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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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Khan EK, Lockspeiser TM, Meier M, Liptzin DR, Baker CD. Improved tracheostomy-dependent patient outcomes after implementation of the Pediatric Resident Education in Pulmonary (PREP) Boot Camp. Pediatr Pulmonol 2024; 59:1388-1393. [PMID: 38372490 DOI: 10.1002/ppul.26925] [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: 08/28/2023] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Children with tracheostomies are high risk for morbidity and mortality. Pediatric resident physicians are not routinely taught skills to care for this vulnerable patient population. Few reports link educational interventions to improved patient outcomes. This study evaluates the impact of an intensive educational training program on pediatric residents' observed skills and tracheostomy-dependent patient outcomes. METHODS Pediatric post-graduate year 2 (PGY2) resident physicians rotating through the inpatient pediatric pulmonology month at Children's Hospital Colorado July 2018-2019 participated in the Pediatric Resident Education in Pulmonary (PREP) Boot Camp, an intensive educational program with an interactive lecture and simulation experience on patients with tracheostomy-dependence. PGY2s who partook in PREP and PGY3s who rotated before PREP initiation were invited to be studied. Primary outcomes included: (1) resident skills assessed by direct observation during simulation encounters and (2) rates of intensive care unit (ICU) transfers in tracheostomy-dependent patients following acute events before and after introduction of PREP. We hypothesized that increased education would enhance resident skills and improve patient outcomes by decreasing the rate of ICU transfers. RESULTS PGY2 residents retained skills learned during PREP up to 11 months following initial participation, and significantly outperformed their PGY3 counterparts. There was a significant decrease in ICU transfer rate in patients with tracheostomies admitted to the pulmonary team during the 19 months following initiation of PREP. CONCLUSIONS Enhanced early education may improve resident physicians' ability to care for complex patients with tracheostomies and could improve outcomes in this high-risk population.
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Affiliation(s)
- Erin K Khan
- Department of Pediatrics, Division of Allergy, Immunology, Pulmonary and Sleep Medicine, Children's Mercy-Kansas City, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Tai M Lockspeiser
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Maxene Meier
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Deborah R Liptzin
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Christopher D Baker
- Department of Pediatrics, Division of Pulmonology and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Mastropietro CW, Sassalos P, Riley CM, Piggott K, Allen KY, Prentice E, Safa R, Buckley JR, Werho DK, Wakeham M, Smerling A, Yates AR, Iliopoulos I, Sandhu H, Chiwane S, Beshish A, Kwiatkowski DM, Flores S, Narashimhulu SS, Loomba R, Capone CA, Pike F, Costello JM. Clinical Outcomes After Tracheostomy in Children With Single Ventricle Physiology: Collaborative Research From the Pediatric Cardiac Intensive Care Society Multicenter Cohort, 2010-2021. Pediatr Crit Care Med 2024:00130478-990000000-00339. [PMID: 38683049 DOI: 10.1097/pcc.0000000000003523] [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: 05/01/2024]
Abstract
OBJECTIVES Multicenter studies reporting outcomes following tracheostomy in children with congenital heart disease are limited, particularly in patients with single ventricle physiology. We aimed to describe clinical characteristics and outcomes in a multicenter cohort of patients with single ventricle physiology who underwent tracheostomy before Fontan operation. DESIGN Multicenter retrospective cohort study.SETTING: Twenty-one tertiary care pediatric institutions participating in the Collaborative Research from the Pediatric Cardiac Intensive Care Society. PATIENTS We reviewed 99 children with single ventricle physiology who underwent tracheostomy before the Fontan operation at 21 institutions participating in Collaborative Research from the Pediatric Cardiac Intensive Care Society between January 2010 and December 2020, with follow-up through December 31, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Death occurred in 51 of 99 patients (52%). Cox proportional hazard analysis was performed to determine factors associated with death after tracheostomy. Results are presented as hazard ratio (HR) with 95% CIs. Nonrespiratory indication(s) for tracheostomy (HR, 2.21; 95% CI, 1.14-4.32) and number of weeks receiving mechanical ventilation before tracheostomy (HR, 1.06; 95% CI, 1.02-1.11) were independently associated with greater hazard of death. In contrast, diagnosis of tricuspid atresia or Ebstein's anomaly was associated with less hazard of death (HR, 0.16; 95% CI, 0.04-0.69). Favorable outcome, defined as survival to Fontan operation or decannulation while awaiting Fontan operation with viable cardiopulmonary physiology, occurred in 29 of 99 patients (29%). Median duration of mechanical ventilation before tracheostomy was shorter in patients who survived to favorable outcome (6.1 vs. 12.1 wk; p < 0.001), and only one of 16 patients with neurologic indications for tracheostomy and 0 of ten patients with cardiac indications for tracheostomy survived to favorable outcome. CONCLUSIONS For children with single ventricle physiology who undergo tracheostomy, mortality risk is high and should be carefully considered when discussing tracheostomy as an option for these children. Favorable outcomes are possible, although thoughtful attention to patient selection and tracheostomy timing are likely necessary to achieve this goal.
