in chondrocytes at 6 months. The impact of these histologic changes on cartilage extracellular matrix regeneration and repair remains unclear.
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Affiliation(s)
- Maxwell Bergman
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University Medical Center, Columbus, Ohio, USA
- Department of Pediatric Otolaryngology, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Jacqueline Harwood
- Department of Pediatric Otolaryngology, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Lumei Liu
- Center for Regenerative Medicine, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Kimberly M. Shontz
- Center for Regenerative Medicine, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Coreena Chan
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Tendy Chiang
- Department of Pediatric Otolaryngology, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Center for Regenerative Medicine, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
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11
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Liu P, Brooks RL, Bailey CH, Whitney C, Sewell A, Brown AF, Kou YF, Johnson RF, Chorney SR. Survival After Declining Pediatric Tracheostomy Placement. Laryngoscope 2023; 133:3602-3607. [PMID: 37096735 DOI: 10.1002/lary.30712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE To determine survival among critically ill children when caregivers decline tracheostomy placement. STUDY DESIGN Retrospective cohort. METHODS All children (<18 years) obtaining a pre-tracheostomy consultation at a tertiary children's hospital between 2016 and 2021 were included. Comorbidities and mortality were compared between children of caregivers that declined or agreed to tracheostomy. RESULTS Tracheostomy was declined for 58 children but was placed for 203 children. After consultation, mortality was 52% (30/58) when declining and 21% (42/230) when agreeing to tracheostomy (p < 0.001) at a mean of 10.7 months (standard deviation [SD]: 16) and 18.1 months (SD: 17.1), respectively (p = 0.07). For those declining, 31% (18/58) died during the hospitalization within a mean of 1.2 months (SD: 1.4) while 21% (12/58) died at a mean of 23.6 months (SD: 17.5) after discharge. Among children of caregivers declining tracheostomy, older age (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.74-0.97, p = 0.01) and chronic lung disease (OR: 0.18, 95% CI: 0.04-0.82, P = .03) were associated with lower odds of mortality but sepsis (OR: 9.62, 95% CI: 1.161-57.43, p = 0.01) and intubation (OR: 4.98, 95% CI: 1.24-20.08, p = 0.02) were associated with higher odds of mortality. Median survival after declining tracheostomy was 31.9 months (interquartile range [IQR]: 2.0-50.7) and declining placement was associated with increased mortality risk (hazard ratio [HR]: 4.04, 95% CI: 2.49-6.55, p < 0.001). CONCLUSION When caregivers declined tracheostomy placement, less than half of critically ill children in this cohort survived with younger age, sepsis, and intubation associated with higher mortality. This information offers valuable insight for families weighing decisions pertaining to pediatric tracheostomy placement. LEVEL OF EVIDENCE 3 Laryngoscope, 133:3602-3607, 2023.
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Affiliation(s)
- Palmila Liu
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rebecca L Brooks
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Candice H Bailey
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Cindy Whitney
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Ashley Sewell
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Ashley F Brown
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
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12
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Rosi-Schumacher M, Nagy R, Favre N, DiNardo L, Carr MM. Financial Toxicity for Caregivers of Pediatric Patients With Long-Term Tracheostomies. Ann Otol Rhinol Laryngol 2023; 132:1503-1510. [PMID: 37081797 DOI: 10.1177/00034894231168200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
OBJECTIVE To assess financial toxicity experienced by caregivers of children with long-term tracheostomies. METHODS Cross-sectional survey study with comparison group conducted at a tertiary pediatric hospital and outpatient clinic. Pediatric (<18 years) patients with tracheostomies for ≥12 months were recruited for the study. Patients who underwent tympanostomy tube placement or adenotonsillectomy were recruited as controls. Eligible patients' caregivers were contacted to fill out a questionnaire including the validated Comprehensive Score for Financial Toxicity survey. RESULTS Surveys were completed for 72 patients, including 31 in the study group (mean age, 6.58 years, 95% confidence interval [CI], 4.85-8.30 years) and 41 controls (mean age, 6.42 years, 95% CI, 5.15-10.52 years) (P = .864). The mean duration of tracheostomy was 3.98 years (95% CI, 2.91-5.05 years). The mean household income and education level were lower in the study group than in the control group. Caregivers of the study group were more likely to have public health insurance or be uninsured. Caregivers of study patients reported greater financial toxicity, with a lower mean Comprehensive Score for Financial Toxicity (18.23 [95% CI, 15.20-21.25]) than caregivers of controls (34.27 [95% CI, 32.05-36.49]; P < .001). Linear regression analysis showed that survey scores were lower for caregivers who employed home nursing care (P < .001). CONCLUSION Caregivers of pediatric patients requiring long-term tracheostomies experience greater financial toxicity than caregivers of pediatric patients who have typical otolaryngologic surgery.
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Affiliation(s)
- Mattie Rosi-Schumacher
- Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Ryan Nagy
- Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Nicole Favre
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Lauren DiNardo
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Michele M Carr
- Department of Otolaryngology-Head and Neck Surgery, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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13
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Liu P, Teplitzky TB, Kou YF, Johnson RF, Chorney SR. Long-Term Outcomes of Tracheostomy-Dependent Children. Otolaryngol Head Neck Surg 2023; 169:1639-1646. [PMID: 37264977 DOI: 10.1002/ohn.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 03/29/2023] [Accepted: 05/13/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To estimate the 1-, 5-, and 10-year survival and decannulation rates of children with a tracheostomy. STUDY DESIGN Ambidirectional cohort. SETTING Tertiary children's hospital. METHODS All patients (<18 years) that had a tracheostomy placed between 2009 and 2020 were included and followed until 21 years of age, decannulation, or death. The Kaplan-Meier method estimated cumulative probabilities of death and decannulation. RESULTS A total of 551 children underwent tracheostomy at a median age of 7.2 months (interquartile range [IQR]: 3.8-49.2). Children were followed for a median of 2.1 years (IQR: 0.7-4.2, range 0-11.5). The cumulative probability of mortality at 1 year was 11.9% (95% confidence interval [CI]: 9.4-15.1), at 5 years was 26.1% (95% CI: 21.6-31.3), and at 10 years was 41.6% (95% CI: 32.7-51.8). Ventilator dependence at index discharge (hazard ratio [HR]: 2.04, 95% CI: 1.10-3.81, p = .03), severe neurologic disability (HR: 2.79, 95% CI: 1.61-4.84, p < .001), and cardiac disease (HR: 1.69, 95% CI: 1.08-2.65, p = .02) were associated with time to death. The cumulative probability of decannulation was 10.4% (95% CI: 8.0-13.5), 44.9% (95% CI: 39.4-50.9), and 54.1% (95% CI: 47.4-61.1) at 1 year, 5 years, and 10 years, respectively. Ventilator dependence (HR: 0.43, 95% CI: 0.31-0.60, p < .001), severe neurologic disability (HR: 0.20, 95% CI: 0.14-0.30, p < .001), and tracheostomy indicated for respiratory failure (HR: 0.68, 95% CI: 0.48-0.96, p = .03) correlated with longer decannulation times. CONCLUSION After tracheostomy, estimated mortality approaches 42% by 10 years and decannulation approaches 54%. Children with ventilator support at discharge and severe neurological disability had poorer long-term survival and longer times to decannulation.
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Affiliation(s)
- Palmila Liu
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Taylor B Teplitzky
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
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14
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Bhende VV, Sharma TS, Krishnakumar M, Kumar A, Panesar G, Soni KA, Dhami KB, Patel MR, Sharma AS, Pathan SR, Majmudar HP. Hemi-Diaphragm Plication and/or Tracheostomy Are Valuable Adjunctive Procedures After Repair of Congenital Heart Defects in Children: A Systematic Review. Cureus 2023; 15:e48648. [PMID: 37954631 PMCID: PMC10638678 DOI: 10.7759/cureus.48648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 11/14/2023] Open
Abstract
Diaphragmatic paralysis (DP), whether unilateral or bilateral, often leads to extended recovery and more severe complications, particularly in neonates and infants undergoing congenital heart surgery. This condition's impact is most pronounced after single-ventricle palliative procedures. Tracheostomy prevalence is rising in pediatric patients with congenital heart disease (CHD) despite its association with high resource utilization and in-hospital mortality. This study examines the reported incidence of diaphragmatic paralysis and timing of tracheostomy in pediatric patients undergoing surgery for congenital heart disease in the literature and a retrospective analysis of cases in our institution between 2018 and 2023, offering insights for prospective management. An electronic search of PubMed databases retrieved 10 studies on pediatric tracheostomy and 11 studies on DP. Our retrospective analysis included 15 patients, of whom 10 underwent tracheostomy, four underwent diaphragmatic plication, and one underwent both. Postoperative tracheostomy had an 11.8% mortality rate in our systematic review, rising to 40% in our observational study. Diaphragm repair and early diagnosis can reduce morbidity, prevent complications, and improve patients' quality of life.
