Impact of tracheostomy on language and cognitive development in infants with severe bronchopulmonary dysplasia

Interdisciplinary clinical bronchopulmonary dysplasia programs: development, evolution, and maturation

Multidisciplinary bronchopulmonary dysplasia (BPD) programs provide improved and consistent medical management, care of the developing infant, family support, and smoother transitions in care resulting in improved survival, pulmonary, and extra-pulmonary outcomes. This review summarizes the benefits of interdisciplinary BPD management, as well as strategies for initial programmatic development, program growth, and maintenance at centers across the United States factoring in institutional, provider, and parent reported goals that were derived from a consensus conference on BPD management.

The impact of early tracheostomy on neurodevelopmental outcomes of infants with severe bronchopulmonary dysplasia exposed to postnatal corticosteroids

OBJECTIVE

To compare the cognitive, language and motor scores of infants with severe BPD exposed to postnatal corticosteroids (PCS) and had early (ET), late (LT) or no tracheostomy (NT).

METHODS

Retrospective study was designed to compare the developmental outcomes of 71 infants born between 2010 and 2017 with severe BPD exposed to PCS and had ET (≤122 days), LT (>122 days), or NT.

RESULTS

Cognitive scores were lower in LT versus NT and ET (p = 0.050); motor scores were worse in LT versus NT and ET (p = 0.004). Dexamethasone use was higher in LT versus NT and ET (p = 0.040). Adjusted for PCS, odds for major cognitive impairment were 90% less in ET versus LT. Trend for improved language and motor outcomes was seen in ET versus LT.

CONCLUSION

Infants with severe BPD exposed to PCS and had ET had significantly better cognitive, and trend toward improved language and motor outcomes.

In-hospital mortality and length of hospital stay in infants requiring tracheostomy with bronchopulmonary dysplasia

PURPOSE

To investigate in-hospital mortality and hospital length of stay (LOS) in infants requiring tracheostomy with bronchopulmonary dysplasia (BPD).

METHODS

We explored the correlation between tracheostomy with in-hospital mortality and LOS in infant patients hospitalized with BPD, using the data from Nationwide Inpatient Sample between 2008 and 2017 in the United States. In-hospital mortality and LOS was compared in patients who underwent tracheostomy with those patients who did not after propensity-score matching.

RESULTS

A total of 10,262 children ≤2 years old hospitalized with BPD, 847 (8%) underwent tracheostomy, and 821 patients underwent tracheostomy were matched with 1602 patients without tracheostomy. Tracheostomy group was correlated with higher in-hospital mortality(OR(95%CI):2.98(2.25-3.95)) and prolonged LOS(absolute difference(95%CI):97.0(85.6-108.4)).

CONCLUSIONS

Tracheostomy was correlated with increased in-hospital mortality and prolonged LOS. Such information may contribute to better decision-making process between clinicians and parents regarding tracheostomy to manage parent expectations, as well as better interdisciplinary teamwork.

Optimizing trajectories of social adaptive competencies after extreme prematurity during the first 1000 days

Over 75% of surviving extremely preterm infants do not have major neurodevelopmental disabilities; however, more than half face difficulties with communication, coordination, attention, learning, social, and executive function abilities. These "minor" challenges can have a negative impact on educational and social outcomes, resulting in physical, behavioral, and social health problems in adulthood. We will review assessment tools for social-emotional and adaptive functional skills in early childhood as these determine family and early childhood supports. We highlight bronchopulmonary dysplasia as an example of the critical intersections of parental wellbeing, medical and developmental adaptive trajectories in infancy and early childhood, and partnerships between child neurologists and community medical and developmental professionals. We examine studies of engaging parents to promote developmental trajectories, with a focus on supporting parent-child interactions that underlie communication, social-adaptive behaviors, and learning in the first 1000 days of life. Recommendations for neurodevelopmental surveillance and screening of extremely preterm infants can also be applied to infants with other risk factors for altered neurodevelopment.

To Trach or Not To Trach: Long-term Tracheostomy Outcomes in Infants with BPD

See Bonus NeoBriefs videos and downloadable teaching slides Infants born preterm who are diagnosed with bronchopulmonary dysplasia (BPD) demonstrate a wide spectrum of illness severity. For infants with the most severe forms of BPD, safe discharge from the hospital may only be possible by providing long-term ventilation via a surgically placed tracheostomy. Though tracheostomy placement in infants with BPD is infrequent, recent reports suggest that rates of tracheostomy placement are increasing in this population. Even though there are known respiratory and neurodevelopmental risks associated with tracheostomy placement, no evidence-based criteria or consensus clinical practice guidelines exist to inform tracheostomy placement in this growing and vulnerable population. An incomplete knowledge of long-term post-tracheostomy outcomes in infants with BPD may unduly bias medical decision-making and family counseling regarding tracheostomy placement. This review aims to summarize our current knowledge of the epidemiology and long-term outcomes of tracheostomy placement in infants with BPD to provide a family-centered framework for tracheostomy counseling.

Hyperinflation and its association with successful transition to home ventilator devices in infants with chronic respiratory failure and severe bronchopulmonary dysplasia

OBJECTIVE

To estimate the association between lung hyperinflation and the time to successful transition to home ventilators in infants with sBPD and chronic respiratory failure.

