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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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Pattisapu P, Abts MF, Bly RA, Bonilla-Velez J, Dahl JP, DeYoung SCH, Horn DL, Johnson KE, Parikh SR. Validation of the Seattle Suprastomal Safety Score (5S): A Novel Measure in Pediatric Tracheostomy-Dependent Patients. Otolaryngol Head Neck Surg 2021; 166:970-975. [PMID: 34488510 DOI: 10.1177/01945998211037254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an instrument with 2 domains: collapse and granulation. STUDY DESIGN Cross-sectional repeated testing survey. SETTING Electronic survey. METHODS A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains. RESULTS ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation. CONCLUSION The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients.
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Affiliation(s)
- Prasanth Pattisapu
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew F Abts
- Department of Pulmonology, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Randall A Bly
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Juliana Bonilla-Velez
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sarah C Hofman DeYoung
- Department of Pulmonology, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - David L Horn
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Pediatric Otolaryngology-Head & Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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Leonard JA, Mamidi IS, Mudd P, Espinel A. Pediatric tracheostomy surveillance. Pediatr Pulmonol 2021; 56:3047-3050. [PMID: 34185970 DOI: 10.1002/ppul.25515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 05/16/2021] [Indexed: 12/26/2022]
Abstract
We report an unusual case of a 14-month-old ex-28 week, ventilator-dependent male with a history of bronchopulmonary dysplasia and tracheostomy at 2 months of age. Lost to follow-up, at age 9 months, he presented to the emergency department with worsening respiratory distress. The patient was taken to the operating room at which time direct visualization of the airway demonstrated a mass filling the entire glottic inlet without supraglottic or pharyngeal mucosal attachments. The solid, nonvascular, mass appeared to be emanating from a suprastomal site. Excision proved to relieve the airway obstruction and postoperatively the patient has thrived.
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Affiliation(s)
- James A Leonard
- Deparment of Otolaryngology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Ishwarya S Mamidi
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Pamela Mudd
- Division of Pediatric Otolaryngology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Alexandra Espinel
- Division of Pediatric Otolaryngology, Children's National Medical Center, Washington, District of Columbia, USA
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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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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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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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Al Bahri K, Liu CC. Surveillance endoscopy in pediatric tracheostomy: A systematic review. Int J Pediatr Otorhinolaryngol 2021; 140:110533. [PMID: 33296833 DOI: 10.1016/j.ijporl.2020.110533] [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: 10/12/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To systematically review the literature on the yield of surveillance airway endoscopy in pediatric patients with tracheostomies. METHODS A systematic search was performed according to PRISMA guidelines of the MEDLINE/Pubmed and Embase databases. Data were collected on the following outcomes of interest: abnormal airway findings in surveillance endoscopy performed in pediatric tracheostomy patients, frequency and nature of interventions performed during endoscopy, and predictive factors associated with abnormal airway findings. RESULTS Seven studies were included in the review. The timing of endoscopy post-tracheostomy placement was variable and ranged from 1 to 24 months. All studies reported abnormal airway findings on initial endoscopic examination, with rates varying from 20 to 87%. Airway granulomas/granulation tissue was the most common finding, followed by airway stenosis and suprastomal collapse. Interventions performed to improve airway safety occurred in 18%-64% of patients undergoing surveillance endoscopy. The most commonly reported interventions were debridement of granulation tissue and dilation of subglottic stenosis. No endoscopy-related complications were reported across the studies. The presence of tracheostomy-related symptoms was the most consistently reported predictor of abnormal airway findings and airway interventions. CONCLUSION Pediatric tracheostomy patients undergoing surveillance airway endoscopy have a high rate of abnormal airway findings and interventions. However, additional studies are needed before routine endoscopy can be recommended in asymptomatic patients.
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Affiliation(s)
- Khaloud Al Bahri
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Canada
| | - C Carrie Liu
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Canada; Division of Pediatric Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Canada.
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Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update on the management of pediatric tracheostomies. RECENT FINDINGS Recent literature has focused on optimization of care for children with tracheostomies including prevention and management of skin breakdown, timing of tracheostomy tube changes, the role of multidisciplinary and team-based approaches to education and management of tracheostomy patients, ideal timing of surveillance endoscopy, and the emerging role of telemedicine in the care of tracheostomy patients. SUMMARY A focus on quality improvement and a systematic, team-based approach to care has the potential to improve the quality of care for pediatric tracheostomy patients.
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Ong T, Liu CC, Elder L, Hill L, Abts M, Dahl JP, Evans KN, Parikh SR, Soares JJ, Striegl AM, Whitlock KB, Johnson KE. The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients. Otolaryngol Head Neck Surg 2020; 163:221-231. [PMID: 32204663 DOI: 10.1177/0194599820911728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC). METHODS An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative. RESULTS In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality. DISCUSSION We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative. IMPLICATION FOR PRACTICE Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.
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Affiliation(s)
- Thida Ong
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - C Carrie Liu
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Leslie Elder
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Leslee Hill
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew Abts
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kelly N Evans
- Seattle Children's Hospital, Seattle, Washington, USA.,Craniofacial Medicine, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | | | - Amanda M Striegl
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathryn B Whitlock
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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