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Affiliation(s)
- Vishal V Bhende
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Tanishq S Sharma
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
- Community Medicine, SAL Institute of Medical Sciences, Ahmedabad, IND
| | | | - Amit Kumar
- Pediatric Cardiac Intensive Care, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Gurpreet Panesar
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Kunal A Soni
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Kartik B Dhami
- Cardiac Anaesthesiology, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Mamta R Patel
- Central Research Services, Bhaikaka University, Karamsad, IND
| | - Ashwin S Sharma
- Internal Medicine, Gujarat Cancer Society Medical College, Hospital and Research Centre, Ahmedabad, IND
| | - Sohilkhan R Pathan
- Clinical Research Services, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
| | - Hardil P Majmudar
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Shree Krishna Hospital, Bhaikaka University, Karamsad, IND
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15
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Powell J, Powell S, Mather MW, Beck L, Nelson A, Palmowski P, Porter A, Coxhead J, Hedley A, Scott J, Rostron AJ, Hellyer TP, Zaidi F, Davey T, Garnett JP, Agbeko R, Ward C, Stewart CJ, Taggart CC, Brodlie M, Simpson AJ. Tracheostomy in children is associated with neutrophilic airway inflammation. Thorax 2023; 78:1019-1027. [PMID: 36808087 PMCID: PMC10511973 DOI: 10.1136/thorax-2022-219557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/29/2022] [Indexed: 02/22/2023]
Abstract
BACKGROUND Tracheostomies in children are associated with significant morbidity, poor quality of life, excess healthcare costs and excess mortality. The underlying mechanisms facilitating adverse respiratory outcomes in tracheostomised children are poorly understood. We aimed to characterise airway host defence in tracheostomised children using serial molecular analyses. METHODS Tracheal aspirates, tracheal cytology brushings and nasal swabs were prospectively collected from children with a tracheostomy and controls. Transcriptomic, proteomic and metabolomic methods were applied to characterise the impact of tracheostomy on host immune response and the airway microbiome. RESULTS Children followed up serially from the time of tracheostomy up to 3 months postprocedure (n=9) were studied. A further cohort of children with a long-term tracheostomy were also enrolled (n=24). Controls (n=13) comprised children without a tracheostomy undergoing bronchoscopy. Long-term tracheostomy was associated with airway neutrophilic inflammation, superoxide production and evidence of proteolysis when compared with controls. Reduced airway microbial diversity was established pre-tracheostomy and sustained thereafter. CONCLUSIONS Long-term childhood tracheostomy is associated with a inflammatory tracheal phenotype characterised by neutrophilic inflammation and the ongoing presence of potential respiratory pathogens. These findings suggest neutrophil recruitment and activation as potential exploratory targets in seeking to prevent recurrent airway complications in this vulnerable group of patients.
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Affiliation(s)
- Jason Powell
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Michael W Mather
- Department of Paediatric Otolaryngology, Great North Children's Hospital, Newcastle upon Tyne, UK
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lauren Beck
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Nelson
- Department of Applied Science, Northumbria University, Newcastle upon Tyne, UK
| | - Pawel Palmowski
- Protein and Proteome Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Porter
- Protein and Proteome Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathan Coxhead
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Hedley
- Bioinformatics Support Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fatima Zaidi
- Discovery and Translational Science, Metabolon, Morrisville, North Carolina, USA
| | - Tracey Davey
- Electron Microscopy Research Services, Newcastle University, Newcastle upon Tyne, UK
| | - James P Garnett
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel Agbeko
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Intensive Care, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Chris Ward
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher J Stewart
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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16
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Miller AN, Shepherd EG, Manning A, Shamim H, Chiang T, El-Ferzli G, Nelin LD. Tracheostomy in Severe Bronchopulmonary Dysplasia-How to Decide in the Absence of Evidence. Biomedicines 2023; 11:2572. [PMID: 37761012 PMCID: PMC10526913 DOI: 10.3390/biomedicines11092572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Infants with the most severe forms of bronchopulmonary dysplasia (BPD) may require long-term invasive positive pressure ventilation for survival, therefore necessitating tracheostomy. Although life-saving, tracheostomy has also been associated with high mortality, postoperative complications, high readmission rates, neurodevelopmental impairment, and significant caregiver burden, making it a highly complex and challenging decision. However, for some infants tracheostomy may be necessary for survival and the only way to facilitate a timely and safe transition home. The specific indications for tracheostomy and the timing of the procedure in infants with severe BPD are currently unknown. Hence, centers and clinicians display broad variations in practice with regard to tracheostomy, which presents barriers to designing evidence-generating studies and establishing a consensus approach. As the incidence of severe BPD continues to rise, the question remains, how do we decide on tracheostomy to provide optimal outcomes for these patients?
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Affiliation(s)
- Audrey N. Miller
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
| | - Edward G. Shepherd
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
| | - Amy Manning
- Department of Otolaryngology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.M.); (H.S.); (T.C.)
| | - Humra Shamim
- Department of Otolaryngology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.M.); (H.S.); (T.C.)
| | - Tendy Chiang
- Department of Otolaryngology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.M.); (H.S.); (T.C.)
| | - George El-Ferzli
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
| | - Leif D. Nelin
- Comprehensive Center for Bronchopulmonary Dysplasia, Department of Pediatrics, Division of Neonatology, Nationwide Children’s Hospital, Ohio State University College of Medicine, Columbus, OH 43205, USA; (A.N.M.); (E.G.S.); (G.E.-F.)
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17
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Batool S, Burks CA, Bergmark RW. Healthcare Disparities in Otolaryngology. CURRENT OTORHINOLARYNGOLOGY REPORTS 2023; 11:1-14. [PMID: 37362031 PMCID: PMC10247342 DOI: 10.1007/s40136-023-00459-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review The purpose of this review is to summarize some of the recent research studies on healthcare disparities across various subspecialties within otolaryngology. This review also highlights the impact of COVID-19 pandemic on disparities and proposes potential interventions to mitigate disparities. Recent Findings Significant healthcare disparities in care and treatment outcomes have been reported across all areas of otolaryngology. Notable differences in survival, disease recurrence, and overall mortality have been noted based on race, ethnicity, socioeconomic status (SES), insurance status, etc. This is most well-researched in head and neck cancer (HNC) within otolaryngology. Summary Healthcare disparities have been identified by numerous research studies within otolaryngology for many vulnerable groups that include racial and ethnic minority groups, low-income populations, and individuals from rural areas among many others. These populations continue to experience suboptimal access to timely, quality otolaryngologic care that exacerbate disparities in health outcomes.
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Affiliation(s)
- Sana Batool
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Ciersten A. Burks
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, USA
| | - Regan W. Bergmark
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, USA
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women’s Hospital and Dana Farber Cancer Institute, 45 Francis Street, Boston, MA 02115 USA
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18
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Killien EY, Grassia KL, Butler EK, Mooney SJ, Watson RS, Vavilala MS, Rivara FP. Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers. J Trauma Acute Care Surg 2023; 94:615-623. [PMID: 36730091 PMCID: PMC10038845 DOI: 10.1097/ta.0000000000003848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults. METHODS We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care. RESULTS Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]). CONCLUSION Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kalee L. Grassia
- Department of Pediatric Critical Care Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Surgery, University of Montreal, Montreal, Quebec, Canada
| | - Stephen J. Mooney
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
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19
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Salik I, Das A, Naftchi AF, Vazquez S, Spirollari E, Dominguez JF, Sukul V, Stewart D, Moscatello A. Effect of tracheostomy timing in pediatric patients with traumatic brain injury. Int J Pediatr Otorhinolaryngol 2023; 164:111414. [PMID: 36527981 DOI: 10.1016/j.ijporl.2022.111414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Irim Salik
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, 10595, USA.
| | - Ankita Das
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | | | - Sima Vazquez
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Eris Spirollari
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Vishad Sukul
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Dylan Stewart
- Department of Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Augustine Moscatello
- Department of Otolaryngology/Head and Neck Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
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20
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Fadil A, Rose A, Snead WM, Kronlage RM, Collins WO, Schrepfer T. Impact of intraoperative wound dressing on post-tracheostomy pressure injuries. Int J Pediatr Otorhinolaryngol 2023; 164:111408. [PMID: 36549017 DOI: 10.1016/j.ijporl.2022.111408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/22/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Determine the efficacy of a team-based approach to reduce tracheostomy-related skin breakdown by creating a standardized intraoperative dressing and nursing wound care protocol. METHODS Prospective data collection of pediatric tracheostomy outcomes before and after interventions consisting of intraoperative wound dressing and standardized nursing wound care bundles. RESULTS Before intervention, the incidence of skin breakdown within the first-week post-tracheostomy was 52% (13/25). Among patients who received an intraoperative wound dressing and nursing wound care bundles, the incidence of skin breakdown was reduced to 6.1% (3/49). CONCLUSION The adoption of intraoperative wound dressings and nursing wound care bundles has nearly eliminated the incidence of skin breakdown in the first week post-tracheostomy among patients 0-12 years of age.
