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Harris B, Kern K, Benner C, Moses J, Artinian H. Quality Improvement Project Reducing Sputum Cultures for Pediatric Patients With a Tracheostomy. Hosp Pediatr 2024; 14:564-572. [PMID: 38916049 DOI: 10.1542/hpeds.2023-007125] [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: 01/11/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND AND OBJECTIVES Current research implies overuse of diagnostic testing and overtreatment in children with tracheostomies. There are no guidelines for obtaining sputum cultures for these patients, yet they are commonly obtained without significantly affecting management or outcomes. The aim of our quality improvement project was to decrease rate of sputum cultures in this population by 50%, from 64% to 32%. METHODS This was a single-center quality improvement project conducted in a pediatric emergency department (ED). Key drivers included: Standardized decision-making, appropriate culture collection, knowledge regarding colonization versus clinically relevant growth, and viral versus bacterial infections in this population. The study team developed an algorithm, used modification to electronic medical records orders, and provided education to drive change. Six months of preintervention and 12 months postintervention data were collected. Run charts/statistical process charts were created for the rate of cultures, length of stay, and return to the ED. RESULTS There were 159 patient encounters and the rate of sputum cultures decreased from 64% at baseline to 25% without change in length of stay or increased rate at which patients returned to the ED, including during local coronavirus disease 2019 and respiratory syncytial virus surges. We observed nonrandom data patterns after introduction of algorithm resulting in centerline shifts. CONCLUSIONS The study team was able to introduce an algorithm coinciding with a reduction in number of sputum cultures obtained. Next steps would be determining safety and efficacy of such an algorithm over a larger population.
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Affiliation(s)
- Baila Harris
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Kristina Kern
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Christopher Benner
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - James Moses
- Quality, Safety, and Experience, Corewell Health, Grand Rapids, Michigan
| | - Hovig Artinian
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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Morrison JM, Kono N, Rush M, Hahn A, Forster CS, Cogen JD, Thomson J, DeYoung SH, Bashiri S, Mack WJ, Neely MN, Simon TD, Russell CJ. Factors associated with tracheostomy-associated infection treatment: A multicenter observational study. Pediatr Pulmonol 2024. [PMID: 38860585 DOI: 10.1002/ppul.27117] [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: 03/06/2024] [Revised: 05/17/2024] [Accepted: 05/28/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE To characterize factors that influence the decision to treat suspected pediatric bacterial tracheostomy-associated respiratory infections (bTRAINs; e.g., pneumonia, tracheitis). METHODS We conducted a multicenter, prospective cohort study of children with pre-existing tracheostomy hospitalized at six children's hospitals for a suspected bTRAIN (receipt of respiratory culture plus ≥1 doses of an antibiotic within 48 h). The primary predictor was respiratory culture growth categorized as Pseudomonas aeruginosa, P. aeruginosa + ≥1 other bacterium, other bacteria alone, or normal flora/no growth. Our primary outcome was bTRAIN treatment with a complete course of antibiotics as documented by the discharge team. We used logistic regression with generalized estimating equations to identify the association between our primary predictor and outcome and to identify demographic, clinical, and diagnostic testing factors associated with treatment. RESULTS Of the 440 admissions among 289 patients meeting inclusion criteria, 307 (69.8%) had positive respiratory culture growth. Overall, 237 (53.9%) of admissions resulted in bTRAIN treatment. Relative to a negative culture, a culture positive for P. aeruginosa plus ≥1 other organism (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.02-5.0)] or ≥1 other organism alone (aOR: 2.8; 95% CI: 1.4-5.6)] was associated with treatment. Several clinical and diagnostic testing (respiratory Gram-stain and chest radiograph) findings were also associated with treatment. Positive respiratory viral testing was associated with reduced odds of treatment (aOR: 0.5; 95% CI: 0.2-0.9). CONCLUSIONS Positive respiratory cultures as well as clinical indicators of acute illness and nonculture test results were associated with bTRAIN treatment. Clinicians may be more comfortable withholding antibiotics when a virus is identified during testing.
