Parents' experiences and views of caring for a child with a tracheostomy: a literature review

"What choice do you have knowing your child can't breathe?!": Adaptation to Parenthood for Children Who Have Received a Tracheostomy

Introduction

A growing number of parents are navigating parenthood influenced by medical complexity and technological dependency as the group of children with long-term tracheostomy grows. However, little is known regarding the parental experiences of parenthood for this heterogeneous group of children now surviving through infancy and intensive care.

Objective

This study aimed to analyze how parents of children who have received a tracheostomy adapted to parenthood.

Methods

Interviews were conducted and analyzed following a constructivist grounded theory approach. Ten parents of seven children living with a tracheostomy in Sweden were recruited via the long-term intensive care unit (ICU).

Results

The core variable of parenthood "Stuck in survival" was explained by two categories and six subcategories. The category "Unaddressed previous history" describes the experiences from being in the ICU environment and how the parents are not able, due to insufficient time and resources, to address these stressful experiences. The category "Falling through the cracks of a rigid system" describes how the parents found themselves and their children to be continuously ill-fitted in a medical system impossible to adapt to their needs and situation. Parents placed the starting point of parenthood with the birth of the child, whilst the tracheotomy only constituted a turning point and would lead to the loss of any previously held expectations regarding parenthood.

Conclusion

This study identified a previously undescribed period prior to tracheostomy placement, which may have long-lasting effects on these families. The care provided in ICUs following the birth of a child who will require tracheostomy may not be tailored or adapted to accommodate the needs of these families leading to long-lasting effects on parenthood.

Case Series - Pediatric Tracheostomy for Upper Airway Obstruction

Certain congenital craniofacial malformations can cause upper airway obstruction. Due to neurological involvement, these craniofacial deformities with upper airway blockage frequently require tracheostomy. Children who need weeks or months of continuous ventilator assistance require tracheostomies, which improve pulmonary toilet and decrease laryngotracheal lesions such subglottic stenosis and tracheomalacia. In this case report we will be discussing about two patients who underwent Pediatric tracheostomy for Pierre Robin sequence and supraglottic stenosis in our institute. This paper emphasizes on some of the rare causes of pediatric upper airway obstruction - Pierre Robin sequence and supraglottic stenosis. Also the importance of tracheostomy procedure, which is the gold standard for management of upper airway obstruction in patients who are not responding to conservative management is emphasized.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03892-1.

Factors influencing quality of life in children with tracheostomy with emphasis on home care visits: a multi-centre investigation

OBJECTIVE

Only a few studies have assessed the quality of life in children with tracheostomies. This study aimed to evaluate the quality of life and the factors influencing it in these children.

METHOD

This cross-sectional, two-centre study was conducted on paediatric patients living in the community with a tracheostomy by using the Pediatric Quality of Life Inventory. Clinical and demographic information of patients, as well as parents' socioeconomic factors, were obtained.

RESULTS

A total of 53 patients met our inclusion criteria, and their parents agreed to participate. The mean age of patients was 6.85 years, and 21 patients were ventilator-dependent. The total paediatric health-related quality of life score was 59.28, and the family impact score was 68.49. In non-ventilator-dependent patients, multivariate analyses indicated that social functioning and health-related quality of life were negatively affected by the duration of tracheostomy. The Quality of Life of ventilator-dependent patients was influenced by care visits and the presence of pulmonary co-morbidities.

CONCLUSION

Children with tracheostomies have a lower quality of life than healthy children do. Routine care visits by a respiratory therapist and nurses yielded significantly improved quality of life in ventilator-dependent children.

Tracheostomy in Severe Bronchopulmonary Dysplasia-How to Decide in the Absence of Evidence

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?

Feeling stretched: Parents' narratives about challenges to resilience when their child has a tracheostomy

This study aimed to examine how parents develop personal resilience when facing the challenges of caring for a child with tracheostomy. This study employed a longitudinal qualitative design. Unstructured narrative interviews with 12 parents (from nine families) whose child had a new tracheostomy were undertaken at three time points over 12 months. Data were analysed using a socio-narratology method. Findings reveal the journey parents experienced, how their feelings changed and the processes involved in developing resilience over the first 12 months of their child having a tracheostomy. Stories told by parents early in their journey revealed emotional upheaval, negative emotions, stress and shock. Due to medical need, parents had little or no choice for their child to have a tracheostomy. Once their child's life was out of danger, parents started to reframe their experiences and beliefs. Resilience played a major part in how parents perceived and faced their situation, allowing them to deal with what came their way and to move forward with their lives. Different aspects of resilience such as self-awareness, grit, gratitude, internal locus of control and reframing came to the fore at different time points. Parents talked feeling stretched by the challenges they faced and how they reframed their perspectives about their child's tracheostomy. Parents' resilience and reframing is discussed in relation to the ABC-X model. This study identifies a theoretical model that explains this process of change, this results in transferable knowledge, useful for understanding and explaining the experience of other parents and families.

Providing care for children with tracheostomies: a qualitative interview study with parents and health professionals

OBJECTIVES

To explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers.