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Affiliation(s)
- Angela Fadil
- University of Florida College of Medicine, Division of Pediatric Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Anita Rose
- University of Florida Shands Childrens Hospital, Department of Medicine, Gainesville, FL, USA
| | - William M Snead
- University of Florida College of Medicine, Division of Pediatric Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - René M Kronlage
- University of Florida College of Medicine, Division of Pediatric Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - William O Collins
- University of Florida College of Medicine, Division of Pediatric Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Thomas Schrepfer
- University of Florida College of Medicine, Division of Pediatric Otolaryngology, University of Florida College of Medicine, Gainesville, FL, USA.
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21
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Wynings EM, Chorney SR, Brooks RL, Brown AF, Sewell A, Bailey CH, Whitney C, Kou YF, Johnson RF. Caregiver quality of life after pediatric tracheostomy. Int J Pediatr Otorhinolaryngol 2023; 164:111416. [PMID: 36525698 DOI: 10.1016/j.ijporl.2022.111416] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/06/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine the impact of a child with a tracheostomy on caregiver quality of life. METHODS A repeated cross-sectional analysis included families with tracheostomy-dependent children between 2019 and 2021. Caregivers were surveyed using the PedsQL™ Family Impact Module with assessments at tracheostomy placement and during ambulatory office visits. RESULTS Two-hundred and fifty-five surveys were performed with 66 at tracheostomy placement (26%) and 189 at follow-up visits (74%). Compared to families with healthy children, total scores at placement (77.2 vs. 87.6, P < .001) and follow-up visits (78.9 vs. 87.6, P < .001) were significantly lower among pediatric tracheostomy families. Caregivers were likely to report significant improvement in emotional functioning (6.2 points; 95% CI: 0.5-12, P = .03) and worry (9 points, 95% CI: 2.1-15.9, P = .01) over time. Demographic variables demonstrated no confounding or interactive effects. CONCLUSIONS The presence of a tracheostomy is associated with lower caregiver quality of life scores in the short- and long-term compared to caregivers of healthy children. Providers should be sensitive to these challenges and provide appropriate support for families of tracheostomy-dependent children.
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Affiliation(s)
- Erin M Wynings
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA.
| | - Rebecca L Brooks
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA
| | - Ashley F Brown
- Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA
| | - Ashley Sewell
- Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA
| | - Candice H Bailey
- Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA
| | - Cindy Whitney
- Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, TX, USA
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22
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Van Horn A, Kim HM, Helman J, Valora H, Epperson M, Fayson S, Brown D, Zopf D. Reduction in inpatient readmissions following implementation of a dedicated tracheostomy care team. Int J Pediatr Otorhinolaryngol 2022; 162:111282. [PMID: 36037673 DOI: 10.1016/j.ijporl.2022.111282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Adam Van Horn
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA.
| | - Hyungjin Myra Kim
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Helman
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Henry Valora
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Madison Epperson
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Shannon Fayson
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David Brown
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David Zopf
- Department of Otolaryngology - Head & Neck Surgery, University of Michigan, Ann Arbor, MI, USA
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23
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Boonjindasup W, Syananondh K, Somboon P, Sritippayawan S. Pediatric Home Tracheostomy Care: The Importance of Knowledge Assessment. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223211061718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Assessment of caregiver knowledge is an essential part of home healthcare education for pediatric tracheostomy care, however, there is a paucity of evidence in long term. This study aims to determine how caregiver knowledge and misconceptions, as assessed by our knowledge test, changed over a 12-month period following our educational program and whether the test score was associated with any demographics of the caregivers and children with tracheostomy. A prospective cohort study was undertaken to evaluate the knowledge at 3 timepoints after tracheostomy education: baseline (T1), 6 months (T2), and 12 months (T3). Test scores were analyzed for trend and relationship with demographics. Items for which less than 80% caregivers gave correct responses at T1 were considered common misconceptions. Fifty-four caregivers were enrolled. Out of a maximum score of 25, the median (IQR) scores were 22 (21-23), 23 (22-24), and 23 (22-25), at T1, T2, and T3, respectively. The scores at T2 and T3 were significantly higher than at T1 ( P ≤ .01). One common misconception “how to manage when suction got less secretion than expected” was found at all timepoints. Caregivers of children with >2 comorbidities scored slightly higher than those of children with 0 to 2 comorbidities ( P = .01). In conclusion, our caregivers achieved high knowledge scores which increased over the 12-month study period potentially because of repeated assessment and practical experience. Common misconceptions and a factor associated with the knowledge were also identified. These advantages highlighted the importance of knowledge assessment for quality improvement.
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24
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Serio P, Fainardi V, Coletta R, Grasso A, Baggi R, Rufini P, Avenali S, Ricci Z, Morabito A, Trabalzini F. Conservative management of posterior tracheal wall injury by endoscopic stent placement in children: Preliminary data of three cases. Int J Pediatr Otorhinolaryngol 2022; 159:111214. [PMID: 35759914 DOI: 10.1016/j.ijporl.2022.111214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/17/2022] [Accepted: 06/18/2022] [Indexed: 11/26/2022]
Abstract
The management of tracheal wall lacerations is debated. Current treatments are mainly derived by the experience on adults and include conservative or surgical treatments depending on the clinical condition of the patient. We report our preliminary data with removable tracheal stents in 3 children with tracheal tears and respiratory failure. If performed in specialized centers with appropriate endoscopic and clinical follow-up, airway stents can be considered a valid and safe conservative treatment for tracheal tears and an alternative to intubation or tracheostomy. Further studies are needed to compare different therapeutic options and better define the management and duration of stent treatment.
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Affiliation(s)
- P Serio
- Department of Paediatric Anaesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy.
| | - V Fainardi
- Department of Medicine and Surgery, Cystic Fibrosis Unit, University of Parma, Italy
| | - R Coletta
- Department of Paediatric Surgery, Meyer Children Hospital, University of Florence, Florence, Italy
| | - A Grasso
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - R Baggi
- Respiratory Endoscopy Unit, Meyer Children Hospital, Florence, Italy
| | - P Rufini
- Department of Paediatric Anaesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy
| | - S Avenali
- Respiratory Endoscopy Unit, Meyer Children Hospital, Florence, Italy
| | - Z Ricci
- Department of Paediatric Anaesthesia and Intensive Care, Meyer Children Hospital, Florence, Italy
| | - A Morabito
- Department of Paediatric Surgery, Meyer Children Hospital, University of Florence, Florence, Italy
| | - F Trabalzini
- Department of Otolaryngology, Meyer Children Hospital, Florence, Italy
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25
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Powell J, Keltie K, Sims A, Richardson H, Brodlie M, Powell S. National Cohort Study of Health Care Resource Use After Pediatric Tracheostomy. JAMA Pediatr 2022; 176:817-819. [PMID: 35575906 PMCID: PMC9112134 DOI: 10.1001/jamapediatrics.2022.1069] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cohort study uses Hospital Episode Statistics admission data to evaluate hospital resource use and associated costs for pediatric tracheostomy.
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Affiliation(s)
- Jason Powell
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kim Keltie
- Northern Medical Physics and Clinical Engineering, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew Sims
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hayley Richardson
- Clinical Coding, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Steven Powell
- Department of Paediatric Otolaryngology, Great North Children’s Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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26
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Efficiency and usability of an elementary hand-held suction assembly in paediatric tracheostomised patients. The Journal of Laryngology & Otology 2022; 136:1077-1080. [DOI: 10.1017/s0022215121004552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective
Commercially available suction devices are expensive, large and heavy, and need electricity, and thus restrict the outdoor activity of tracheostomised children and their carers. This study evaluated the efficacy and usability of a simple suction assembly using a syringe and feeding tube in paediatric tracheostomised patients.
Methods
Following the domiciliary usage of this suction assembly instead of their existing suction device for a minimum of 15 days, carers responded to a set of questionnaires containing a subjective scoring system.
Results
Ninety-three per cent of the carers considered this assembly as average, good or very good in cleaning the tracheostomy tube. Eighty per cent of the carers considered that this assembly would be suitable when their existing suction machines are unavailable, indicating high usability, and 66.67 per cent of the carers would be confident using this assembly in outdoor settings.
Conclusion
Larger studies with objective evaluation methods can validate the high efficacy of this simple, inexpensive and easy-to-use, hand-held suction apparatus as reported by the carers of 15 paediatric tracheostomised patients in this study.