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Affiliation(s)
- John M Morrison
- Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Naoko Kono
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Margaret Rush
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washingto, District Columbia, USA
- Division of Hospital Medicine, Children's National Hospital, Washington, District Columbia, USA
| | - Andrea Hahn
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washingto, District Columbia, USA
- Division of Infectious Diseases, Children's National Hospital, Washington, District Columbia, USA
- Center for Genetic Medicine Research, Children's National Research Institute, Washington, District Columbia, USA
| | - Catherine S Forster
- Divisions of Pediatric Hospital Medicine and Pediatric Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan D Cogen
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Joanna Thomson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sarah Hofman DeYoung
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Seattle Children's Hospital/University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington, USA
| | - Sowgand Bashiri
- Divisions of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Wendy J Mack
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Michael N Neely
- Division of Infectious Disease, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Tamara D Simon
- Divisions of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Christopher J Russell
- Divisions of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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García-Boyano M, Climent Alcalá FJ, Rodríguez Alonso A, García Fernández de Villalta M, Zubiaur Alonso O, Rabanal Retolaza I, Quiles Melero I, Calvo C, Escosa García L. Pneumonia in Children With Complex Chronic Conditions With Tracheostomy: An Emerging Challenge. Pediatr Infect Dis J 2024:00006454-990000000-00864. [PMID: 38753990 DOI: 10.1097/inf.0000000000004395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND Despite respiratory infections being a leading cause of hospitalization in children with tracheostomy tubes, there are no published guidelines for their diagnosis and management. This study aims to outline the clinical, laboratory and microbiological aspects of pneumonia in these children, along with the antibiotics used and outcomes. Additionally, it seeks to determine pneumonia incidence and associated risk factors. METHODS We conducted a retrospective study using the medical records of tracheostomized children at La Paz University Hospital in Madrid from 2010 to 2021. RESULTS Thirty-three pneumonia cases were observed in 25 tracheostomized children. Pseudomonas aeruginosa was the predominant bacterium (52%), followed by Escherichia coli, Staphylococcus aureus and Serratia marcescens. The same microorganism isolated in the tracheal aspirate culture during pneumonia was previously isolated in 83% of cases that had a similar culture, with some growth obtained within 7-30 days prior. Multiplex respiratory PCR detected respiratory viruses in 73% of cases tested. Antibiotic treatment was administered in all cases except 1, mostly intravenously (81%), with piperacillin/tazobactam and meropenem being commonly used. Only 1 of the described episodes had a fatal outcome. CONCLUSIONS It is advisable to include coverage for P. aeruginosa, E. coli, S. aureus, and S. marcescens in the empirical antibiotic treatment for pneumonia in tracheostomized children, along with the microorganisms identified in tracheal cultures obtained within 7-30 days prior, if available. A positive PCR for respiratory viruses is often discovered in bacterial pneumonia in tracheostomized children.
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Affiliation(s)
| | | | | | | | | | | | | | - Cristina Calvo
- From the Pediatric Infectious and Tropical Diseases Department
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
- Institute for Health Research IdiPAZ, Madrid, Spain
- Pediatric Department, Autonomous University, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Escosa García
- Department of Pediatric Internal Medicine
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
- Institute for Health Research IdiPAZ, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Foran PL, Benjamin WJ, Sperry ED, Best SR, Boisen SE, Bosworth B, Brodsky MB, Shaye D, Brenner MJ, Pandian V. Tracheostomy-related durable medical equipment: Insurance coverage, gaps, and barriers. Am J Otolaryngol 2024; 45:104179. [PMID: 38118384 PMCID: PMC10939813 DOI: 10.1016/j.amjoto.2023.104179] [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: 10/08/2023] [Accepted: 12/05/2023] [Indexed: 12/22/2023]
Abstract
PURPOSE Tracheostomy care is supply- and resource-intensive, and airway-related adverse events in community settings have high rates of readmission and mortality. Devices are often implicated in harm, but little is known about insurance coverage, gaps, and barriers to obtaining tracheostomy-related medically necessary durable medical equipment. We aimed to identify barriers patients may encounter in procuring tracheostomy-related durable medical equipment through insurance plan coverage. MATERIALS AND METHODS Tracheostomy-related durable medical equipment provisions were evaluated across insurers, extracting data via structured telephone interviews and web-based searches. Each insurance company was contacted four times and queried iteratively regarding the range of coverage and co-pay policies. Outcome measures include call duration, consistency of explanation of benefits, and the number of transfers and disconnects. We also identified six qualitative themes from patient interviews. RESULTS Tracheostomy-related durable medical equipment coverage was offered in some form by 98.1 % (53/54) of plans across 11 insurers studied. Co-pays or deductibles were required in 42.6 % (23/54). There was significant variability in out-of-pocket expenditures. Fixed co-pays ranged from $0-30, and floating co-pays ranged from 0 to 40 %. During phone interviews, mean call duration was 19 ± 10 min, with an average of 2 ± 1 transfers between agents. Repeated calls revealed high information variability (mean score 2.4 ± 1.5). Insurance sites proved challenging to navigate, scoring poorly on usability, literacy, and information quality. CONCLUSIONS Several factors may limit access to potentially life-saving durable medical equipment for patients with tracheostomy. Barriers include out-of-pocket expenditures, lack of transparency on coverage, and low-quality information. Further research is necessary to evaluate patient outcomes.
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Affiliation(s)
- Palmer L Foran
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University, Baltimore, MD, United States
| | | | | | - Simon R Best
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University, Baltimore, MD, United States
| | - Sarah E Boisen
- Pediatric Intensive Care Unit, Seattle Children's Hospital, Seattle, WA, United States
| | | | - Martin B Brodsky
- Head and Neck Institute, Cleveland Clinic, Cleveland, OH; Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, United States; Department of Physical and Rehabilitation, Johns Hopkins University, Baltimore, MD, United States
| | - David Shaye
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School Massachusetts Eye and Ear, United States
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, MI, United States; Global Tracheostomy Collaborative, Raleigh, NC, United States; Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Vinciya Pandian
- Center for Immersive Learning and Digital Innovation Johns Hopkins University School of Nursing, Baltimore, MD, United States; Global Tracheostomy Collaborative, Raleigh, NC, United States; Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, United States; Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States.