DESIGN

Qualitative semistructured interview study.

SETTING

One region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation.

PARTICIPANTS

A purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre.

INTERVENTION

Interviews undertaken by telephone or video link.

PRIMARY AND SECONDARY OUTCOME MEASURES

Qualitative reflexive thematic analysis with QSR Nvivo 12.

RESULTS

This paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies.

CONCLUSIONS

Understanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.

Psychosocial Measures and Outcomes Among Caregivers of Children With Tracheostomies: A Systematic Review

OBJECTIVE

Children with tracheostomies have complex medical issues that require long-term technology dependence and continuous medical care at home. Parents of tracheostomy-dependent children often assume the majority of their child's home care leading to a shift in family dynamics and a decrease in caregiver quality of life. This systematic review sought to identify instruments to measure caregiver psychosocial outcomes after their child's tracheostomy and report on the findings.

DATA SOURCES

A systematic review was performed using Medline, CINAHL, and EMBASE.

REVIEW METHODS

Studies that evaluated psychosocial outcomes in caregivers of tracheostomy-dependent children were included.

RESULTS

We screened a total of 1286 nonduplicate records to include a total of 12 studies assessing the psychosocial outcomes of parents of tracheostomy-dependent children. Fourteen instruments were identified. Caregivers reported lower quality of life when compared to other chronic caregiver groups. They experienced high degrees of stress, struggled to cope individually and as a family unit, and experienced decision regret and conflict.

CONCLUSION

Findings from this review suggest a significant impact on caregiver psychosocial well-being, but few quantitative studies investigated this dynamic with measures validated in this caregiver population. This review demonstrates the need for longitudinal studies using validated tools to assess the long-term impacts and outcomes of caregivers of the tracheostomy-dependent child.

Caregiver quality of life after pediatric tracheostomy

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.

Overwhelmed to ownership: The lived experience of parents learning to become caregivers of children with tracheostomies

BACKGROUND

Caring for a child with a tracheostomy is challenging and requires parents to master advanced medical skills, often without prior medical training. Tracheostomy education programs are well-established, yet the experience of parents becoming competent caregivers is unexplored. Providing effective education may impact long-term child and caregiver outcomes and mitigates preventable hospital readmissions.

OBJECTIVE

This study aimed to explore parents' experience completing tracheostomy education within a children's hospital and understand the factors that promote or hinder learning.

METHODS

We conducted a qualitative descriptive study on twenty-three purposively sampled parents of children with new tracheostomies from 2020 to 2021 who were admitted to the Transitional Intensive Care Unit (TICU) at a quaternary pediatric hospital. Semi-structured interviews were conducted after parents completed tracheostomy education and before discharge. Inductive thematic analysis was employed to identify themes and subthemes.

RESULTS

Five major themes emerged: decision making, balancing benefits, becoming a caregiver, healthcare providers (HCPs) as barriers and facilitators for learning, and recommendations for tracheostomy education programs. Parents described becoming a caregiver in four stages: initial realization, overwhelmed, owning care, and role transition. Learning tracheostomy management in a positive, collaborative, supportive environment helped parents be more confident in their skills and eased their transition to home. Previous life experience, learning style, and healthcare professional behaviors influenced parents' transition into the caregiver role.

CONCLUSIONS

Findings will inform interventions for improving pediatric tracheostomy education programs, including the HCP's role in supporting families. Equipping caregivers with the skills to provide tracheostomy interventions in the home could decrease preventable readmissions and improve outcomes in this medically fragile, high-risk pediatric population.

Caregiver Perceptions of a Tracheostomy "Go-Bag" Standardization Initiative

INTRODUCTION

This project aimed to standardize and improve the emergency tracheostomy "go-bag" provided by our institution and to increase "go-bag" compliance, supply organization, and emergency preparedness and confidence among caregivers of tracheostomy-dependent children.

METHOD

We provided caregivers with a new trifold "go-bag," containing four zippered pockets. Diagram-based supply checklists were placed in each "go-bag" to assist with supply organization and supply checks performed by the clinical team. Caregiver questionnaires were administered before and after "go-bag" distribution to assess the impact of the practice change.

RESULTS

Between July 1, 2020 and February 28, 2021, 43% (n = 30) of tracheostomy-dependent children followed by the Department of Otolaryngology received a new "go-bag." Overall, "go-bag" compliance, supply organization, and caregiver confidence related to providing care at home and intervening in an emergency improved from baseline. Caregivers reported overwhelmingly positive feedback regarding the new "go-bag" design and utility.

DISCUSSION

These findings support the use of standardized, user-friendly tracheostomy "go-bags" provided by health care institutions and the performance of routine "go-bag" supply checks to ensure patient safety and caregiver preparedness.

Families' experiences of central-line infection in children: a qualitative study

OBJECTIVE

Central venous access devices (CVADs), often known as central lines, are important for delivering medically complex care in children, and are increasingly used for children living at home. Central line-associated bloodstream infection (CLABSI) is a serious, life-threatening complication. Although the physical consequences of CLABSIs are well documented, families' views and experiences of CLABSI are poorly understood.