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27
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Gursoy TR, Eyuboglu TS, Aslan AT, Pekcan S, Buyukkaya EZ, Hangul M, Kose M, Budakoglu II, Soysal S. The associations between the clinical course of children with tracheostomy and their mothers' depression, burnout, burden, and self-esteem. J Clin Nurs 2022. [PMID: 35818330 DOI: 10.1111/jocn.16450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/16/2022] [Accepted: 06/27/2022] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study was to evaluate the clinical features of children with tracheostomy and the predictors of psychological status of their primary caregivers in order to determine the associations between the children's clinical course with their caregivers' psychological status. BACKGROUND The caregivers of children with tracheostomy are responsible for providing basic tracheostomy care at home. All these responsibilities may be associated with significant changes in family members' lifestyles, daily routines and family dynamics. DESIGN This study is a cross sectional study. METHODS Data of the family's socioeconomic status and clinical status of children with tracheostomy were noted in four paediatric pulmonology centers. The Beck Depression Inventory, Maslach Burnout Inventory, Zarit Caregiver Burden Scale, and Rosenberg Self-esteem Scale were used for psychological measurements of the caregivers. The STROBE checklist was used for this study. RESULTS Eighty-five children and their primary caregivers were enrolled in the study. The children's median age was 4.1 years. Thirty-eight of them were dependent on home ventilators. Twenty-one had bacterial colonisation. All children's primary caregivers were their mothers. Beck Depression Inventory scores of mothers of children with colonisation were higher. Number of hospitalizations in previous 6 months was related to mothers' emotional exhaustion and depersonalization scores. Duration of children's hospitalizations in previous 6 months was positively correlated to mothers' emotional exhaustion, depersonalization, and Beck Depression Inventory scores. CONCLUSIONS Mothers of children with tracheostomy may experience psychological conditions, such as high levels of depression, burnout, burden and low levels of self-esteem. Frequent and long-term hospitalizations of children correlated with mother's depression and burnout. Therefore, primary caregivers should be evaluated and supported psychologically. RELEVANCE TO CLINICAL PRACTICE Preventing mothers of children with tracheostomy from experiencing psychological conditions such as depression, burnout, burden and low self-esteem can also increase the quality of care for children.
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Affiliation(s)
- Tugba Ramasli Gursoy
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey.,Department of Pediatric Pulmonology, University of Health Sciences, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | | | - Ayse Tana Aslan
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sevgi Pekcan
- Department of Pediatric Pulmonology, Necmettin Erbakan University Meram Medicine Faculty, Konya, Turkey
| | - Eda Zeynep Buyukkaya
- Department of Pediatrics, Necmettin Erbakan University Meram Medicine Faculty, Konya, Turkey
| | - Melih Hangul
- Department of Pediatric Pulmonology, Erciyes University Faculty of Medicine, Kayseri, Turkey.,Department of Pediatric Pulmonology, Cengiz Gokcek Maternity and Children's Hospital, Gaziantep, Turkey
| | - Mehmet Kose
- Department of Pediatric Pulmonology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Isıl Irem Budakoglu
- Department of Medical Education, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Sebnem Soysal
- Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
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28
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Shi JY, Orkin J, Walsh CM, Chu S, Keilty K, McKay S, Mocanu C, Qazi A, Ambreen M, Amin R. Pediatric Chronic Tracheostomy Care: An Evaluation of an Innovative Competency-Based Education Program for Community Health Care Providers. Front Pediatr 2022; 10:885405. [PMID: 35757113 PMCID: PMC9220937 DOI: 10.3389/fped.2022.885405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/05/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the immediate and sustained knowledge retention and sense of self-efficacy of homecare nurses following completion of a standardized competency-based tracheostomy education course. Safe discharge of children requiring tracheostomy with or without ventilation relies on the competence of homecare nurses. Study Design Pragmatic, randomized controlled trial of 44 homecare nurses. Participants were randomized into the intervention group (n = 21), which received the tracheostomy course, or the control group (n = 23), which received an enterostomy and vascular access course. Multiple-choice question (MCQ) knowledge assessments and self-efficacy questionnaires were administered to both groups pre-course and post-course at 6 week, 3 month, 6 month, and 12 month follow-ups. Results Twenty participants in the intervention group and 19 in the control group were included. Four withdrew from the study and two crossed over from the control into the intervention arm. The change in mean self-efficacy scores (total score = 100) was significantly higher in the intervention group than in the control group at 6 weeks (intervention (mean ± SD): 18.6 ± 14.5; control: 6.6 ± 20.4; p = 0.04) and 3 months (intervention: 19.6 ± 14.2; control: 5.2 ± 17.0; p = 0.007), and trended higher at 6 months (intervention: 18.0 ± 14.5; control: 6.9 ± 24.1; p = 0.1). The change in mean MCQ assessment scores (total score = 20) trended higher in the intervention group than in the control group at 6 weeks (intervention (mean ± SD): 1.8 ± 2.2; control: 1.6, ± 2.9; p = 0.8). Conclusions Homecare nurses who attended the tracheostomy course demonstrated a higher sense of self-efficacy at long-term follow-up. Clinical Trial Registration www.ClinicalTrials.gov, identifier: NCT04559932.
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Affiliation(s)
- Jenny Y. Shi
- Paediatric Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Julia Orkin
- Complex Care Program, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Catharine M. Walsh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics and the SickKids Research and Learning Institutes, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Stephanie Chu
- Connected Care, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Krista Keilty
- Connected Care, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Cora Mocanu
- Paediatric Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Adam Qazi
- Paediatric Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Munazzah Ambreen
- Paediatric Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Reshma Amin
- Paediatric Respiratory Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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29
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Kohne JG, MacLaren G, Rider E, Carr B, Mallory P, Gebremariam A, Friedman M, Barbaro RP. Tracheostomy Practices and Outcomes in Children During Respiratory Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2022; 23:268-276. [PMID: 35081085 PMCID: PMC9197266 DOI: 10.1097/pcc.0000000000002902] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Children receiving prolonged extracorporeal membrane oxygenation (ECMO) support may benefit from tracheostomy during ECMO by facilitating rehabilitation; however, the procedure carries risks, especially hemorrhagic complications. Knowledge of tracheostomy practices and outcomes of ECMO-supported children who undergo tracheostomy on ECMO may inform decision-making. DESIGN Retrospective cohort study. SETTING ECMO centers contributing to the Extracorporeal Life Support Organization registry. PATIENTS Children from birth to 18 years who received ECMO support for greater than or equal to 7 days for respiratory failure from January 1, 2015, to December 31, 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three thousand six hundred eighty-five children received at least 7 days of ECMO support for respiratory failure. The median duration of ECMO support was 13.0 days (interquartile range [IQR], 9.3-19.9 d), and inhospital mortality was 38.7% (1,426/3,685). A tracheostomy was placed during ECMO support in 94/3,685 (2.6%). Of those who received a tracheostomy on ECMO, the procedure was performed at a median 13.2 days (IQR, 6.3-25.9 d) after initiation of ECMO. Surgical site bleeding was documented in 26% of children who received a tracheostomy (12% after tracheostomy placement). Among children who received a tracheostomy, the median duration of ECMO support was 24.2 days (IQR, 13.0-58.7 d); inhospital mortality was 30/94 (32%). Those that received a tracheostomy before 14 days on ECMO were older (median age, 15.8 yr [IQR, 4.7-15.5] vs 11.7 yr [IQR, 11.5-17.3 yr]; p =0.002) and more likely to have been supported on venovenous-ECMO (84% vs 52%; p = 0.001). Twenty-two percent (11/50) of those who received a tracheostomy before 14 days died in the hospital, compared with 19/44 (43%) of those who received a tracheostomy at 14 days or later (p = 0.03). CONCLUSIONS Tracheostomies during ECMO were uncommon in children. One in four patients who received a tracheostomy on ECMO had surgical site bleeding. Children who had tracheostomies placed after 14 days were younger and had worse outcomes, potentially representing tracheostomy as a "secondary" strategy for prolonged ECMO support.
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Affiliation(s)
- Joseph G. Kohne
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
- Pediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, Australia
| | - Erica Rider
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
| | | | | | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | - Ryan P Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
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Phuaksaman C, Niyomkarn W, Somboon P, Boonjindasup W, Hantragool S, Sritippayawan S. Long-term Outcomes of Pediatric Tracheostomy Home Care in a Limited Resource Setting of Professional Home Nurse. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223221082661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Long-term outcomes of pediatric patients with a tracheostomy in developing countries where professional home nurse is not accessible has rarely been reported. We, therefore, investigated the prevalence and associating factors of long-term outcomes in these children. Retrospective chart review was conducted in 85 tracheostomized children who were discharged to home during January 2012 to December 2020. Tracheostomy home care was provided by caregivers who completed the tracheostomy home care program. Prevalence of unplanned readmission with acute respiratory problems within 30 days after the first hospital discharge was 17.6%. Lower respiratory tract infection (LRTI) after hospital discharge was found in 72.9% (median frequency of 1.0 episode/case/year). Among 80 children who had surveillance airway endoscopy, 46.3% demonstrated late tracheostomy-related airway complications. Independent factor associated with late tracheostomy-related airway complications was a follow-up period longer than 1 year. Decannulation success was found in 21.2%. Most of them had tracheostomy for their upper airway anomalies. The mortality rate was 7%. Most of them died from their underlying diseases. In conclusion, pediatric tracheostomy home care undertaken by caregivers is feasible in developing countries where home nurse is not available. The prevalence of unplanned readmission with acute respiratory problems within 30 days after hospital discharge and late tracheostomy-related airway complications were comparable with those reported in developed countries. However, we still had a high prevalence of post-tracheostomy LRTI which was a challenging problem that needed to be investigated and resolved.