DESIGN/METHODS

Infants with sBPD <32 weeks' gestation who received tracheostomies were identified. Hyperinflation was the main exposure. Time from tracheostomy to successful transition to the home ventilator was the main outcome. Kaplan-Meier and multivariable Cox proportional hazards were used to estimate the relationships between hyperinflation and the main outcome.

RESULTS

Sixty-two infants were included; 26 (42%) were hyperinflated. Eleven died before transition, and 51 successfully transitioned. Hyperinflation was associated with both mortality (31% vs 8.3%, p = 0.02) and an increased duration (72 vs. 56 days) to successful transition (hazard ratio (HR) = 0.38, 95% CI: 0.19, 0.76, p = 0.006). Growth velocity was similar after tracheostomy placement.

CONCLUSIONS

In infants with chronic respiratory failure and sBPD <32 weeks' gestation, hyperinflation is related to mortality and inpatient morbidities.

Intraoperative management for ex-utero intrapartum treatment: focusing on the fetus

Ex-utero intrapartum treatment (EXIT) is a method of securing the airway of a fetus while maintaining umbilical circulation for newborns who are experiencing life-threatening airway obstruction. Cesarean section is completed only after ensuring the neonate's safety. However, managing the airway of a neonate while maintaining umbilical circulation is a major challenge for anesthesiologists. Anesthesiologists must understand the physiology of both the mother and fetus, and extensive discussions with obstetricians, pediatricians, otolaryngologists, and nursing staff prior to the procedure are essential. This review provides an overview of the EXIT and details of airway management for neonates.

Tracheostomy in infants with severe bronchopulmonary dysplasia: A review

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.

Qualitative indications for tracheostomy and chronic mechanical ventilation in patients with severe bronchopulmonary dysplasia

BACKGROUND

The decision to pursue chronic mechanical ventilation involves a complex mix of clinical and social considerations. Understanding the medical indications to pursue tracheostomy would reduce the ambiguity for both providers and families and facilitate focus on appropriate clinical goals.

OBJECTIVE

To describe potential indications to pursue tracheostomy and chronic mechanical ventilation in infants with severe BPD (sBPD).

STUDY DESIGN

We surveyed centers participating in the Children's Hospitals Neonatal Consortium to describe their approach to proceed with tracheostomy in infants with sBPD. We requested a single representative response per institution. Question types were fixed form and free text responses.

RESULTS

The response rate was high (31/34, 91%). Tracheostomy was strongly considered when: airway malacia was present, PCO₂ ≥ 76-85 mmHg, FiO₂ ≥ 0.60, PEEP ≥ 9-11 cm H₂O, respiratory rate ≥ 61-70 breaths/min, PMA ≥ 44 weeks, and weight <10th %ile at 44 weeks PMA.

CONCLUSIONS

Understanding the range of indications utilized by high level NICUs around the country to pursue a tracheostomy in an infant with sBPD is one step toward standardizing consensus indications for tracheostomy in the future.

Long-term respiratory and developmental outcomes in children with bronchopulmonary dysplasia and history of tracheostomy

OBJECTIVE

The long-term morbidity among children with severe bronchopulmonary dysplasia who require tracheostomy (tBPD) relative to those without tracheostomy (sBPD) is not well characterized. We compared childhood lung function and neurodevelopmental outcomes in tBPD and sBPD.

STUDY DESIGN

Retrospective case-control study of N = 49 tBPD and N = 280 sBPD subjects in Boston Children's Hospital Preterm Lung Patient Registry and medical record. We compared NICU course, childhood spirometry, and neurodevelopmental testing.

RESULT

tBPD subjects were more likely than sBPD to be Black, have pulmonary hypertension, and have subglottic stenosis. tBPD subjects had lower maximal childhood FEV₁ % predicted (β = -0.14) and FEV₁/FVC (β = -0.08); spirometry curves were more likely to suggest fixed extrathoracic obstruction. tBPD subjects had greater cognitive and motor delays <24 months, and greater cognitive delays >24 months.

CONCLUSION

Compared to subjects with sBPD who did not require tracheostomy, tBPD subjects suffer from increased long-term impairment in respiratory function and neurodevelopment.

Bronchopulmonary dysplasia requiring tracheostomy: A review of management and outcomes

Bronchopulmonary Dysplasia (BPD) is a pulmonary disease affecting newborns, commonly those with prematurity or low birth weight. Its pathogenesis involves underdevelopment of lung tissue with subsequent limitations in ventilation and oxygenation, resulting in impaired postnatal alveolarization. Despite advances in care with improved survival, BPD remains a prevalent comorbidity of prematurity. In severe cases, management may involve mechanical ventilation via tracheostomy. BPD's demand for multidisciplinary care compounds the challenges in management of this condition. Here, we review existing literature: the history of disease, criteria for diagnosis, pathogenesis, and modes of treatment with a focus on the severe subtype: that which is associated with pulmonary hypertension (PAH) for which tracheostomy is often required to facilitate long-term mechanical ventilation. We review the current recommendations for tracheostomy and decannulation.