DESIGN

Qualitative study using semistructured interviews with participants from 11 families of a child living at home with a CVAD.

PARTICIPANTS

Parents of children aged 4-12 years living at home with a CVAD. Four fathers and nine mothers participated in interviews.

RESULTS

The risk of CLABSI is a constant fear for families of a child with a CVAD. Though avoiding infection is a key priority for families, it is not the only one: maintaining a sense of 'normal life' is another goal. Infection prevention and control require much work and expertise on the part of families, contributing significantly to families' physical and emotional workload.

CONCLUSIONS

Living with the risk of CLABSI poses additional burdens that impact on the physical and emotional well-being of families. Services to better support families to manage these burdens are needed.

Adapting user-centered design principles to improve communication of peer parent narratives on pediatric tracheostomy

BACKGROUND

Parents who have to make tracheostomy decisions for their critically ill child may face forecasting errors and wish to learn from peer parents. We sought to develop an intervention with peer parent narratives to help parents anticipate and prepare for future challenges before making a decision.

METHODS

To ensure that the intervention reflects parents' needs (rather than experts' opinions), we adapted a user-centered design (UCD) process to identify decision-critical information and refine the presentation format by interviewing parents who had tracheostomy decision making experience. Phase 1 (n = 10) presented 15 possible forecasting errors and asked participants to prioritize and justify the problematic ones. It also asked participants to comment on the draft narratives and preferred delivery mode and time of the intervention. Phase 2 (n = 9 additional parents and 1 previous parent) iteratively collected feedback over four waves of user interviews to guide revisions to the informational booklet.

RESULTS

Phase 1 revealed that parents wanted information to address all forecasting errors as soon as tracheostomy becomes an option. They also highlighted diverse family situations and the importance of offering management strategies. The resulting prototype booklet contained five sections: introduction, child's quality of life, home care, practical challenges, and resources. Feedback from Phase 2 focused on emphasizing individualized situations, personal choice, seriousness of the decision, and caregiver health as well as presenting concrete illustrations of future challenges with acknowledgement of positive outcomes and advice. We also learned that parents preferred to use the booklet with support from the care team rather than read it alone.

CONCLUSIONS

A UCD process enabled inclusion of parental perspectives that were initially overlooked and tailoring of the intervention to meet parental expectations. Similar UCD-based approaches may be valuable in the design of other types of patient communications (e.g., decision aids).

Long-term results of slide laryngotracheoplasty for congenital subglottic stenosis in newborns and infants

OBJECTIVES

Slide laryngotracheoplasty is an effective, single-step procedure without tracheostomy and stenting for treating high-grade congenital subglottic stenosis in neonates and infants. Long-term outcomes were evaluated to assess the reliability of the procedure performed in this age of rapid development of the laryngeal structures.

METHODS

We report five children who underwent slide laryngotracheoplasty before the age of 4 months, each with >3 years follow-up. Increases of length and bodyweight were systematically assessed. Breathing, swallowing, voice, and overall satisfaction was assessed by a quality of life questionnaire. Voice quality was objectively evaluated by measuring shimmer, jitter, fundamental frequency, and the harmonics-to-noise ratio.

RESULTS

All patients had a stable and adequate airway during follow-up without any additional open airway surgery. The patients' voices were physiological, and the intervention had no negative impact on speech development. Swallowing function was optimally retained, and the patients' bodyweight gain and length were satisfactory. During at least 3 years of observation, the anastomosis remained stable and grew dynamically with the patient.

CONCLUSIONS

Slide laryngotracheoplasty (as a single-step procedure) provides an adequate airway without tracheostomy, grafting, or stenting with good long-term functional results in selected neonates and infants with congenital subglottic stenosis.

Hospital training and preparedness of parents and carers in paediatric tracheostomy care: A mixed methods study

INTRODUCTION

Within the UK, the majority of paediatric tracheostomy care is delivered by parents and carers at home. To facilitate this, extensive in-hospital training is delivered by a variety of health care professionals. Our goal was to assess carer perceptions of this process and highlight areas in which we can further improve our service and the training for other hospital providers of paediatric tracheostomy care.

METHODS

A mixed method approach was adopted. In Phase I, qualitative data from five semi-structured interviews with carers of children with a tracheostomy were thematically analysed and subsequently used to develop a questionnaire. In Phase II, the piloted questionnaire was distributed via telephone, email or post to all eligible caregivers who had been tracheostomy trained at GOSH in the last three years (n = 92). Qualitative and quantitative data were analysed using thematic analysis and descriptive statistics respectively.

RESULTS

Thirty-five completed questionnaires were received (38% response rate). Overall participants were highly satisfied with the training provided (mean score 8.42 on a scale of 1 (lowest) to 10 (highest)). Carer identified areas requiring improvement were caregiver education pre-tracheostomy; emergency and complication training; supervision and training post hospital discharge; training schedule; emotional support; and support from community healthcare teams. These findings led to multiple subsequent interventions to further improve the carer training programme including training videos, psychology provision on request and increased community training.