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Mian MUM, Kennedy C, Fogarty T, Naeem B, Lam F, Coss-Bu J, Arikan AA, Nguyen T, Bashir D, Virk M, Harpavat S, Raynor T, Rana AA, Goss J, Leung D, Desai MS. The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single-center experience. Pediatr Transplant 2022; 26:e14140. [PMID: 34523781 DOI: 10.1111/petr.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/07/2021] [Accepted: 09/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Children with end-stage liver disease and multi-organ failure, previously considered as poor surgical candidates, can now benefit from liver transplantation (LT). They often need prolonged mechanical ventilation (MV) post-LT and may need tracheostomy to advance care. Data on tracheostomy after pediatric LT are lacking. METHOD Retrospective chart review of children who required tracheostomy in the peri-LT period in a large, freestanding quaternary children's hospital from 2014 to 2019. RESULTS Out of 205 total orthotopic LTs performed in 200 children, 18 (9%) required tracheostomy in the peri-transplant period: 4 (2%) pre-LT and 14 (7%) post-LT. Among those 14 needing tracheostomy post-LT, median age was 9 months [IQR = 7, 14] at LT and 10 months [9, 17] at tracheostomy. Nine (64%) were infants and 12 (85%) were cirrhotic at the time of LT. Seven (50%) were intubated before LT. Median MV days prior to LT was 23 [7, 36]. Eight (57%) patients received perioperative continuous renal replacement therapy (CRRT). The median MV days from LT to tracheostomy was 46 [33, 56]; total MV days from initial intubation to tracheostomy was 57 [37, 66]. Four (28%) children died, of which 3 (21%) died within 1 year of transplant. Total ICU and hospital length of stay were 92 days [I72, 126] and 177 days [115, 212] respectively. Among survivors, 3/10 (30%) required MV at home and 8/10 (80%) were successfully decannulated at 400 median days [283, 584]. CONCLUSION Tracheostomy though rare after LT remains a feasible option to support and rehabilitate critically ill children who need prolonged MV in the peri-LT period.
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Affiliation(s)
- Muhammad Umair M Mian
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Curtis Kennedy
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Thomas Fogarty
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Buria Naeem
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fong Lam
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jorge Coss-Bu
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ayse A Arikan
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Trung Nguyen
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dalia Bashir
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Manpreet Virk
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sanjiv Harpavat
- Department of Pediatrics, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Tiffany Raynor
- Department of Surgery, Division of Pediatric Otolaryngology, Baylor College of Medicine, Houston, TX, USA
| | - Abbas A Rana
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX, USA
| | - John Goss
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Leung
- Department of Pediatrics, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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Yilmaz Yegit C, Kilinc AA, Can Oksay S, Unal F, Yazan H, Köstereli E, Gulieva A, Arslan H, Uzuner S, Onay ZR, Kilic Baskan A, Collak A, Atag E, Ergenekon AP, Bas Ikizoğlu N, Ay P, Oktem S, Gokdemir Y, Girit S, Cakir E, Uyan ZS, Cokugras H, Karadag B, Karakoc F, Erdem Eralp E. The ISPAT project: Implementation of a standardized training program for caregivers of children with tracheostomy. Pediatr Pulmonol 2022; 57:176-184. [PMID: 34562057 DOI: 10.1002/ppul.25704] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/15/2021] [Accepted: 09/15/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Tracheostomy-related morbidity and mortality mainly occur due to decannulation, misplacement, or obstruction of the tube. A standardized training can improve the skills and confidence of the caregivers in tracheostomy care (TC). OBJECTIVE Our primary aim was to evaluate the efficiency of standardized training program on the knowledge and skills (changing-suctioning the tracheostomy tube) of the participants regarding TC. MATERIALS AND METHODS Sixty-five caregivers of children with tracheostomy were included. First, participants were evaluated with written test about TC and participated in the practical tests. Then, they were asked to participate in a standardized training session, including theoretical and practical parts. Baseline and postintervention assessments were compared through written and practical tests conducted on the same day. RESULTS A significant improvement was observed in the written test score after the training. The median number of correct answers of the written test including 23 questions increased 26%, from 12 to 18 (p < .001). The median number of correct steps in tracheostomy tube change (from 9 to 16 correct steps out of 16 steps, 44% increase) and suctioning the tracheostomy tube (from 9 to 17 correct steps out of 18 steps, 44% increase) also improved significantly after the training (p < .001, for both). CONCLUSION Theoretical courses and practical hands-on-training (HOT) courses are highly effective in improving the practices in TC. A standardized training program including HOT should be implemented before discharge from the hospital. Still there is a need to assess the impact of the program on tracheostomy-related complications, morbidity, and mortality in the long term.
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Affiliation(s)
- Cansu Yilmaz Yegit
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Ayse Ayzit Kilinc
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Sinem Can Oksay
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Fusun Unal
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Hakan Yazan
- Division of Pediatric Pulmonology, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Ebru Köstereli
- Division of Pediatric Pulmonology, Koc University, School of Medicine, Istanbul, Turkey
| | - Aynur Gulieva
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Hüseyin Arslan
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Selçuk Uzuner
- Division of Pediatrics, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Zeynep Reyhan Onay
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Azer Kilic Baskan
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Abdulhamit Collak
- Division of Pediatrics, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Emine Atag
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Almala Pinar Ergenekon
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Nilay Bas Ikizoğlu
- Division of Pediatric Pulmonology, Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital
| | - Pinar Ay
- Division of Public Health, Marmara University, School of Medicine, Istanbul, Turkey
| | - Sedat Oktem
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Yasemin Gokdemir
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Saniye Girit
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Erkan Cakir
- Division of Pediatric Pulmonology, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Zeynep Seda Uyan
- Division of Pediatric Pulmonology, Koc University, School of Medicine, Istanbul, Turkey
| | - Haluk Cokugras
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Bulent Karadag
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Fazilet Karakoc
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Ela Erdem Eralp
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
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Racial disparities in pediatric otolaryngology: current state and future hope. Curr Opin Otolaryngol Head Neck Surg 2021; 29:492-503. [PMID: 34710068 DOI: 10.1097/moo.0000000000000759] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current article reviews the current literature and selected sentinel papers on health disparities particularly relevant to the field of pediatric otolaryngology. The discussion will explore racial disparities in otologic and airway intervention areas, as well as general adenotonsillar disease management. Access to and quality of care will be examined, and disparate outcomes discussed. RECENT FINDINGS Growing published data demonstrate children from nonwhite backgrounds receive disparate specialty care in representative fields of pediatric otolaryngology. SUMMARY Racial disparities exist in specialty care pediatric otolaryngology. Such disparities should be viewed in the light of generational inequalities in the United States and the foundational inequities that perpetuate them. Parity in the delivery of such specialty care depends on recognizing our current state and intentional efforts to modulate the impact of such effectual factors.
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Pettitt-Schieber B, Mahendran G, Tey CS, Prickett KK. Risk factors for return visits in children discharged with tracheostomy. Int J Pediatr Otorhinolaryngol 2021; 150:110860. [PMID: 34403974 DOI: 10.1016/j.ijporl.2021.110860] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/11/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVES To determine associations between demographic and clinical characteristics and rate of unplanned returns to system (RTS) in pediatric patients discharged with tracheostomy. METHODS Medical records were examined for pediatric patients discharged after tracheostomy placement between January 1, 2011 and December 31, 2015. Exclusion criteria included death or decannulation prior to discharge and lack of follow-up through 180 days post-discharge. Readmissions were grouped by time interval after discharge (within 30 days or within 31-180 days). Chi-squared analysis and Fisher's Exact Test were utilized to determine associations between patient characteristics, rate and frequency of RTS, and type of admission (Emergency Department [ED] or inpatient [IP]). RESULTS One hundred twenty-one patients were eligible for the study, and 80 (66.1 %) had an unanticipated RTS during the follow-up period. Patients with early RTS had a higher total number of RTS. Patients with two or more RTS were more likely to be younger, while patients with five or more RTS were more likely to have greater organ system involvement and cardiovascular (CV) disease in particular. Patients presenting with GI diagnoses were more likely to be discharged from the ED. The rate of RTS remained constant throughout the time period examined. CONCLUSION Pediatric patients discharged with tracheostomy are medically complex and at high risk of RTS, especially for respiratory and GI problems. This risk does not decrease after the initial post-discharge period and long-term follow-up is warranted. Younger patients and patients with history of early RTS are at highest risk for repeat RTS and should be identified for closer outpatient care.
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Affiliation(s)
| | | | - Ching Siong Tey
- School of Medicine, Department of Pediatrics, Emory University, USA
| | - Kara K Prickett
- School of Medicine, Department of Pediatrics, Emory University, USA; School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Emory University, USA.