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Affiliation(s)
- Christopher W Mastropietro
- Department of Pediatrics, Division of Critical Care Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Peter Sassalos
- Department of Cardiac Surgery, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Christine M Riley
- Department of Pediatrics, Division of Cardiac Critical Care, Children's National Health System, Washington, DC
| | - Kurt Piggott
- Department of Pediatrics, Division of Pediatric Cardiac Critical Care LSU School of Medicine Children's Hospital, New Orleans, LA
| | - Kiona Y Allen
- Department of Pediatrics, Division of Cardiac Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth Prentice
- Department of Pediatrics, Division of Critical Care, Helen Devos Children's Hospital, Grand Rapids, MI
| | - Raya Safa
- Department of Pediatrics, Division of Critical Care, Children's Hospital of Michigan, Detroit, MI
| | - Jason R Buckley
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC
| | - David K Werho
- Department of Pediatrics, Division of Pediatric Cardiology, University of California San Diego, Rady Children's Hospital, San Diego, CA
| | - Martin Wakeham
- Department of Pediatrics, Division of Cardiac Critical Care, Medical College of Wisconsin, Herma Heart Institute-Children's Wisconsin, Milwaukee, WI
| | - Arthur Smerling
- Department of Pediatrics, Division of Critical Care, Columbia University Irving Medical Center, New York, NY
| | - Andrew R Yates
- Department of Pediatrics, Sections of Cardiology and Critical Care, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Ilias Iliopoulos
- Department of Pediatrics, Division of Cardiac Critical Care, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Hitesh Sandhu
- Department of Pediatrics, Division of Pediatric Critical Care, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, TN
| | - Saurabh Chiwane
- Department of Pediatrics, Division of Pediatric Critical Care, Saint Louis University, Cardinal Glennon Children's Hospital, Saint Louis, MO
| | - Asaad Beshish
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - David M Kwiatkowski
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Saul Flores
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Rohit Loomba
- Department of Pediatrics, Division of Cardiology, Chicago Medical School, Advocate Children's Hospital, Chicago, IL
| | - Christine A Capone
- Department of Pediatrics, Division of Pediatric Critical Care, Cohen Children's Medical Center, New Hyde Park, NY
| | - Francis Pike
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - John M Costello
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC
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Sherman J, Bower KL, Eskandanian K. "100 Things I Wish Someone Would Have Told Me": Everyday Challenges Parents Face While Caring for Their Children With a Tracheostomy. QUALITATIVE HEALTH RESEARCH 2024:10497323231217387. [PMID: 38193439 DOI: 10.1177/10497323231217387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Equitable access to appropriate care, emergency department services, and in-home support aids are needed to minimize the occurrences of adverse events that have a significant impact on families. However, many families of children with medical complexity (CMC) lack consistent care due to issues of health inequity. We conducted 11 qualitative interviews with primary caregivers who were asked about their experiences of providing care to children who have a tracheostomy and are supported by multiple life-saving machines at home. Guided by ecological systems theory, we identified three themes that contextualize the lived experiences of the participants who expressed needs that arose from poor interactions within the mesosystem. Findings convey participant frustrations that result from insufficient support, ineffective training, and inadequate healthcare coverage. Although each theme is organized systematically to emphasize specific concerns within the mesosystem, together these themes emphasize the inextricable relationship between daily needs with systemic barriers to care. We provide a discussion of these needs with a broader context that also impacts the perceived quality of care among families managing the needs of their children who are supported by life-saving technology. By addressing existing challenges and identifying opportunities for improvement within the healthcare system, we seek to contribute to the collective effort of advocating for ethical systemic change on behalf of CMC and their families.