CONCLUSION

Although the evaluation of the service revealed high participant satisfaction in home carer training overall, in-depth analysis of caregivers' experiences indicated common themes in the tracheostomy training service where further support would be beneficial. A carer-centred rather than health professional focus on training needs will allow future attention to be directed to areas of need identified by carers themselves as important to improve the tracheostomy training programme.

Impact of COVID-19 on carers of children with tracheostomies

OBJECTIVES

To explore the impact of the COVID-19 pandemic on the experiences of caregivers of children with tracheostomies.

DESIGN

Qualitative semistructured interviews.

SETTING

All participants were currently, or had previously cared for, a tracheostomised child who had attended a tertiary care centre in the North of England. Health professionals were purposively sampled to include accounts from a range of professions from primary, community, secondary and tertiary care.

PARTICIPANTS

Carers of children with tracheostomies (n=34), including health professionals (n=17) and parents (n=17).

INTERVENTIONS

Interviews were undertaken between July 2020 and February 2021 by telephone or video link.

MAIN OUTCOME MEASURE

Qualitative reflexive thematic analysis with QSR NVivo V.12.

RESULTS

The pandemic has presented an additional and, for some, substantial challenge when caring for tracheostomised children, but this was not always felt to be the most overriding concern. Interviews demonstrated rapid adaptation, normalisation and varying degrees of stoicism and citizenship around constantly changing pandemic-related requirements, rules and regulations. This paper focuses on four key themes: 'reconceptualising safe care and safe places'; 'disrupted support and isolation'; 'relationships, trust and communication'; and 'coping with uncertainty and shifting boundaries of responsibility'. These are described within the context of the impact on the child, the emotional and physical well-being of carers and the challenges to maintaining the values of family-centred care.

CONCLUSIONS

As we move to the next phase of the pandemic, we need to understand the impact on vulnerable groups so that their needs can be prioritised.

The impact of pediatric tracheostomy on the quality of life of caregivers

OBJECTIVE

Pediatric tracheostomy is a challenge in otolaryngology practice and it is associated with greater morbidity and mortality than in adults; hence, constant vigilance by the designated family caregiver is critical. This study was designed to assess the impact of on quality of life of caregivers in a homecare setting as a result of the presence of child with a tracheostomy.

METHODS

This was a combined retrospective and prospective cohort study with caregivers of children younger than 16 years who had undergone a tracheostomy, had been discharged home with a tracheostomy tube and completed 6 months of domiciliary tracheostomy care. The consenting primary caregivers were assessed for their quality of life based on the PedsQL v 4.0 questionnaires across various domains.

RESULTS

We identified the primary caregivers of 85 children who had undergone a tracheostomy during the study period. The children's median age was 3.5 years (range, 9 months to 14 years). The mean caregiver health-related quality of life (HRQOL) score was 59.3, the mean family functioning score was 62.8, and the mean total family impact score was 54.7 with relative deficits seen in caregiver's social functioning (56.9) and emotional functioning (53.2). Good or average quality of physical and social function was seen among 74 % and 65 % of caregivers respectively while only 55 % were reported having good or average emotional function. Emotional disturbance, interfering with everyday family activities, and sleep disturbance were the major concerns among caregivers.

CONCLUSION

The biopsychosocial consequences of caring for a child with a tracheostomy are profound for the family, affecting the quality of life of caregivers and adding to the emotional and social burden of the child's family.

A Child with Home Mechanical Ventilation Affects the Family: A Danish Study shows that well Siblings may become Shadow Children

BACKGROUND

Having a child with chronic respiratory illness and home mechanical ventilation (HMV) may not only affect the ill child, but also the family, including well siblings' everyday life and physical and mental well-being.

PURPOSE

To explore the perspectives of parents to a child with HMV on well siblings' lives.

DESIGN AND METHODS

A qualitative phenomenological-hermeneutic approach using semistructured interviews with eight families, that included a child on HMV and well siblings. Data were collected from March to June 2019 at a Danish University Hospital.

RESULTS

Three main themes emerged: Tying emotional bonds with both children, Protection of everyday life for well siblings and A different family life - sharing attentiveness. The findings showed that being a parent to an HMV child and well siblings is complex to manage, and may make parents feel inadequate towards their children.

CONCLUSIONS

Parents feel inadequate in being parents to both the HMV child and well siblings, often transferring adult responsibilities to the well sibling, and sometimes leaving the well siblings in the shadow.

IMPLICATIONS

Clinical practice needs to expand interventions to support parents and well siblings by using a more family-centred care approach, not only during admission, but also in a long-term perspective.

"New Trach Mom Here…": A qualitative study of internet-based resources by caregivers of children with tracheostomy

OBJECTIVE

Decision-making around tracheostomy placement and chronic respiratory support in children is complicated. Families often seek support and advice from outside the medical care team, including from social media. We undertook this study to characterize the content and nature of online resources created and managed primarily by caregivers of children living with tracheostomy and chronic mechanical ventilation.