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Collaco JM, Tsukahara KR, Tracy MC, Sheils CA, Rice JL, Rhein LM, Popova AP, Nelin L, Miller AN, Manimtim WM, Levin JC, Lai K, Kaslow JA, Hayden LP, Bansal M, Austin ED, Aoyama B, Akangire G, Agarwal A, Villafranco N, McGrath-Morrow SA. Number of children in the household influences respiratory morbidities in children with bronchopulmonary dysplasia in the outpatient setting. Pediatr Pulmonol 2024; 59:314-322. [PMID: 37937888 PMCID: PMC10872663 DOI: 10.1002/ppul.26747] [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: 07/14/2023] [Revised: 09/20/2023] [Accepted: 10/28/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), a common complication of prematurity, is associated with outpatient morbidities, including respiratory exacerbations. Daycare attendance is associated with increased rates of acute and chronic morbidities in children with BPD. We sought to determine if additional children in the household conferred similar risks for children with BPD. METHODS The number of children in the household and clinical outcomes were obtained via validated instruments for 933 subjects recruited from 13 BPD specialty clinics in the United States. Clustered logistic regression models were used to test for associations. RESULTS The mean gestational age of the study population was 26.5 ± 2.2 weeks and most subjects (69.1%) had severe BPD. The mean number of children in households (including the subject) was 2.1 ± 1.3 children. Each additional child in the household was associated with a 13% increased risk for hospital admission, 13% increased risk for antibiotic use for respiratory illnesses, 10% increased risk for coughing/wheezing/shortness of breath, 14% increased risk for nighttime symptoms, and 18% increased risk for rescue medication use. Additional analyses found that the increased risks were most prominent when there were three or more other children in the household. CONCLUSIONS We observed that additional children in the household were a risk factor for adverse respiratory outcomes. We speculate that secondary person-to-person transmission of respiratory viral infections drives this finding. While this risk factor is not easily modified, measures do exist to mitigate this disease burden. Further studies are needed to define best practices for mitigating this risk associated with household viral transmission.
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Affiliation(s)
- Joseph M. Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, MD
| | - Katharine R. Tsukahara
- Division of Pediatric Pulmonary and Sleep Medicine, University of Utah, Salt Lake City, UT
| | - Michael C. Tracy
- Division of Pediatric Pulmonary, Asthma and Sleep Medicine, Stanford University, Stanford, CA
| | - Catherine A. Sheils
- Division of Pulmonary Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Jessica L. Rice
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Lawrence M Rhein
- Neonatal-Perinatal Medicine/Pediatric Pulmonology, University of Massachusetts, Worcester, MA
| | | | - Leif Nelin
- Division of Neonatology, Nationwide Children’s Hospital and Ohio State University, Columbus, OH
| | - Audrey N. Miller
- Division of Neonatology, Nationwide Children’s Hospital and Ohio State University, Columbus, OH
| | - Winston M. Manimtim
- Division of Neonatology, Children’s Mercy-Kansas City and University of Missouri Kansas City School of Medicine
| | - Jonathan C. Levin
- Division of Pulmonary Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Khanh Lai
- Division of Pediatric Pulmonary and Sleep Medicine, University of Utah, Salt Lake City, UT
| | - Jacob A. Kaslow
- Pulmonary Medicine, Vanderbilt University and Vanderbilt University Medical Center, Nashville, TN
| | - Lystra P. Hayden
- Division of Pulmonary Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Manvi Bansal
- Pulmonology and Sleep Medicine, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Eric D. Austin
- Pulmonary Medicine, Vanderbilt University and Vanderbilt University Medical Center, Nashville, TN
| | - Brianna Aoyama
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, MD
| | - Gangaram Akangire
- Division of Neonatology, Children’s Mercy-Kansas City and University of Missouri Kansas City School of Medicine
| | - Amit Agarwal
- Division of Pulmonary Medicine, Arkansas Children’s Hospital and University of Arkansas for Medical Sciences, Little Rock, AR
| | - Natalie Villafranco
- Pulmonary Medicine, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Sharon A. McGrath-Morrow
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
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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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García-Boyano M, Alcalá FJC, Alonso AR, de Villalta MGF, Alonso OZ, Retolaza IR, Melero IQ, Calvo C, García LE. Microbiological patterns of bacterial infections in tracheostomized children: Reducing uncertainty in continuous care. Pediatr Pulmonol 2023; 58:3507-3515. [PMID: 37701951 DOI: 10.1002/ppul.26684] [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: 06/15/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Respiratory infections are the most frequent cause of hospitalization in tracheostomized children. However, there is a lack of publications to guide their management. The primary objective was to describe the microbiological isolates and their antibiotic susceptibilities of bacterial respiratory infections in a population of tracheostomized children. METHODS Retrospective follow-up study of children with tracheostomy seen