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35
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Powell J, Buckley HL, Agbeko R, Brodlie M, Powell S. Tracheostomy trends in paediatric intensive care. Arch Dis Child 2021; 106:712-714. [PMID: 33023889 DOI: 10.1136/archdischild-2020-319396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/28/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
Paediatric tracheostomy is most commonly performed in children on the paediatric intensive care unit (PICU) to facilitate long-term ventilation. We sought to identify trends in UK tracheostomy practice in PICUs. Data were analysed from 250 261 admissions, including 4409 children tracheostomised between 2003 and 2017. The incidence of tracheostomy in 2017 was approximately half that in 2003 (incidence rate ratio=0.48, 95% CI 0.40 to 0.57). The percentage of patients tracheostomised during a PICU admission, as a proportion of all admissions, was 2.44% (n=319) in 2003 and reduced to 0.97% (n=180) in 2017. Nevertheless, we identified great variability in practice between different PICUs with tracheostomy rates between 0.0% and 4.0% of all admissions. Risk-adjusted PICU mortality was comparable between tracheostomised children and all admissions to PICU.
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Affiliation(s)
- Jason Powell
- Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK .,Paediatric Otolaryngology, Great North Children's Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Hannah L Buckley
- Paediatric Intensive Care Audit Network, University of Leeds, Leeds, West Yorkshire, UK
| | - Rachel Agbeko
- Paediatric Intensive Care, Great North Children's Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Malcolm Brodlie
- Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK.,Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Steven Powell
- Paediatric Otolaryngology, Great North Children's Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
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Abstract
Over the last few decades, tracheostomy has been increasingly performed in children with various complex and chronic conditions. We have seen a dramatic change in indications for tracheostomy in pediatric patients due to better survival of premature infants and those suffering from severe congenital anomalies. There is no consensus about the timing of tracheostomy in pediatric patients. Although percutaneous tracheostomy has become the standard of care for adults, there is not sufficient evidence to start performing it routinely in pediatric patients. The indications, preoperative considerations, and different procedures for tracheostomy in children are reviewed. Surgical tracheostomy is described step by step placing an emphasis on safety measures to minimize complications. There is also a great variability in tracheostomy care protocols in the literature. Post-operative tracheostomy care is discussed for the early and late post-operative periods. There is no general consensus on decannulation protocols, but prevailing expert opinion is presented. There is growing evidence in support for an interdisciplinary approach to pediatric tracheostomized patients. The focus of this paper is the review of the literature regarding safety improvement strategies from the surgical and post-operative point of view.
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Affiliation(s)
- Alvaro E Pacheco
- Department of Otolaryngology, Hospital Dr. Luis Calvo Mackenna, Clínica Universidad de Los Andes, Santiago, Chile.
| | - Eduardo Leopold
- Division of Pediatric Surgery Pediatric Airway and Chest Wall Center Hospital de Niños Luis Calvo Mackenna University of Chile Santiago, Chile.
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37
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Tarfa RA, Morris J, Melder KL, McCoy JL, Tobey ABJ. Readmissions and mortality in pediatric tracheostomy patients: Are we doing enough? Int J Pediatr Otorhinolaryngol 2021; 145:110704. [PMID: 33882340 DOI: 10.1016/j.ijporl.2021.110704] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/29/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Pediatric patients who undergo tracheostomy tube placement are medically complex with a high risk of morbidity and mortality. They are often premature with multiple cardiopulmonary comorbidities. This study reviews the demographics and outcomes within this population to identify at-risk patient groups at our hospital. METHODS A retrospective chart review of those with pediatric tracheostomy placement from 2015 to 2016 at our hospital was performed (n = 92). Demographic and post-discharge data were collected at 30, 60, and 90-days during the global period. RESULTS Ventilator dependence was the most common reason for placement. 79.3% of patients had two or more major comorbidities. 44% had an emergency department (ED) visit and subsequent hospital admission within the first 90 days post-discharge, with 36% being trach/respiratory-related. The 90-day mortality was 19.6%; however, at the time of chart review, mortality was 35% with only 1 (1.1%) being from trach-related complications. Patients with longer admissions were more likely to die prior to discharge, p = .001. Lastly, patients who died were 3 times more likely to have > 25% no-shows to their outpatient appointments compared to those living throughout the study period. CONCLUSION Our population had a high incidence of ED visits, readmission rates, and mortality; however, trach-related causes remained low. Mortality risk increased with more no-show appointments and residing a further distance from our hospital. Furthermore, multiple co-morbidities, with longer hospital stays also increased risk of mortality. Identifying those with the highest risk for complications will enable us to target families for increased home-care education to decrease readmissions and mortality. LEVEL OF EVIDENCE 4.
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Affiliation(s)
| | | | - Katie L Melder
- University of Pittsburgh Medical Center, Department of Otolaryngology, USA
| | - Jennifer L McCoy
- UPMC Children's Hospital of Pittsburgh, Division of Pediatric Otolaryngology, USA
| | - Allison B J Tobey
- University of Pittsburgh Medical Center, Department of Otolaryngology, USA; UPMC Children's Hospital of Pittsburgh, Division of Pediatric Otolaryngology, USA.
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Baddour K, Mady LJ, Schwarzbach HL, Sabik LM, Thomas TH, McCoy JL, Tobey A. Exploring caregiver burden and financial toxicity in caregivers of tracheostomy-dependent children. Int J Pediatr Otorhinolaryngol 2021; 145:110713. [PMID: 33882339 DOI: 10.1016/j.ijporl.2021.110713] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Measure the prevalence of and factors associated with financial toxicity (FT) and caregiver burden in families of tracheostomy-dependent children. FT is defined as the objective and subjective patient-level impact of the costs of medical care and has been associated with lower quality of life, decreased compliance with treatment, and increased mortality. METHODS A medical record review was performed on all children with a tracheostomy tube placed from 2009 to 2018 at a tertiary children's hospital to identify and include children younger than 18 years old, not deceased, and not decannulated at the time of review. Eligible children's caregivers were contacted to fill out a 36-item questionnaire and three validated instruments: The Comprehensive Score for Financial Toxicity (COST) and the Financial Distress Questionnaire (FDQ), both addressed to the parent/primary caregiver, and the Burden Scale for Family Caregivers - short version (BSFC-s). RESULTS Of the 140 eligible tracheostomy patients identified, 45 caregivers (32.1%) returned the survey. The average COST score was 18 ± 1.7 with 73.3% of caregivers reporting high toxicity based on FDQ, and 75.6% having severe-to-very severe caregiver burden. Significant increase in FT was seen in households where an adult had to leave a paid position (p = 0.047) or work less (p = 0.002) because of their child's condition; or needed to omit some of the child's medical services or medications due to cost-prohibitive reasons (p<0.001). Financial toxicity was associated with caregiver burden (by BSFC-s) [r = -596; beta coefficient = -0.95, t(43) = -4.87, p<0.001] and financial distress (by FDQ; p<0.001). CONCLUSION Caregivers of children with medically complex, tracheostomy-dependent conditions suffer from FT and caregiver burden. As a result, harmful financial coping mechanisms such as missing necessary care components or forgoing prescribed treatments, may be adopted for cost-prohibitive reasons.
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Affiliation(s)
- Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Hannah L Schwarzbach
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Teresa H Thomas
- Department of Health Promotion and Development, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jennifer L McCoy
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allison Tobey
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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39
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Liao K, Chorney SR, Brown AB, Brooks RL, Sewell A, Bailey C, Whitney C, Johnson RF. The Impact of Socioeconomic Disadvantage on Pediatric Tracheostomy Outcomes. Laryngoscope 2021; 131:2603-2609. [PMID: 33860942 DOI: 10.1002/lary.29576] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/15/2021] [Accepted: 04/07/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine if socioeconomic disadvantage impacts perioperative outcomes after tracheostomy. METHODS We performed a retrospective case series of children who underwent tracheostomy. Children were divided into less and more disadvantaged groups based on their community's Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure. Primary outcomes were the length of stay, total cost, in-hospital mortality, and 30-day all-cause readmission after tracheostomy placement. Length of stay was further analyzed using parametric survival analysis. RESULTS A total of 239 patients met inclusion criteria, with 153 (64%) residing in more disadvantaged communities. Children from more disadvantaged communities were less likely to be White (42% vs. 26%, P = .009) and more likely to have Medicaid coverage (90% vs. 62%, P < .001). The two groups had similar medical complexity and comorbidities. The main outcome measures showed differences in median total length of stay (113 vs. 79 days, P = .04) and median total cost ($461 000 vs. $279 000, P = .01). Children with tracheostomies who were from more disadvantaged communities also had increased risk of prolonged hospitalizations (HR = 0.63, 95% CI = 0.48-0.83, P = .001). Readmissions, mortality rates, and quality of life scores were similar between groups. CONCLUSIONS Community disadvantage was associated with differences in hospitalization length and costs after pediatric tracheostomy placement. Further research should continue to describe how health disparities impact children's safe and efficient care with tracheostomies. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Kershena Liao
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Ashley B Brown
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Rebecca L Brooks
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Ashley Sewell
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Candice Bailey
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Cindy Whitney
- Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Children's Medical Center of Dallas, Dallas, Texas, U.S.A
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40
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Update on Pediatric Tracheostomy: Indications, Technique, Education, and Decannulation. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021; 9:188-199. [PMID: 33875932 PMCID: PMC8047564 DOI: 10.1007/s40136-021-00340-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 12/23/2022]
Abstract
Purpose of Review Tracheostomy in a child demands critical pre-operative evaluation, deliberate family education, competent surgical technique, and multidisciplinary post-operative care. The goals of pediatric tracheostomy are to establish a safe airway, optimize ventilation, and expedite discharge. Herein we provide an update regarding timing, surgical technique, complications, and decannulation, focusing on a longitudinal approach to pediatric tracheostomy care. Recent Findings Pediatric tracheostomy is performed in approximately 0.2% of inpatient stays among tertiary pediatric hospitals. Mortality in children with tracheostomies ranges from 10–20% due to significant comorbidities in this population. Tracheostomy-specific mortality and complications are now rare. Recent global initiatives have aimed to optimize decision-making, lower surgical costs, reduce the length of intensive care, and eliminate perioperative wound complications. The safest road to tracheostomy decannulation in children remains to be both patient and provider dependent. Summary Recent literature provides guidance on safe, uncomplicated, and long-term tracheostomy care in children. Further research is needed to help standardize decannulation protocols.