DESIGN/SETTING

We used a "grey literature" search methodology to identify internet resources created by caregivers of children with tracheostomy. We included only publicly available, nonindustry associated, English language, North American websites updated at least once in 2019. We then applied inductive content analysis to establish central themes, patterns and associations.

MEASUREMENTS/MAIN RESULTS

We identified six blogs/forums that met our search criteria. We identified four main themes: (1) Uncertainty, (2) Lived experience-wants, needs, and emotions, (3) Seeking context and meaning, and (4) Advice/information sharing/support. Two patterns of coping were identified on the basis of the relationships between codes. The "Acceptance pathway" is associated with a sense of self-actualization, mastery, satisfaction, return to normalcy, and ultimately acceptance. The "Resignation pathway" is associated with a sense of lack of control, frustration, burnout and stress, persistent lack of normalcy, and resignation to the tracheostomy as a negative but necessary outcome.

CONCLUSION

Caregivers often come to see themselves as experts in the care of children with tracheostomy, though many still express ambivalence about their knowledge and skills. Those early in the experience express a desire for community and can potentially benefit from online resources.

Using Narratives to Correct Forecasting Errors in Pediatric Tracheostomy Decision Making

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The Family Impact of Having a Child with a Tracheostomy

OBJECTIVES

Measure the quality of life among families with children with tracheostomies.

METHODS

We performed a prospective cross-sectional analysis of families with children with tracheostomies utilizing the PedQL Family Impact Module-a validated quality of life assessment. We determined if scores were impacted by demographics using regression analysis. We also compared the tracheostomy sample's scores to a previously published cohort of children with severe cerebral palsy and birth defects that required home nursing or nursing home placement using the student's t-test. We determined the effect size of the difference between the two groups using the Cohen's d test.

RESULTS

Ninety-eight families are included in the study. The average (SD) age of tracheostomy placement was 1.6 (3.5) years. The population was 60% (59/98) male and 39% (38/98) Hispanic. The principal reason for tracheostomy was due to respiratory failure (76 out of 98; 78%). The mean (SD) total Family Impact score was 76 (19). The lowest domain score was daily activity problems, mean (SD) = 67 (30) followed by worry (mean = 69, SD = 24). The lowest question score was, "I worry about my child's future," mean (SD) = 52 (37). When compared to the comparison group of medically fragile children, the scores were statistically similar except for communication totals where tracheostomy patients reported superior scores (78.3 vs. 62.9, 95% CI, -26 to -4.8, P = .005, Cohen's d = -0.66).

CONCLUSION

The presence of a tracheostomy is associated with QOL scores like other medically fragile children.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:911-915, 2021.

Holding Their Own and Being Resilient: Narratives of Parents over the First 12 Months of Their Child Having Tracheostomy

Caring for a child with a tracheostomy can be challenging for parents and learning to safely manage their child's airway can be frightening due to their child's breathing issues, complex diagnosis and the difficult decisions they have to make. The aim of this longitudinal narrative study was to tell the stories of parents whose child had a new tracheostomy. Twenty three narrative interviews were conducted with twelve parents from nine families at three time points over a 12 month period. Data were analyzed using a socio-narratological approach. The stories told how parents were able to 'hold their own' despite experiencing shock, emotional upheaval and uncertainty during the period of their child's surgery. 'Holding their own' was possible for parents because resilience played an important part of their journey. Parents continued to be resilient as they adapted to being at home and dealt with ongoing challenging and stressful circumstances. All of the parents told stories reflecting on and recognizing that there were times when they exhibited higher levels of resilience and times when their resilience was lower. Looking back on their experiences parents appreciated that they reframed their initial often negative views about their child's need for a tracheostomy into more positive understandings and a future orientated perspective.

Technology-dependent children

In recent past, revolution in medical technology resulted in improved survival rates and outcomes of critically ill children. Unfortunately, its impact relating to morbidity is not well documented. Although survival rates of these critically ill children who are medically fragile and technology-dependent have improved, we as health professionals are still in the learning curve to improve the quality of life of these children at home. Factors such as support from society, infrastructure, and funding play an important role in technology-dependent child care at home. In this review, commonly prescribed home-based medical technologies such as home ventilation, enteral nutrition, renal replacement therapy, and peripherally inserted central catheter, which are useful for quick revision, are described.

Pediatric tracheostomies in patients less than 2 years of age: Analysis of complications and long-term follow-up

PURPOSE

Identify variables that are predictive of morbidity and mortality in children under the age of two undergoing tracheostomy and to provide longitudinal data on this patient population.

METHODS

Patients were retrospectively identified using Current Procedural Terminology codes 31600, 31601, 31610 from 2009 to 2016.