at a tertiary hospital. Respiratory infection episodes in patients under 18 years of age who had a tracheostomy and bacterial isolation with a count ≥104 Colony Forming Units/mL in tracheal aspirate were included. RESULTS The study analyzed 328 respiratory infection episodes: 164 tracheobronchitis (50%), 112 nonspecific respiratory episodes (34.1%), and 52 pneumonias (15.9%). The most commonly isolated microorganisms were Pseudomonas aeruginosa, Serratia marcescens, and Staphylococcus aureus. The antibiotics that exhibited the highest effectiveness were meropenem (92%), imipenem (87%), and levofloxacin (86%). When hospitalization exceeded 7 days, there was a higher chance of isolating Escherichia coli and Klebsiella pneumoniae (p < 0.001 and p = 0.001, respectively), as well as an increased rate of multidrug resistance (27% vs. 7%, p = 0.035). In 75.3% of cases, the microorganism had been previously isolated in a sample taken 7-30 days before the current one, with a higher frequency observed in the case of P. aeruginosa (95.2%) compared to other microorganisms (65.3%, p < 0.001). CONCLUSIONS Meropenem, imipenem, and levofloxacin provided the most effective coverage for these infections. The risk of multidrug resistance increased with longer hospital stays, especially for E. coli and K. pneumoniae. Recent isolation of P. aeruginosa may justify empirical coverage.
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Affiliation(s)
| | | | - Aroa Rodríguez Alonso
- Department of Pediatric Internal Medicine, La Paz University Hospital, Madrid, Spain
| | | | - Oihane Zubiaur Alonso
- Department of Pediatric Internal Medicine, La Paz University Hospital, Madrid, Spain
| | | | | | - Cristina Calvo
- Infectious Diseases Department, La Paz University Hospital, Madrid, Spain
- RITIP (Red de Investigación Translacional en Infectología Pediátrica), Spain
- Área de Enfermedades Infecciosas del Centro de Investigación Biomédica en Red del Instituto de Salud Carlos III (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Escosa García
- Department of Pediatric Internal Medicine, La Paz University Hospital, Madrid, Spain
- RITIP (Red de Investigación Translacional en Infectología Pediátrica), Spain
- Área de Enfermedades Infecciosas del Centro de Investigación Biomédica en Red del Instituto de Salud Carlos III (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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8
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Birru F, Gerdung CA, Castro-Codesal M. Microbiology and management of respiratory infections in children with tracheostomy. Paediatr Respir Rev 2023; 48:39-46. [PMID: 37330411 DOI: 10.1016/j.prrv.2023.05.006] [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: 04/17/2023] [Accepted: 05/23/2023] [Indexed: 06/19/2023]
Abstract
Tracheostomy-related respiratory infections are common, though the diagnosis and management can be challenging in children. The goal of this review article was to provide an overview of the current knowledge known about recognizing and treating respiratory infections in this population and to emphasize future areas for further research. While several small and retrospective papers attempt to provide information, there remain more questions than answers. We have reviewed ten published articles to understand this topic, bringing to light significant variation in clinical practices across institutions. While identifying the microbiology is important, it is also crucial to recognize when to treat. Differentiating acute infection, chronic infection, and colonization are important features that influence the treatment of lower respiratory tract infection in children with a tracheostomy.
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Affiliation(s)
- F Birru
- Division of Pediatric Respiratory Medicine, University of Alberta, Edmonton, AB, Canada.
| | - C A Gerdung
- Division of Pediatric Respiratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Castro-Codesal
- Division of Pediatric Respiratory Medicine, University of Alberta, Edmonton, AB, Canada
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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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10
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Kukora SK, Van Horn A, Thatcher A, Pace RA, Schumacher RE, Attar MA. Risk of death at home or on hospital readmission after discharge with pediatric tracheostomy. J Perinatol 2023; 43:1020-1028. [PMID: 37443270 DOI: 10.1038/s41372-023-01721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE To evaluate outcomes of patients discharged home following tracheostomy, including the timing and place of death for non-survivors. STUDY DESIGN We retrospectively reviewed medical records of infants undergoing tracheostomy between 2006 and 2017, within the first year of life for congenital or acquired neonatal conditions. RESULTS Of the 224 patients discharged after tracheostomy, 127 (57%) required home mechanical ventilation (MV). Overall, 40 (18%) patients died (65% were on MV); 38% of the deaths occurred at home and 63% at a subsequent hospitalization. Having tube feeding was identified as significantly associated with increased mortality on multivariate analysis. Having a tracheostomy for upper airway obstruction was the only variable significantly associated with increased risk of death at home on multivariate analysis. CONCLUSIONS Having tube feeding was associated with increased risk of death overall and having the tracheostomy for obstructive airway conditions was associated with death occurring at home.