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Neunhoeffer F, Miarka-Mauthe C, Harnischmacher C, Engel J, Renk H, Michel J, Hofbeck M, Hanser A, Kumpf M. Severe adverse events in children with tracheostomy and home mechanical ventilation - Comparison of pediatric home care and a specialized pediatric nursing care facility. Respir Med 2021; 191:106392. [PMID: 33865662 DOI: 10.1016/j.rmed.2021.106392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advances in medical care and ventilator technologies increase the number of children with tracheostomy and home mechanical ventilation (HMV). Data on severe adverse events in home care and in specialized nursing care facilities are limited. PATIENTS AND METHODS Retrospective analysis of incidence and type of severe adverse events in children with tracheostomy and HMV in home care compared to a specialized nursing care facility over a 7-year period. RESULTS 163.9 patient-years in 70 children (home care: 110.7 patient-years, 24 patients; nursing care facility: 53.2 patient-years, 46 patients) were analyzed. In 34 (48.6%) patients tracheostomy was initiated at the age of <1 year. 35 severe adverse events were identified, incidence of severe adverse events per patient-year was 0.21 (median 0.0 (0.0-3.0)). We observed no difference in the rate of severe adverse events between home care and specialized nursing care facility (0.21 [y-1]; median 0.0 (0.0-3.0) versus 0.23 [y-1]; median 0.0 (0.0-1.6); p = 0.690), however, significantly more tracheostomy related incidents and infections occurred in the home care setting. Young age (<1 year) (Odds ratio 3.27; p = 0.045) and feeding difficulties (nasogastric tubes and percutaneous endoscopic gastrostomy) (Odds ratio 9.08; p = 0.016) significantly increased the risk of severe adverse events. Furthermore, the rate of severe adverse events was significantly higher in patients with a higher nursing score. CONCLUSION Pediatric home mechanical ventilation via tracheostomy is rarely associated with emergencies or adverse events in home care as well as in a specialized nursing care facility setting.
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Affiliation(s)
- Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany.
| | - Christiane Miarka-Mauthe
- Arche IntensivKinder, Specialized Pediatric Nursing Care Facility, Bergstr. 36, 72127, Kusterdingen, Germany
| | - Cornelia Harnischmacher
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Juliane Engel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Hanna Renk
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Anja Hanser
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
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Koenigs MB, Behzadpour HK, Zalzal GH, Preciado DA. Barriers to Decannulation After Double-Stage Laryngotracheal Reconstruction. Laryngoscope 2021; 131:2141-2147. [PMID: 33635575 DOI: 10.1002/lary.29486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES/HYPOTHESIS To identify any potential barriers for decannulation in children undergoing double-staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself. STUDY DESIGN Case series with chart review. METHODS We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR. RESULTS Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log-rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log-rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log-rank), and race/ethnicity (P = .001 Log-rank). CONCLUSION In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2141-2147, 2021.
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Affiliation(s)
- Maria B Koenigs
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Hengameh K Behzadpour
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - George H Zalzal
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Diego A Preciado
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
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Salley JR, Kou YF, Shah GB, Johnson RF. Comparing Long-Term Outcomes in Tracheostomy Placed in the First Year of Life. Laryngoscope 2021; 131:2115-2120. [PMID: 33567156 DOI: 10.1002/lary.29440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES//HYPOTHESIS To characterize long-term outcomes in pediatric patients requiring tracheotomy in the first year of life. STUDY DESIGN Retrospective case series. METHODS A retrospective longitudinal registry of tracheostomy patients was queried for patients who underwent tracheotomy from birth to 11 months. Primary outcomes were decannulation and survival. Secondary outcomes included neurocognitive quality of life assessed with the PedsQL Family Impact Module (scored from worst to best, 0 to 100 points). RESULTS The study included 337 children. Thirty (8.90%) were neonates and 307 (91.10%) were infants. The population was 56.08% male (n = 189), and the racial and ethnicity composition were equally distributed (29.97% White, 31.45% Black, and 31.16% Hispanic). Significant differences between neonates and postneonates included birth weight in grams (2,731.40 vs. 1,950.44, P < .05), extreme prematurity (13.33% vs. 38.88%, P = .01), upper airway obstruction (80.00% vs. 42.67%, P < .05), and the need for mechanical ventilation (40.00% vs. 83.71%, P < .05). Despite these differences, long-term outcomes were similar: decannulation (X2 = 2.19, P = .14), death (X2 = 2.63, P = .11), and neurocognitive quality of life (X2 = 2.63, P = .27). Having a child with a tracheostomy caused the most problems with being physically tired (mean = 75.32 ± 3.90), emotional frustration (mean = 77.31 ± 5.05), and worry (mean standard deviation = 74.23 ± 6.48). CONCLUSION There were demographic differences between neonatal and infantile tracheostomy patients, but they did not affect long-term outcomes. The presence of a tracheostomy caused a significant impact on a family's quality of life. LEVEL OF EVIDENCE 3 Laryngoscope, 131:2115-2120, 2021.
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Affiliation(s)
- Jordan R Salley
- Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Yann-Fuu Kou
- Department of Pediatric Otolaryngology, Cincinnati Children's Hospital, Cincinnati, Ohio, U.S.A
| | - Gopi B Shah
- Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Medical Center, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children's Medical Center, Dallas, Texas, U.S.A
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Smith MM, Hart CK, Benscoter DT, Epperson M, de Alarcon A, Born H, Meinzen-Derr J. The Impact of Socioeconomic Status on Time to Decannulation Among Children With Tracheostomies. Otolaryngol Head Neck Surg 2021; 165:876-880. [PMID: 33528307 DOI: 10.1177/0194599820988501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine if time to tracheostomy decannulation differs among children by socioeconomic status. STUDY DESIGN Case series with chart review. SETTING Tertiary pediatric medical center. METHODS Patients (≤21 years old) who underwent tracheostomy from January 1, 2011, to December 31, 2016. Patients were divided into 2 groups based on their socioeconomic status (SES), low SES and high SES. Principal components analysis was used to create an index for SES using census data obtained by the US Census Bureau's American Community Survey 5 year data profile from 2013 to 2017. Statistical analysis was performed using a χ2 for categorical variables and Wilcoxon rank-sum test for continuous variables. A general linear model was constructed to control for clinical factors to understand the independent effect of SES on time to decannulation. RESULTS In total, 215 patients were included; of these patients, 111 patients (52%) were included in the high-SES group and 104 patients (48%) were included in the low-SES group. There was a significant difference in the time to decannulation for children based on SES status, with those children in the low-SES group taking on average 10 months longer to decannulate (38.7 vs 28.0 months, P = .0007). Median follow-up was 44.1 months (interquartile range, 29.6-61.3 months). CONCLUSION Health care disparities appear to exist among children undergoing decannulation of their tracheostomy tube. Patients with lower SES had a significantly longer time to decannulation than those with higher SES.
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Affiliation(s)
- Matthew M Smith
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Catherine K Hart
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dan T Benscoter
- Cincinnati Children's Hospital Medical Center, Division of Pulmonary Medicine, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Madison Epperson
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alessandro de Alarcon
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Hayley Born
- Cincinnati Children's Hospital Medical Center, Division of Pediatric Otolaryngology-Head and Neck Surgery, Cincinnati, Ohio, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jareen Meinzen-Derr
- Cincinnati Children's Hospital Medical Center, Division of Biostatistics and Epidemiology, Cincinnati, Ohio, USA
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Davidson C, Jacob B, Brown A, Brooks R, Bailey C, Whitney C, Chorney S, Lenes-Voit F, Johnson RF. Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients. Laryngoscope 2021; 131:E2469-E2474. [PMID: 33464608 DOI: 10.1002/lary.29402] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity. STUDY DESIGN Retrospective case series. METHODS All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients. RESULTS A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length. CONCLUSIONS Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2469-E2474, 2021.