RESULTS

Median age at time of tracheostomy was 0.43 years (interquartile range, 0.27-0.61). Patients were followed for a median of 1.39 years (range 0.03-4.25). Overall mortality rate in this cohort was 23.5% with the majority (81.3%) of deaths occurring >30 days following tracheostomy. The most frequently encountered major complication was cardiopulmonary arrest (10.29%) in the short-term follow up period (<30 days) and accidental decannulation (32.81%) during long-term follow up (>30 days). Peristomal skin breakdown was less likely to develop in patients who did not receive paralytics following tracheostomy. Most patients (54.4%) were discharged to home following initial admission and experienced a mean of 2.10 readmissions for any reason during the follow-up period. 64.4% of patients underwent surveillance direct laryngoscopy and bronchoscopy during the follow-up period and suprastomal granuloma formation was detected in 31.2% of these patients. 9 patients underwent decannulation at a median of 2 years from original tracheostomy placement.

CONCLUSION

Pediatric patients under the age of 2 undergoing tracheostomy exhibit high morbidity during both the initial hospital admission and the subsequent months following discharge. However, major complications were low and mortality was not directly related to tracheostomy status in any case.

Quality of life in paediatric tracheostomy patients and their caregivers - A cross-sectional study

OBJECTIVES

(1) To better outline quality of life outcomes in paediatric tracheostomy patients and their caregivers. (2) To establish whether quality of life outcomes for children are associated with those of their caregivers. (3) To establish whether quality of life outcomes were associated with the demographic and clinical variables of age, duration of time with a tracheostomy, number of comorbidities, and ventilator dependence.

METHODS

Cross-sectional methodology was applied to gather quantitative data on quality of life outcomes, through PedsQL written questionnaires. These questionnaires covered social, emotional, physical and role/cognitive functioning. Caregivers also provided information on communication, worries, daily activities and family relationships. All children with a tracheostomy in situ, or recently decannulated, attending Sheffield Children's Hospital during the study period were eligible for inclusion.

RESULTS

25 families wished to participate, with patients ranging from 0.5 to 16.5 years (median 6.25). Both patients and caregivers attained lower scores than many other chronic diseases studied. Mean patient HRQoL was 56.2, with a physical health score of 52.4, psychosocial health score of 61.7. Caregiver HRQoL was 63.8, family functioning score was 68.1 and total family impact score was 61.6. Relative deficits were seen in caregiver social functioning (54.9), communication (56.3), worries (49.1) and daily activities (48.9), whilst role/cognitive functioning (73.8) and family relationships (79.6) subsections produced higher scores. Child psychosocial health showed moderate positive correlation (r = 0.492, p = 0.015) with both caregiver HRQoL and total family impact score. No correlation was identified between quality of life outcomes and demographic or clinical variables.

CONCLUSIONS

Disease burden appears to be particularly high for children and families with tracheostomies, especially when compared to other serious childhood disease. Lack of time and energy to complete daily activities, social isolation, worries, as well as difficulty communicating and perceived lack of understanding of their child's health were instrumental in reduced quality of life of caregivers. Anxiety about the future affected the majority of caregivers. This psychosocial impact may be lost in the busyness of delivery of medical care. We recommend provision of psychosocial support for these families as is now also recommended in other chronic childhood illness.

Slide laryngotracheoplasty for congenital subglottic stenosis in newborns and infants

OBJECTIVES

Subglottic stenosis is the most common laryngeal anomaly necessitating tracheostomy in early childhood. Crico- and laryngotracheal resection and laryngotracheal reconstruction-usually with autologous cartilage graft implantation-are the most effective treatments. These surgical techniques are obviously challenging in neonatal age and infancy. However, a reconstructive surgery performed at early age may prevent the sequel of complications.

METHODS

The authors present their novel surgical method for congenital subglottic stenosis. Seven infants had inspiratory stridor; two of them had to be intubated and one required tracheostomy. Laryngotracheoscopy, CT or MRI revealed subglottic stenosis: Cotton-Myer grade II in one, and grade III in six cases. Slide laryngotracheoplasty was performed before 5 months of age (10-130 days), with a follow-up period of average 36 months (4-80 months). Phoniatry and quality of life questionnaire were used for evaluation of postoperative results.

RESULTS

Slide laryngotracheoplasty in the neonatal age made the temporary tracheostomy unnecessary. All babies remained intubated for 3 to 10 days with an uncuffed tracheal tube. After extubation, no dyspnea or swallowing disorder occurred. A subjective quality of life questionnaire, laryngotracheoscopy, clinical growth charts showed satisfactory functional results.

CONCLUSIONS

Single-stage slide laryngotracheoplasty might be a favorable solution for subglottic stenosis, even in early childhood. In one step, the airway can be maintained without stenting and tracheostomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E199-E205, 2020.

Boot Camp for Caregivers of Children With Medically Complex Conditions

BACKGROUND

The safe transition of children with complex medical conditions who are dependent on technology from hospital to home requires that caregivers receive specialized training from qualified health care professionals. Inadequate caregiver training can lead to discharge delays and hospital readmissions, often resulting in caregiver distress.

OBJECTIVE

To determine the effectiveness of a structured boot camp-style predischarge training program for caregivers of pediatric patients with complex medical conditions.