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Affiliation(s)
- Stephanie K Kukora
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Adam Van Horn
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Aaron Thatcher
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Rachel A Pace
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Robert E Schumacher
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Mohammad A Attar
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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11
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Manimtim WM, Agarwal A, Alexiou S, Levin JC, Aoyama B, Austin ED, Bansal M, Bauer SE, Cristea AI, Fierro JL, Garey DM, Hayden LP, Kaslow JA, Miller AN, Moore PE, Nelin LD, Popova AP, Rice JL, Tracy MC, Baker CD, Dawson SK, Eldredge LC, Lai K, Rhein LM, Siddaiah R, Villafranco N, McGrath-Morrow SA, Collaco JM. Respiratory Outcomes for Ventilator-Dependent Children With Bronchopulmonary Dysplasia. Pediatrics 2023; 151:e2022060651. [PMID: 37122061 PMCID: PMC10158083 DOI: 10.1542/peds.2022-060651] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 05/02/2023] Open
Abstract
OBJECTIVES To describe outpatient respiratory outcomes and center-level variability among children with severe bronchopulmonary dysplasia (BPD) who require tracheostomy and long-term mechanical ventilation. METHODS Retrospective cohort of subjects with severe BPD, born between 2016 and 2021, who received tracheostomy and were discharged on home ventilator support from 12 tertiary care centers participating in the BPD Collaborative Outpatient Registry. Timing of key respiratory events including time to tracheostomy placement, initial hospital discharge, first outpatient clinic visit, liberation from the ventilator, and decannulation were assessed using Kaplan-Meier analysis. Differences between centers for the timing of events were assessed via log-rank tests. RESULTS There were 155 patients who met inclusion criteria. Median age at the time of the study was 32 months. The median age of tracheostomy placement was 5 months (48 weeks' postmenstrual age). The median ages of hospital discharge and first respiratory clinic visit were 10 months and 11 months of age, respectively. During the study period, 64% of the subjects were liberated from the ventilator at a median age of 27 months and 32% were decannulated at a median age of 49 months. The median ages for all key events differed significantly by center (P ≤ .001 for all events). CONCLUSIONS There is wide variability in the outpatient respiratory outcomes of ventilator-dependent infants and children with severe BPD. Further studies are needed to identify the factors that contribute to variability in practice among the different BPD outpatient centers, which may include inpatient practices.
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Affiliation(s)
- Winston M. Manimtim
- Division of Neonatology, Children’s Mercy-Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Amit Agarwal
- Division of Pulmonary Medicine, Arkansas Children’s Hospital and University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Stamatia Alexiou
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan C. Levin
- Division of Pulmonary Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brianna Aoyama
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Eric D. Austin
- Pulmonary Medicine, Vanderbilt University and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manvi Bansal
- Pulmonology and Sleep Medicine, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Sarah E. Bauer
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Children’s Hospital and Indiana University, Indianapolis, Indiana
| | - A. Ioana Cristea
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Children’s Hospital and Indiana University, Indianapolis, Indiana
| | - Julie L. Fierro
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna M. Garey
- Department of Pediatrics, Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, Arizona
| | - Lystra P. Hayden
- Division of Pulmonary Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jacob A. Kaslow
- Pulmonary Medicine, Vanderbilt University and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Audrey N. Miller
- Division of Neonatology, Nationwide Children’s Hospital and Ohio State University, Columbus, Ohio
| | - Paul E. Moore
- Pulmonology and Sleep Medicine, Children’s Hospital of Los Angeles, Los Angeles, California
| | - Leif D. Nelin
- Division of Neonatology, Nationwide Children’s Hospital and Ohio State University, Columbus, Ohio
| | | | - Jessica L. Rice
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C. Tracy
- Division of Pediatric Pulmonary, Asthma and Sleep Medicine, Stanford University, Stanford, California
| | - Christopher D. Baker
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Sara K. Dawson
- Department of Pediatrics, Medical College of Wisconsin Milwaukee, Wisconsin
| | - Laurie C. Eldredge
- Division of Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington
| | - Khanh Lai
- Division of Pediatric Pulmonary and Sleep Medicine, University of Utah, Salt Lake City, Utah
| | - Lawrence M. Rhein
- Neonatal-Perinatal Medicine/Pediatric Pulmonology, University of Massachusetts, Worcester, Massachusetts
| | - Roopa Siddaiah
- Pediatric Pulmonology, Penn State Health, Hershey Pennsylvania
| | - Natalie Villafranco
- Pulmonary Medicine, Texas Children’s Hospital and Baylor University, Houston, Texas
| | - Sharon A. McGrath-Morrow
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph M. Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, Maryland
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12
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Akangire G, Lachica C, Noel-MacDonnell J, Begley A, Sampath V, Truog W, Manimtim W. Outcomes of infants with severe bronchopulmonary dysplasia who received tracheostomy and home ventilation. Pediatr Pulmonol 2023; 58:753-762. [PMID: 36377273 DOI: 10.1002/ppul.26248] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/02/2022] [Accepted: 11/13/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the survival rate, timing of liberation from the ventilator, and factors favorable for decannulation among infants with severe bronchopulmonary dysplasia (sBPD) who received tracheostomy. METHODS Demographics and clinical outcomes were obtained through retrospective chart review of 98 infants with sBPD who were born between 2004 and 2017, received tracheostomy at <1 year of age, and were followed in the Infant Tracheostomy and Home Ventilator clinic up to 4 years of age. RESULTS The number of infants with sBPD who received tracheostomy increased significantly over the study period. The median age at tracheostomy was 4 months (IQR 3, 5) or 43 weeks corrected gestational age; the median age at NICU discharge was 7 months (IQR 6, 9). At 48 months of age, all subjects had been liberated from the ventilator, at a median age of 24 months (IQR 18, 29); 52% had been decannulated with a median age at decannulation of 32 months (IQR 26, 39). Only 1 (1%) infant died. Multivariate logistic regression showed infants who were White, liberated from the ventilator by 24 months of age and have public insurance had significantly greater odds of being decannulated by 48 months of age. Tracheobronchomalacia was associated with decreased odds of decannulation. CONCLUSION Infants with sBPD who received tracheostomy had an excellent survival rate. Liberation from home ventilation and decannulation are likely to occur by 4 years of age.