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Affiliation(s)
- Christian Davidson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Benjamin Jacob
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Ashley Brown
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Rebecca Brooks
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Candace Bailey
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Cindy Whitney
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Stephen Chorney
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Felicity Lenes-Voit
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
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Yallapragada S, Savani RC, Mūnoz-Blanco S, Lagatta JM, Truog WE, Porta NFM, Nelin LD, Zhang H, Vyas-Read S, DiGeronimo R, Natarajan G, Wymore E, Haberman B, Machry J, Potoka K, Murthy K. Qualitative indications for tracheostomy and chronic mechanical ventilation in patients with severe bronchopulmonary dysplasia. J Perinatol 2021; 41:2651-2657. [PMID: 34349231 PMCID: PMC8331995 DOI: 10.1038/s41372-021-01165-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/13/2021] [Accepted: 07/13/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND The decision to pursue chronic mechanical ventilation involves a complex mix of clinical and social considerations. Understanding the medical indications to pursue tracheostomy would reduce the ambiguity for both providers and families and facilitate focus on appropriate clinical goals. OBJECTIVE To describe potential indications to pursue tracheostomy and chronic mechanical ventilation in infants with severe BPD (sBPD). STUDY DESIGN We surveyed centers participating in the Children's Hospitals Neonatal Consortium to describe their approach to proceed with tracheostomy in infants with sBPD. We requested a single representative response per institution. Question types were fixed form and free text responses. RESULTS The response rate was high (31/34, 91%). Tracheostomy was strongly considered when: airway malacia was present, PCO2 ≥ 76-85 mmHg, FiO2 ≥ 0.60, PEEP ≥ 9-11 cm H2O, respiratory rate ≥ 61-70 breaths/min, PMA ≥ 44 weeks, and weight <10th %ile at 44 weeks PMA. CONCLUSIONS Understanding the range of indications utilized by high level NICUs around the country to pursue a tracheostomy in an infant with sBPD is one step toward standardizing consensus indications for tracheostomy in the future.
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Affiliation(s)
| | - Rashmin C. Savani
- grid.267313.20000 0000 9482 7121UT Southwestern Medical Center, Dallas, TX USA
| | - Sara Mūnoz-Blanco
- grid.267313.20000 0000 9482 7121UT Southwestern Medical Center, Dallas, TX USA
| | - Joanne M. Lagatta
- grid.30760.320000 0001 2111 8460Medical College of Wisconsin, Milwaukee, WI USA
| | - William E. Truog
- grid.239559.10000 0004 0415 5050Children’s Mercy-Kansas City and the University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Nicolas F. M. Porta
- grid.413808.60000 0004 0388 2248Northwestern University & Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
| | - Leif D. Nelin
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA
| | - Huayan Zhang
- grid.239552.a0000 0001 0680 8770Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Shilpa Vyas-Read
- grid.189967.80000 0001 0941 6502Emory University, Atlanta, GA USA
| | - Robert DiGeronimo
- grid.240741.40000 0000 9026 4165Seattle Children’s Hospital/University of Washington, Seattle, WA USA
| | - Girija Natarajan
- grid.414154.10000 0000 9144 1055Children’s Hospital of Michigan, Detroit, MI USA
| | - Erica Wymore
- grid.430503.10000 0001 0703 675XUniversity of Colorado, Aurora, CO USA
| | - Beth Haberman
- grid.239573.90000 0000 9025 8099Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Joana Machry
- grid.413611.00000 0004 0467 2330Johns Hopkins All Children’s Hospital, St. Petersburg, FL USA
| | - Karin Potoka
- grid.413473.60000 0000 9013 1194Akron Children’s Hospital, Akron, OH USA
| | | | - Karna Murthy
- grid.413808.60000 0004 0388 2248Northwestern University & Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
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Karkoutli AA, Brumund MR, Evans AK. Bronchopulmonary dysplasia requiring tracheostomy: A review of management and outcomes. Int J Pediatr Otorhinolaryngol 2020; 139:110449. [PMID: 33157458 DOI: 10.1016/j.ijporl.2020.110449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/10/2020] [Indexed: 12/27/2022]
Abstract
Bronchopulmonary Dysplasia (BPD) is a pulmonary disease affecting newborns, commonly those with prematurity or low birth weight. Its pathogenesis involves underdevelopment of lung tissue with subsequent limitations in ventilation and oxygenation, resulting in impaired postnatal alveolarization. Despite advances in care with improved survival, BPD remains a prevalent comorbidity of prematurity. In severe cases, management may involve mechanical ventilation via tracheostomy. BPD's demand for multidisciplinary care compounds the challenges in management of this condition. Here, we review existing literature: the history of disease, criteria for diagnosis, pathogenesis, and modes of treatment with a focus on the severe subtype: that which is associated with pulmonary hypertension (PAH) for which tracheostomy is often required to facilitate long-term mechanical ventilation. We review the current recommendations for tracheostomy and decannulation.
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Affiliation(s)
- Adam Ahmad Karkoutli
- Louisiana State University Health Sciences Center, School of Medicine, 533 Bolivar Street, New Orleans, LA, 70112, USA
| | - Michael R Brumund
- Pediatric Cardiology, Louisiana State University Health Sciences Center, Department of Pediatrics, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA; Children's Hospital New Orleans, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA
| | - Adele K Evans
- Pediatric Otolaryngology, Louisiana State University Health Sciences Center, Department of Otolaryngology - Head and Neck Surgery, 533 Bolivar Street, Suite 566, New Orleans, LA, 70112, USA; Children's Hospital New Orleans, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA.
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Lubianca Neto JF, Castagno OC, Schuster AK. Complications of tracheostomy in children: a systematic review. Braz J Otorhinolaryngol 2020; 88:882-890. [PMID: 33472759 PMCID: PMC9615521 DOI: 10.1016/j.bjorl.2020.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Tracheostomy is a procedure that can be associated with several well-described complications in the literature, which can be divided into transoperative, early postoperative and late postoperative. When performed in children, these risks are more common than in adults. Objective To perform a systematic review of complications, including deaths, in tracheostomized pediatric patients. Methods A search was carried out for articles in the Latin American and Caribbean Health Sciences Literature and PubMed databases. Cohort studies and series reports were selected, in addition to systematic reviews, published between January 1978 and June 2020, with patients up to 18 years old, and written in English, Spanish or Portuguese. Results 1560 articles were found, of which 49 were included in this review. The average complication rate was 40%, which showed an association with age, birth weight, prematurity, comorbidities, and emergency procedures. The most common complications were cutaneous lesions and granulomas. Mortality related to the procedure reached up to 6% in children and was mainly related to cannula obstruction or accidental decannulation. Conclusion Pediatric tracheostomy is associated with several complications. The tracheostomy-related mortality rate is low, but the overall mortality of tracheostomized patients is not negligible.
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Affiliation(s)
- José Faibes Lubianca Neto
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Disciplina de Otorrinolaringologia (ORL) e Programa de Pós-Graduação em Pediatria, Porto Alegre, RS, Brazil; Hospital da Criança Santo Antônio, Serviço de ORL Pediátrica, Programa Programa de Fellowship em ORL Pediátrica Otorrinolaringologia Pediátrica, Porto Alegre, RS, Brazil; Santa Casa de Misericórdia de Porto Alegre (UFCSPA), Serviço de ORL, Programa de Residência Médica em Otorrinolaringologia, Porto Alegre, RS, Brazil.
| | - Octavia Carvalhal Castagno
- Hospital da Criança Santo Antônio, Serviço de ORL Pediátrica, Programa Programa de Fellowship em ORL Pediátrica Otorrinolaringologia Pediátrica, Porto Alegre, RS, Brazil
| | - Artur Koerig Schuster
- Santa Casa de Misericórdia de Porto Alegre (UFCSPA), Serviço de ORL, Programa de Residência Médica em Otorrinolaringologia, Porto Alegre, RS, Brazil
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Mai K, Davis RK, Hamilton S, Robertson-James C, Calaman S, Turchi RM. Identifying Caregiver Needs for Children With a Tracheostomy Living at Home. Clin Pediatr (Phila) 2020; 59:1169-1181. [PMID: 32672065 DOI: 10.1177/0009922820941209] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study sought to understand caregiver needs of children with tracheostomies (CWT) living at home and inform development of standardized tracheostomy simulation training curricula. Long-term goals are decreasing hospital readmissions following tracheostomy placement and improving family experiences while implementing a medical home model. We recruited caregivers of CWT and conducted semistructured interviews, subsequently recorded, transcribed, and analyzed for emerging themes using NVivo. Demographic data were collected via quantitative surveys. Twenty-seven caregivers participated. Emerging themes included the following: (1) caregivers felt overwhelmed, sad, frightened when learning need for tracheostomy; (2) training described as adequate, but individualized training desired; (3) families felt prepared to go home, but transition was difficult; (4) home nursing care fraught with difficulty and yet essential for families of CWT. Families of CWT have specific needs related to discharge training, resources, support, and home nursing. Provider understanding of caregiver needs is essential for child well-being, patient-/family-centered care, and may improve health outcomes.
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Affiliation(s)
- Katherine Mai
- Drexel University, Philadelphia, PA, USA.,St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Sue Hamilton
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Sharon Calaman
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Renee M Turchi
- Drexel University, Philadelphia, PA, USA.,St. Christopher's Hospital for Children, Philadelphia, PA, USA
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