METHODS

We conducted a quasi-experimental interventional study to compare outcomes before and after implementation of the training program, which involved 34 caregivers. Pre-boot camp data were collected retrospectively from the medical records of 34 control patients.

RESULTS

After program implementation, statistically significant decreases were found in mean unit length of stay (92 vs 60 days; P = .02), mean discharge training days (60 vs 16 days; P < .001), and median total parental stress score, expressed as a percentile (49 vs 45; P < .001). More than 90% of caregiver participants were very satisfied with the program. On the basis of minimal length of stay limits, cost savings were estimated at between $53 300 and $69 900 per patient.

CONCLUSION

The results of this study indicate that the training program is a valuable tool to track and verify caregiver education, reduce hospital length of stay, increase caregiver satisfaction, decrease caregiver stress, and reduce medical costs.

A Descriptive Qualitative Study of Home Care Experiences in Parents of Children with Tracheostomies

PURPOSE

The number of pediatric patients who require a long-term tracheal tube at home is gradually increasing. Studies have demonstrated that the parents of these children report high levels of stress, anxiety and other negative emotions as early as shortly after discharge from the hospital. The purpose of this study is to describe the home care experiences of parents of children with tracheostomies during the transition from hospital to home in China to more effectively address their needs.

DESIGN AND METHODS

This study used a qualitative descriptive design and face-to-face interviews with semi-structured questions to learn about the home care experiences of parents whose children had undergone a tracheostomy.

RESULTS

Thirteen parents were recruited from the otorhinolaryngology outpatient ward of Xinhua Hospital in Shanghai, China. These parents described three categories of home care experiences: "direct care overload," "psychological overload," and "personal growth." Subcategories included parental "role change," "from helplessness to skillfulness," "lack of professional support," "anxiety and depression," and "social isolation." They also reported personal growth, which was mainly reflected by "changing their perspectives" and "developing potential."

CONCLUSION

Although the findings of this study indicate that the physical and psychological overload reported by parents of children with tracheostomies during home care is inevitable, a better understanding of parents' caring experiences among professionals may facilitate clinical practice and promote continued community nursing care in China.

PRACTICE IMPLICATIONS

Parents hope to receive systematic education during hospitalization, including web-based video education for skills training after discharge. In addition, parents desire public recognition so that they can participate in normal family and community activities.

Tracheostomy care: Clinical practice patterns of pediatric otolaryngologists-head and neck surgeons in a publicly funded (Canadian) health care system

OBJECTIVES

To investigate variability in pediatric tracheostomy tube care practice patterns and access to resources across Canada.

METHODS

Canadian pediatric otolaryngologists-head & neck surgeons reported their own practice patterns for children with chronic tracheostomy tubes using a web-based, 29-item multiple choice and short answer questionnaire. Domains investigated included tracheostomy team membership, inpatient care practices, caregiver education, homecare resources, speech and communication, and completeness of emergency tracheostomy kits.

RESULTS

The response rate was 86.4% (38/44). Most respondents care for children with tracheostomy tubes as part of an inter-professional team (25/36; 69.4%) and arrange routine follow-up with a speech and language pathologist (22/36; 61.1%). However, the majority (23/34; 67.6%) of respondents do not formally reassess caregiver competencies (i.e. cardiopulmonary resuscitation, emergency tracheostomy care). Notably, respondents were also unsure 36.1% (13/36) of how frequently Shiley tracheostomy tubes should be washed and reused with the majority (15/36; 41.7%) reporting never. Most (15/36; 41.7%) respondents were also unsure of reuse recommendations for Bivona tracheostomy tubes. One third (12/36; 33.3%) of respondents were unsure about government-funded homecare services being provided in their community to children with tracheostomy tubes.

CONCLUSION

There is much variability in pediatric tracheostomy tube care practice patterns across Canada. Results suggest that an evidence-based Canadian clinical practice guideline may help to streamline care provided to Canadian children with tracheostomy tubes.

Caregiver Perceptions about their Decision to Pursue Tracheostomy for Children with Medical Complexity

OBJECTIVE

To describe the perceptions of caregivers of children with medical complexity (CMC) about their decision to pursue tracheostomy for their children, in particular the satisfaction with their decision.

STUDY DESIGN

In this qualitative study conducted in western North Carolina between 2013 and 2014, we interviewed 56 caregivers of 41 CMC who had received tracheostomies in the past 5 years. Three of the CMC were deceased at the time of the interview; 8 were decannulated. In-depth interviews (35 English, 6 Spanish) were conducted, audio-recorded, and transcribed verbatim. We used ATLAS.ti software to manage data and identified themes related to caregiver perceptions about tracheostomy decision.

RESULTS

We found that caregivers often chose tracheostomy because extending the lives of their children and being able to care for them at home were important. Caregivers reported the many benefits of tracheostomy including improvement in respiratory symptoms, physical and developmental health, quality of life, and means to provide medical care quickly when needed. There were negative effects of tracheostomy such as mucous plugs, excessive secretions, accidental decannulation necessitating emergency tracheostomy tube change, and the increased infection risk. Providing medical care for CMC with tracheostomy at home was difficult, but improved over time. Caregivers were generally satisfied with their decision to pursue tracheostomy for their CMC.