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Affiliation(s)
- Gangaram Akangire
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Charisse Lachica
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Janelle Noel-MacDonnell
- Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA.,Department of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Addie Begley
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - William Truog
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Winston Manimtim
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
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13
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Acorda DE, Jackson A, Lam AK, Molchen W. Overwhelmed to ownership: The lived experience of parents learning to become caregivers of children with tracheostomies. Int J Pediatr Otorhinolaryngol 2022; 163:111364. [PMID: 36330951 DOI: 10.1016/j.ijporl.2022.111364] [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: 06/13/2022] [Revised: 10/06/2022] [Accepted: 10/14/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | | | - Anne K Lam
- Texas Children's Hospital, Houston, TX, USA
| | - Wallis Molchen
- Texas Children's Hospital, Houston, TX, USA; Section of Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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14
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Beams DR, Chorney SR, Kou YF, Teplitzky TB, Wynings EM, Johnson RF. Emergency Department Visits and Hospitalizations After Pediatric Tracheostomy. Laryngoscope 2022. [PMID: 36177909 DOI: 10.1002/lary.30416] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 08/16/2022] [Accepted: 09/08/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy. METHODS A prospective cohort of children (<18 years) with a tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits). RESULTS A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory-related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18-3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35-5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47-10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy-related complications, which accounted for 4.8% of all encounters. A sub-analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure. CONCLUSION Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy-related visits are uncommon, strategies to anticipate and decrease respiratory-related admissions may have the most impact. LEVEL OF EVIDENCE 3 Laryngoscope, 2022.
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Affiliation(s)
- Dylan R Beams
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center Dallas, Dallas, Texas, U.S.A
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center Dallas, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children 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, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children Medical Center Dallas, Dallas, Texas, U.S.A
| | - Taylor B Teplitzky
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center Dallas, Dallas, Texas, U.S.A
| | - Erin M Wynings
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern 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, Dallas, Texas, U.S.A.,Department of Pediatric Otolaryngology, Children Medical Center Dallas, Dallas, Texas, U.S.A
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15
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Morrison JM, Hassan A, Kysh L, Dudas RA, Russell CJ. Diagnosis, management, and outcomes of pediatric tracheostomy-associated infections: A scoping review. Pediatr Pulmonol 2022; 57:1145-1156. [PMID: 35229491 PMCID: PMC9313552 DOI: 10.1002/ppul.25873] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/15/2022] [Accepted: 02/27/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Children with tracheostomy are frequently admitted to the hospital for tracheostomy-associated respiratory infections (TRAINs). However, there remains a paucity of evidence to direct the diagnosis, treatment, and prevention of TRAINs. An important first step to addressing this knowledge gap is to synthesize existing data regarding TRAINs to inform current practice and facilitate innovation. DATA SOURCES We searched PubMed, Embase, Cochrane Library, CINAHL, and Web of Science from inception to October 2020. Original research articles and published abstracts including children and young adults 0-21 years of age with tracheostomy were included. Included studies assessed the clinical definitions of and risk factors for TRAINs, microbiologic epidemiology and colonization of tracheostomies, and treatment and outcomes of TRAINs. DATA SYNTHESIS Out of 5755 studies identified in the search, 78 full-text studies were included in the final review. A substantial number of studies focused on the detection of specific pathogens in respiratory cultures including Pseudomonas aeruginosa. Several different definitions of TRAIN including clinical, microbiologic, and laboratory testing results were utilized; however, no uniform set of criteria were identified. The few studies focused on treatment and prevention of TRAIN emphasized the role of empiric antimicrobial therapy and the use of inhaled antibiotics. CONCLUSIONS Despite a growing number of research articles studying TRAINs, there is a paucity of prospective interventional trials to guide the diagnosis, treatment, and prevention of respiratory disease in this vulnerable population. Future research should include studies of interventions designed to improve short- and long-term respiratory-related outcomes of children with tracheostomy.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Amir Hassan
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Lynn Kysh
- The Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Robert A Dudas