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Affiliation(s)
| | - Kyle L Bower
- Department of Human Development & Family Science, The University of Georgia, Athens, GA, USA
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Magge HN, Schild SD, Mantilla-Rivas E, Landry EC, Afsar NM, Behzadpour HK, Manrique M, Rana MS, Oh AK, Reilly BK. Trends in Natural Decannulation in Patients with Robin Sequence: A Twenty-five Year Retrospective Review. Ann Otol Rhinol Laryngol 2024; 133:69-77. [PMID: 37497838 DOI: 10.1177/00034894231187290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE Robin sequence (RS) consists of micrognathia and glossoptosis that result in upper airway obstruction (UAO). In RS patients who undergo tracheostomy, long-term goals include natural decannulation (ND) without further surgical airway intervention. The objective of this study was to identify long-term trends in the rate and length of time to ND. METHODS Retrospective chart review on 144 patients with RS treated from 1995 to 2020 at a pediatric tertiary care center. Patients were grouped by year of tracheostomy. Demographic data, UAO management, postoperative care, complications, and time to decannulation were recorded. RESULTS Thirty-six patients met the inclusion criteria. Tracheostomy was performed at a median age of 45.5 days. 19 (53%) patients experienced ND at a median time of 66.1 months. ND rate was higher in non-syndromic patients (93% non-syndromic vs 27% syndromic; P < .0001) and during the first study period (1995-2006: 78%, 2007-2020: 28%; P = .003). Cox proportional-hazard regression demonstrated that white race [aHR 0.15 (0.03-0.8); P = .023] and higher birthweight [aHR 0.9 (0.8-0.98); P = .018] were associated with a higher likelihood of ND while a syndromic diagnosis had a negative association with ND [aHR 12.5 (3.3-50.0); P < .001]. CONCLUSIONS Our study documented that ND in patients with RS who underwent tracheostomy was significantly associated with ethnicity, birthweight, and syndromic status. The negative impact on successful ND was most observed in patients with syndromic associations. Additionally, ND rates are lower in the 2007 to 2020 subgroup. We suspect this is because alternative management techniques such as tongue lip adhesion and mandibular distraction osteogenesis became primary surgical treatment in severe RS upper airway obstruction at our institution starting in 2007.
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Affiliation(s)
- Hari N Magge
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sam D Schild
- Division of Otolaryngology, Children's National Hospital, Washington, DC, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Evie C Landry
- Division of Otolaryngology, Children's National Hospital, Washington, DC, USA
| | - Nina M Afsar
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Division of Surgery, Children's National Hospital, Washington, DC, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC, USA
| | - Brian K Reilly
- Division of Otolaryngology, Children's National Hospital, Washington, DC, USA
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6
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La-Anyane OM, Whitney NB, Harmon KA, Karas AF, Jeffe JS, Tragos C. Tracheostomy, the Not So Definitive Airway?: Tracheostomy Morbidity in Pediatric Craniofacial Patients. J Craniofac Surg 2023; 34:2413-2416. [PMID: 37639682 DOI: 10.1097/scs.0000000000009627] [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: 03/16/2023] [Accepted: 06/03/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Tracheostomy is the definitive treatment for airway management in severe cases of craniofacial-associated upper airway obstruction, like the Pierre-Robin sequence, but is associated with significant morbidity. The purpose of this study was to examine tracheostomy-associated morbidities and mortalities in craniofacial patients to identify opportunities to improve clinical care and patient prognosis. METHODS The study was a retrospective review of pediatric craniofacial patients who were tracheostomized between 2016 and 2022. Data regarding their demographics, craniofacial diagnoses, endoscopic airway anomalies, intubation grade of view classification, tracheostomy-related complications, and causes of mortality were analyzed. RESULTS Sixteen of the 17 tracheostomized pediatric patients had the Pierre-Robin sequence, with 5 of those patients having an additional syndromic craniofacial diagnosis. Additional airway anomalies were found in 82.4% of the patients. The mean length of hospital stay after tracheostomy was 4.08 months. Infection was the most common complication, observed in 94.1% of patients, followed by stomal granulation in 76.5% of patients. Two mortalities were observed: one following the compassionate removal of ventilator support and the other following the accidental dislodgment of the tracheostomy tube. CONCLUSIONS Tracheostomy-related complications were observed in all craniofacial patients in this group. Compared with the general pediatric population, tracheostomized craniofacial patients may endure longer hospital stays and greater stomal granulation rates. Mandibular distraction osteogenesis may allow for tracheostomy avoidance in these patients, and future research should focus on comparing the long-term complication rates and outcomes between tracheostomy mandibular distraction osteogenesis in this challenging patient population.