CONCLUSIONS

Decisional satisfaction with tracheostomy for CMC is high. In counseling caregivers about tracheostomy, clinicians should present both the benefits and risks. Future studies should quantify the outcomes described in this study.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Perspectives on neonatal and infant tracheostomy

Neonates and infants may need a tracheostomy for many different reasons, ranging from airway obstruction to a requirement for long term mechanical ventilator support. Here, we present the pathophysiology of the many congenital and acquired conditions that might be managed with a tracheostomy. Decisions about tracheostomy demand consideration of not only the benefits, but also the potential side-effects, which may differ in the short and long term and may be attributable to underlying conditions as well as the tracheostomy. Evaluation of potential advantages of tracheostomy will influence decisions about optimal timing. In many cases, an infant may 'graduate' from dependence on a tracheostomy and resume a natural airway, although some will require reconstructive airway surgery.

Long-term quality of life in children after open airway surgery for laryngotracheal stenosis

OBJECTIVES

The purpose of this study is to evaluate the long-term health related quality of life (HRQoL) in a cohort of children surgically treated for laryngotracheal stenosis (LTS).

STUDY DESIGN

Prospective cohort study.

METHODS

Parents of children between 4 and 18 years at follow-up completed the Child Health Questionnaire Parent Form (CHQ-PF50). Children between 11 and 18 years at follow-up completed the Child Health Questionnaire Child Form (CHQ-CF87). Biographical and pre-operative data were extracted from the hospital records. Post-operative measurements consisted of the Bruce treadmill test and pulmonary function testing (PFT).

RESULTS

Fifty-four parents completed the CHQ-PF50; twenty-one children completed the CHQ-CF87. The CHQ-PF50 was significantly worse than the norm population on the subscales physical functioning, role functioning: emotional/behavior, general health perceptions, family activities, parental impact: emotional, and time. CHQ-CF87 was significantly worse than the norm population on physical functioning and better on mental health. After multivariate analysis, presence of co-morbidities and glottic stenosis are the most important pre-operative factors for worse scores on general health. As post-operative measurements, the Bruce treadmill test and peak expiratory flow (PEF) correlate well with HRQoL physical subscales.

CONCLUSIONS

At long-term follow-up after treatment for LTS, deficits in HRQoL may still exist. Presence of co-morbidities and glottic stenosis are important negative factors for long-term HRQoL. The Bruce treadmill test and peak expiratory flow on pulmonary function testing correlate well with physical subscales on HRQoL. A long-term multidisciplinary follow-up with assessment of HRQoL is advised in patients treated for LTS.

LEVEL OF EVIDENCE

2B, individual prospective cohort study.

How family carers engage with technical health procedures in the home: a grounded theory study

OBJECTIVES

To explore the experiences of family carers who manage technical health procedures at home and describe their learning process.

DESIGN

A qualitative study using grounded theory.

PARTICIPANTS

New Zealand family carers (21 women, 5 men) who managed technical health procedures such as enteral feeding, peritoneal dialysis, tracheostomy care, a central venous line or urinary catheter. In addition, 15 health professionals involved in teaching carers were interviewed.

METHODS

Semistructured interviews were coded soon after completion and preliminary analysis influenced subsequent interviews. Additional data were compared with existing material and as analysis proceeded, initial codes were grouped into higher order concepts until a core concept was described. Interviewing continued until no new ideas emerged and concepts were well defined.

RESULTS

The response of carers to the role of managing technical health procedures in the home is presented in terms of five dispositions: (1) Embracing care, (2) Resisting, (3) Reluctant acceptance, (4) Relinquishing and (5) Being overwhelmed. These dispositions were not static and carers commonly changed between them. Embracing care included cognitive understanding of the purpose and benefits of a procedure; accepting a 'technical' solution; practical management; and an emotional response. Accepting embrace is primarily motivated by perceived benefits for the recipient. It may also be driven by a lack of alternatives. Resisting or reluctant acceptance results from a lack of understanding about the procedure or willingness to manage it. Carers need adequate support to avoid becoming overwhelmed, and there are times when it is appropriate to encourage them to relinquish care for the sake of their own needs.

CONCLUSIONS

The concept of embracing care encourages health professionals to extend their attention beyond simply the practical aspects of technical procedures to assessing and addressing carers' emotional and behavioural responses to health technology during the training process.

Shared decision-making about assistive technology for the child with severe neurologic impairment

Shared decision-making is a process that helps frame conversations about value-sensitive decisions, such as introduction of assistive technology for children with neurologic impairment. In the shared decision-making model, the health care provider elicits family values relevant to the decision, provides applicable evidence in the context of those values, and collaborates with the family to identify the preferred option. This article outlines clinical, quality of life, and ethical considerations for shared decision-making discussions with families of children with neurologic impairment about gastrostomy tube and tracheostomy tube placement.