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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16
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Gipsman A, Prero M, Toltzis P, Craven D. Tracheobronchitis in children with tracheostomy tubes: Overview of a challenging problem. Pediatr Pulmonol 2022; 57:814-821. [PMID: 34981895 DOI: 10.1002/ppul.25814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 12/21/2022]
Abstract
Tracheobronchitis is common in children with tracheostomy tubes. These children are predisposed to respiratory infections due to the bypassing of normal upper airway defense mechanisms by the tracheostomy, bacterial colonization of the tracheostomy tube itself, and underlying medical conditions. Diagnosis of bacterial tracheobronchitis is challenging due to the difficulty in differentiating between bacterial colonization and infection, as well as between viral and bacterial etiologies. Difficulty in diagnosis complicates management decisions, and there are currently no consensus guidelines to assist clinicians in the treatment of these patients. Frequent administration of systemic antibiotics causes adverse effects and leads to the emergence of resistant organisms. Topical administration of antibiotics via nebulization or direct instillation may lead to a significantly higher concentration of drug in the upper and lower airways without causing systemic side effects, although therapeutic trials in children with tracheostomy tubes are lacking. Several preventative measures such as regular airway clearance and the use of a speaking valve may mitigate the risk of developing respiratory infections.
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Affiliation(s)
- Alexander Gipsman
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Moshe Prero
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Philip Toltzis
- Department of Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel Craven
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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17
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Finding a New Normal: Maternal Experiences Transitioning to Home From the Neonatal Intensive Care Unit Caring for Technology-Dependent Infants. Adv Neonatal Care 2022; 22:E2-E12. [PMID: 35113827 DOI: 10.1097/anc.0000000000000850] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infants discharged from the neonatal intensive care unit (NICU) dependent on medical technology (eg, respiratory or nutritional support) are a growing vulnerable population. These infants are medically fragile, prone to emergency department visits and readmissions, and require increased caregiver demands at home. The experiences of their maternal caregiver's after NICU discharge however, are not well understood. PURPOSE This qualitative descriptive study addressed this knowledge gap by interviewing mothers of technology-dependent infants about their experience during their first 2 weeks transitioning to home from the NICU. This is a critical period in which mothers must first assume advanced caretaking responsibilities in the home. METHODS Eight mothers participated in semistructured audio-recorded interviews via the Web conferencing system Zoom and completed demographic questionnaires. RESULTS Five themes emerged from the data that described essential features of the mothers' transition to home: (a) needing coordinated discharge care; (b) establishing a routine; (c) being an advocate; (d) having a support system; and (e) finding normalcy. An additional important finding of this study was the presence of maternal posttraumatic stress and postpartum depression. IMPLICATIONS FOR PRACTICE Results highlight the importance of providing mothers hands-on practice opportunities and identifying social support and home healthcare options prior to discharge of technology-dependent infants. IMPLICATIONS FOR RESEARCH Future research should focus on multidisciplinary interventions targeted toward discharge preparation, transitional support, and understanding maternal psychiatric symptoms among mothers of technology-dependent infants.
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18
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Akangire G, Manimtim W. Tracheostomy in infants with severe bronchopulmonary dysplasia: A review. Front Pediatr 2022; 10:1066367. [PMID: 36714650 PMCID: PMC9878282 DOI: 10.3389/fped.2022.1066367] [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: 10/10/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
In recent years, with increased survival of infants with severe bronchopulmonary dysplasia (BPD), long term ventilation due to severe BPD has increased and become the most common indication for tracheostomy in infants less than one year of age. Evidence shows that tracheostomy in severe BPD may improve short- and long-term respiratory and neurodevelopmental outcomes. However, there is significant variation among centers in the indication, timing, intensive care management, and follow-up care after hospital discharge of infants with severe BPD who received tracheostomy for chronic ventilation. The timing of liberation from the ventilator, odds of decannulation, rate of rehospitalization, growth, and neurodevelopment are all clinically important outcomes that can guide both clinicians and parents to make a well-informed decision when choosing tracheostomy and long-term assisted ventilation for infants with severe BPD. This review summarizes the current literature regarding the indications and timing of tracheostomy placement in infants with severe BPD, highlights center variability in both intensive care and outpatient follow-up settings, and describes outcomes of infants with severe BPD who received tracheostomy.