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Affiliation(s)
- Okensama M La-Anyane
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Natalia B Whitney
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Kelly A Harmon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Anatoli F Karas
- Department of Otorhinolaryngology, Rush University Medical Center, Chicago, IL
| | - Jill S Jeffe
- Department of Otorhinolaryngology, Rush University Medical Center, Chicago, IL
- Department of Otolaryngology, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Christina Tragos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL
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Wasserman MG, Graham RJ, Mansbach JM. Airway Bacterial Colonization, Biofilms and Blooms, and Acute Respiratory Infection. Pediatr Crit Care Med 2022; 23:e476-e482. [PMID: 35767569 PMCID: PMC9529803 DOI: 10.1097/pcc.0000000000003017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Mollie G Wasserman
- Department of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Robert J Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA
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Sobotka SA, Laudon S, Jackson AJ, Harendt SE, Baker CD. A Literature Review of Feeding Disorders in Children with Tracheostomies and Ventilators. Pediatr Ann 2022; 51:e291-e296. [PMID: 35858218 PMCID: PMC9584144 DOI: 10.3928/19382359-20220504-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Feeding disorders and gastrostomy use are highly prevalent in children with invasive mechanical ventilation (IMV) due to both common risk factors (eg, prematurity, neurological disorders) and resultant experiential deprivation (eg, long hospitalizations, delayed feeding experiences). Feeding in children with IMV is complicated by the presence of a tracheostomy, lung vulnerability, and medical complexity. The potential comorbidity of swallowing difficulties (dysphagia) and atypical early feeding experiences can result in complex feeding disorders. In this review of pediatric feeding disorders in children with invasive mechanical ventilation (IMV), we identify gaps in clinical translational research for this patient population and opportunities for improving evidence-based management. To improve long-term feeding outcomes and maximize oral feeding in this vulnerable population, children would benefit from earlier feeding opportunities during critical developmental windows, standardized protocols for advancing oral feeding, and involvement of intensive, comprehensive therapies throughout hospitalizations and early childhood. [Pediatr Ann. 2022;51(7):e291-e296.].
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9
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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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10
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de Araujo OR, Azevedo RT, de Oliveira FRC, Colleti Junior J. Tracheostomy practices in children on mechanical ventilation: a systematic review and meta-analysis. J Pediatr (Rio J) 2022; 98:126-135. [PMID: 34509427 PMCID: PMC9432186 DOI: 10.1016/j.jped.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To evaluate current practices of tracheostomy in children regarding the ideal timing of tracheostomy placement, complications, indications, mortality, and success in decannulation. SOURCE OF DATA The authors searched PubMed, Embase, Cochrane Library, Google Scholar, and complemented by manual search. The guidelines of PRISMA and MOOSE were applied. The quality of the included studies was evaluated with the Newcastle-Ottawa Scale. Information extracted included patients' characteristics, outcomes, time to tracheostomy, and associated complications. Odds ratios (ORs) with 95% CIs were computed using the Mantel-Haenszel method. SYNTHESIS OF DATA Sixty-six articles were included in the qualitative analysis, and 8 were included in the meta-analysis about timing for tracheostomy placement. The risk ratio for "death in hospital outcome" did not show any benefit from performing a tracheostomy before or after 14 days of mechanical ventilation (p = 0.49). The early tracheostomy before 14 days had a great impact on the days of mechanical ventilation (-26 days in mean difference, p < 0.00001). The authors also found a great reduction in hospital length of stay (-31.4 days, p < 0.008). For the days in PICU, the mean reduction was of 14.7 days (p < 0.007). CONCLUSIONS The meta-analysis suggests that tracheostomy performed in the first 14 days of ventilation can reduce the time spent on the ventilator, and the length of stay in the hospital, with no effect on mortality. The decision to perform a tracheostomy early or late may be more dependent on the baseline disease than on the time spent on ventilation .
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Affiliation(s)
| | | | - Felipe Rezende Caino de Oliveira
- Instituto de Oncologia Pediátrica de São Paulo - GRAACC, São Paulo, SP, Brazil; Hospital Alvorada Moema, Departamento de Pediatria, São Paulo, SP, Brazil
| | - José Colleti Junior
- Hospital Alvorada Moema, Departamento de Pediatria, São Paulo, SP, Brazil; Hospital Assunção Rede D'Or São Luiz, Departamento de Pediatria, São Bernardo do Campo, SP, Brazil.
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Mian MUM, Kennedy C, Fogarty T, Naeem B, Lam F, Coss-Bu J, Arikan AA, Nguyen T, Bashir D, Virk M, Harpavat S, Raynor T, Rana AA, Goss J, Leung D, Desai MS. The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single-center experience. Pediatr Transplant 2022; 26:e14140. [PMID: 34523781 DOI: 10.1111/petr.14140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 06/07/2021] [Accepted: 09/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Children with end-stage liver disease and multi-organ failure, previously considered as poor surgical candidates, can now benefit from liver transplantation (LT). They often need prolonged mechanical ventilation (MV) post-LT and may need tracheostomy to advance care. Data on tracheostomy after pediatric LT are lacking. METHOD Retrospective chart review of children who required tracheostomy in the peri-LT period in a large, freestanding quaternary children's hospital from 2014 to 2019. RESULTS Out of 205 total orthotopic LTs performed in 200 children, 18 (9%) required tracheostomy in the peri-transplant period: 4 (2%) pre-LT and 14 (7%) post-LT. Among those 14 needing tracheostomy post-LT, median age was 9 months [IQR = 7, 14] at LT and 10 months [9, 17] at tracheostomy. Nine (64%) were infants and 12 (85%) were cirrhotic at the time of LT. Seven (50%) were intubated before LT. Median MV days prior to LT was 23 [7, 36]. Eight (57%) patients received perioperative continuous renal replacement therapy (CRRT). The median MV days from LT to tracheostomy was 46 [33, 56]; total MV days from initial intubation to tracheostomy was 57 [37, 66]. Four (28%) children died, of which 3 (21%) died within 1 year of transplant. Total ICU and hospital length of stay were 92 days [I72, 126] and 177 days [115, 212] respectively. Among survivors, 3/10 (30%) required MV at home and 8/10 (80%) were successfully decannulated at 400 median days [283, 584]. CONCLUSION Tracheostomy though rare after LT remains a feasible option to support and rehabilitate critically ill children who need prolonged MV in the peri-LT period.
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Affiliation(s)
- Muhammad Umair M Mian
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Curtis Kennedy
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Thomas Fogarty
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Buria Naeem
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fong Lam
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jorge Coss-Bu
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ayse A Arikan
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Section of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Trung Nguyen
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dalia Bashir
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Manpreet Virk
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sanjiv Harpavat
- Department of Pediatrics, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Tiffany Raynor
- Department of Surgery, Division of Pediatric Otolaryngology, Baylor College of Medicine, Houston, TX, USA
| | - Abbas A Rana
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX, USA
| | - John Goss
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Leung
- Department of Pediatrics, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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12
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Kang KT, Lin YS, Lin CY, Lee CH, Hsu WC. Epidemiology of pediatric tracheotomy: A population-based study using National Health Insurance Research Database in Taiwan. Int J Pediatr Otorhinolaryngol 2022; 152:110989. [PMID: 34861553 DOI: 10.1016/j.ijporl.2021.110989] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 10/03/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Tracheostomy in children is a surgical procedure with considerable morbidity and mortality. However, there is still a lack of population-based survey in pediatric tracheostomy. This study analyses population-based data in pediatric tracheostomy among different ages in Taiwan. METHODS This study used National Health Insurance Research