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Affiliation(s)
- Gangaram Akangire
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, United States.,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Winston Manimtim
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, United States.,Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
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19
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Akangire G, Begley A, Lachica C, Jensen DR, Manimtim W. Impact of the COVID-19 Pandemic on Children <5 Years of Age With Tracheostomy and Home Ventilator Dependence. Clin Pediatr (Phila) 2021; 60:549-553. [PMID: 34541923 DOI: 10.1177/00099228211046697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gangaram Akangire
- Children's Mercy Kansas City, MO, USA.,University of Missouri Kansas City, MO, USA
| | | | - Charisse Lachica
- Children's Mercy Kansas City, MO, USA.,University of Missouri Kansas City, MO, USA
| | - Daniel R Jensen
- Children's Mercy Kansas City, MO, USA.,University of Missouri Kansas City, MO, USA
| | - Winston Manimtim
- Children's Mercy Kansas City, MO, USA.,University of Missouri Kansas City, MO, USA
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20
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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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21
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Attar MA, Pace RA, Schumacher RE. Back Transfer of Infants with Tracheostomies: A Regional Center Experience. J Pediatr Intensive Care 2021; 12:118-124. [PMID: 37082470 PMCID: PMC10113006 DOI: 10.1055/s-0041-1730929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractWe describe our center's experience with the back transfer of infants following tracheostomies. We conducted a retrospective cohort study of infants transferred to pediatric critical care units of our regional center with conditions originating in the neonatal period who underwent tracheostomy during the hospitalization within their first year of life between 2006 and 2017. Recovering patients are discharged home or transferred back to the referring hospitals. We evaluated patient characteristics, destination of discharge and type of pulmonary support at discharge, and mechanical ventilation (MV) or tracheotomy masks (TM). Of the 139 included patients, 72% were transferred to the neonatal intensive care unit, 21% to the pediatric cardiothoracic unit, and 7% to the pediatric intensive care unit. Their median gestational age was 35 weeks. They were admitted at a median 22 days of life and lived at a median distance of 56 miles from our center. Furthermore, 34 infants (24%) were back transferred closer to their homes (23 with MV and 11 with TM), and 84 (60%) were discharged home (53 on MV and 31 on TM). Twenty-one patients (15%) died in the hospital (before discharge or transfer). Back transferred patients on MV had a significantly shorter duration between tracheostomy and transfer compared with those discharged home from our center: MV (median = 22 vs. 103 days, p < 0.0001) and TM (median = 13 vs. 35 days, p < 0.0001). Back transfer of infants with tracheostomies closer to their homes was associated with a significantly shorter hospitalization and more efficient use of the subspecialized resources at the RC.
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Affiliation(s)
- Mohammad A. Attar
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, United States
| | - Rachael A. Pace
- Department of Critical Care Support Services, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Robert E. Schumacher
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, United States
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Respiratory, growth, and survival outcomes of infants with tracheostomy and ventilator dependence. Pediatr Res 2021; 90:381-389. [PMID: 33010793 PMCID: PMC7605149 DOI: 10.1038/s41390-020-01183-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Outcome of infants with tracheostomy have not been well described in the literature. Our objective was to describe the respiratory, growth, and survival outcomes of infants with tracheostomy. METHODS A retrospective study was conducted on 204 infants born between 2005 and 2015 with tracheostomy at <1 year of age and follow-up in the Infant Tracheostomy and Home Ventilator Clinic up to 4 years of age. RESULTS The mean age at tracheostomy was 4.5 months with median age of 3 months. Median age of decannulation was 32 months. The time from tracheostomy placement to complete discontinuation of mechanical ventilation was 15.4 months and from tracheostomy to decannulation was 33.8 months. Mortality rate was 21% and median age of death was 18 months. Preterm infants with acquired airway and lung disease (BPD) and born at <28 weeks' gestation had a significantly higher survival rate compared to term infants. The z-scores for weight and weight for length improved from the time of discharge (mean chronological age 6.5 months) to first year and remained consistent through 3 years. CONCLUSIONS Premature infants had a higher rate of discontinuation of mechanical ventilation and decannulation compared to term infants. These infants showed consistent growth and comparable survival rate. IMPACT Infants with tracheostomy and ventilator dependence followed in a multidisciplinary clinic model may have improved survival, growth, and earlier time to decannulation. Preterm infants with acquired airway and lung disease (BPD) with tracheostomy had a higher survival rate compared to term infants with various tracheostomy indications. The age at tracheostomy in infants was 4.5 months and of decannulation was 37 months. Time from tracheostomy to complete discontinuation of mechanical ventilation was 15.4 months. Addition of this data to the sparse literature will be crucial in counseling the families and education of medical staff.
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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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Paes B, Saleem M, Kim D, Lanctôt KL, Mitchell I. Respiratory illness and respiratory syncytial virus hospitalization in infants with a tracheostomy following prophylaxis with palivizumab. Eur J Clin Microbiol Infect Dis 2019; 38:1561-1568. [DOI: 10.1007/s10096-019-03588-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/13/2019] [Indexed: 11/28/2022]
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