Database in Taiwan. All children (aged <18 years) who underwent tracheostomy during 1997-2016 were identified. We retrieved data regarding baseline characteristics, perioperative care, and mortality associated with pediatric tracheostomy, and compared differences in variables between different age groups. RESULTS We observed that 2300 children received tracheostomy (mean age, 8.7 years; 64% boys). Regarding the age group distribution of the patients, 585 (25.4%) were infants (<1 year), 227 (9.9%) were toddlers (1-3 years), 175 (7.6%) were preschool-aged children (3-6 years), 317 (13.8%) were school-aged children (6-12 years), and 996 (43.3%) were adolescents (12-18 years). Surgical indications included pulmonary disorders (64.9%), neurological disorders (38.4%), trauma (32.3%), head injury (25.2%), and congenital anomalies (21.5%). Of these patients, 94.9% required intensive care unit (ICU) care, with the mean length of ICU stay being 63.8 days. The mean length of hospital stay was 74.5 days. The overall mortality at the last follow-up was 43.96% (1011/2300), and the tracheostomy related mortality at the last follow-up was 1.43% (33/2300). Compared with adolescents, infants more commonly underwent tracheostomy in the northern area (66.7% vs 37.2%, P < .001), more commonly received tracheostomy indicated by congenital anomalies (53.7 vs 4.6%, P < .001), had longer ICU stays, had longer hospital stays (100.7 vs 57.5 days, P < .001), and had a higher 5-year mortality rate (42.4 vs 29.6%, P < .001). Multivariable logistic and Cox regression models revealed that young age was associated with an increased risk of prolonged hospital stay and long-term mortality, respectively. CONCLUSIONS This study elaborates the epidemiology of pediatric tracheostomy in different age groups.
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Affiliation(s)
- Kun-Tai Kang
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan; Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Che-Yi Lin
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hsuan Lee
- Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan; Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Nursing, Hsin Sheng Junior College of Medical Care and Management, Taoyuan, Taiwan
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan; Department of Otolaryngology, College of Medicine, National Taiwan University, Taipei, Taiwan.
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13
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Marcet-Gonzalez J, Barton G, Lambert E. Severity of sialorrhea and tracheal secretions in infants and toddlers with a tracheostomy with a focus on quality of life. Am J Otolaryngol 2021; 42:103074. [PMID: 33895631 DOI: 10.1016/j.amjoto.2021.103074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 04/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Sialorrhea and tracheal secretions can be present in patients with a tracheostomy. The current study seeks to survey the severity of sialorrhea and tracheal secretions in infants and toddlers with a tracheostomy, and to correlate this severity with quality of life. METHODS Prospective cross-sectional survey pilot study: 26 patients (ages 0.33 years - 4.09 years) were given the Infant/Toddler Quality of Life Questionnaire Short Form 47, the Drooling Impact Scale and assessed for severity of tracheal secretions with a Tracheostomy Secretion Severity Scale. Spearman's correlation and Mann Whitney U tests were used to assess correlation between and contributors to quality of life, drooling severity, and tracheostomy secretion severity, number of outpatient visits, and respiratory related hospitalizations. RESULTS Average health perception quality of life was 46.7 and average parental impact quality of life was 58.85. The average for the Drooling Impact Scale overall was 19.7, for frequency 4.16, for severity 3.12 and for the Tracheostomy Secretion Severity Scale 2.4. There was strong correlation between the Drooling Impact Scale and the Tracheostomy Secretion Severity Scale (R = 0.432 p = 0.03) overall, and moderate correlation between Drooling Impact Scale and Tracheostomy Secretion Severity Scale (R = 0.39956 p = 0.047) frequency. There was no correlation between health perception quality of life or parental impact quality of life and Drooling Impact Scale or Tracheostomy Secretion Severity Scale. CONCLUSION Drooling severity does not have significant impacts on health perception and parental impact quality of life for infants and toddlers who have a tracheostomy. Overall drooling impact scores and drooling frequency are related to tracheostomy secretion severity.
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14
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Giambra BK, Mangeot C, Benscoter DT, Britto MT. A Description of Children Dependent on Long Term Ventilation via Tracheostomy and Their Hospital Resource Use. J Pediatr Nurs 2021; 61:96-101. [PMID: 33813374 DOI: 10.1016/j.pedn.2021.03.028] [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: 01/25/2021] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe the proportion of children with an index hospitalization in 2014 who had established long-term invasive ventilator dependence (LTVD), and determine regional variation in hospital length of stay, charges, and readmissions. DESIGN AND METHODS Multicenter, longitudinal, retrospective cohort study using a recently established algorithm to identify children with LTVD from the Pediatric Health Information System database with an index hospitalization at least once during 2014, excluding normal newborn care or chemotherapy, and the subset with established LTVD. Hospitals were grouped by geographic regions. Analysis included descriptive statistics and multi-variable mixed modeling for length of stay, charges, and readmissions. RESULTS Of the 615,883 unique children discharged from 45 children's hospitals in 2014, 2235 (0.4%) had established LTVD. Of these, 342 (15%) were hospitalized in the Northeast, 677 (30%) Midwest, 733 (32%) South and 481 (22%) West. Most had at least two complex chronic conditions (97%) and used a medical device for at least two body systems (71%). No statistically significant regional variation was found for length of stay, charges, or readmissions after adjustment for child demographics, admission type, disposition, primary diagnosis, ICU stay, and number of chronic conditions. CONCLUSIONS This study characterized the population of children with LTVD hospitalized in 2014. No regional variation was found for length of stay, charges, or readmissions. PRACTICE IMPLICATIONS Children with established LTVD make up a small subset of all children admitted to children's hospitals however, they require substantial, costly, multifaceted care as most have additional complex chronic conditions and require multiple medical devices.
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Affiliation(s)
- Barbara K Giambra
- Cincinnati Children's Hospital Medical Center, OH, United States of America; University of Cincinnati College of Nursing, OH, United States of America.
| | - Colleen Mangeot
- Cincinnati Children's Hospital Medical Center, OH, United States of America.
| | - Dan T Benscoter
- Cincinnati Children's Hospital Medical Center, OH, United States of America; Department of Pediatrics, University of Cincinnati College of Medicine, OH, United States of America.
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Center, OH, United States of America; Department of Pediatrics, University of Cincinnati College of Medicine, OH, United States of America.
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15
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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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16
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Neunhoeffer F, Miarka-Mauthe C, Harnischmacher C, Engel J, Renk H, Michel J, Hofbeck M, Hanser A, Kumpf M. Severe adverse events in children with tracheostomy and home mechanical ventilation - Comparison of pediatric home care and a specialized pediatric nursing care facility. Respir Med 2021; 191:106392. [PMID: 33865662 DOI: 10.1016/j.rmed.2021.106392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advances in medical care and ventilator technologies increase the number of children with tracheostomy and home mechanical ventilation (HMV). Data on severe adverse events in home care and in specialized nursing care facilities are limited. PATIENTS AND METHODS Retrospective analysis of incidence and type of severe adverse events in children with tracheostomy and HMV in home care compared to a specialized nursing care facility over a 7-year period. RESULTS 163.9 patient-years in 70 children (home care: 110.7 patient-years, 24 patients; nursing care facility: 53.2 patient-years, 46 patients) were analyzed. In 34 (48.6%) patients tracheostomy was initiated at the age of <1 year. 35 severe adverse events were identified, incidence of severe adverse events per patient-year was 0.21 (median 0.0 (0.0-3.0)). We observed no difference in the rate of severe adverse events between home care and specialized nursing care facility (0.21 [y-1]; median 0.0 (0.0-3.0) versus 0.23 [y-1]; median 0.0 (0.0-1.6); p = 0.690), however, significantly more tracheostomy related incidents and infections occurred in the home care setting. Young age (<1 year) (Odds ratio 3.27; p = 0.045) and feeding difficulties (nasogastric tubes and percutaneous endoscopic gastrostomy) (Odds ratio 9.08; p = 0.016) significantly increased the risk of severe adverse events. Furthermore, the rate of severe adverse events was significantly higher in patients with a higher nursing score. CONCLUSION Pediatric home mechanical ventilation via tracheostomy is rarely associated with emergencies or adverse events in home care as well as in a specialized nursing care facility setting.
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Affiliation(s)
- Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany.
| | - Christiane Miarka-Mauthe
- Arche IntensivKinder, Specialized Pediatric Nursing Care Facility, Bergstr. 36, 72127, Kusterdingen, Germany
| | - Cornelia Harnischmacher
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Juliane Engel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Hanna Renk
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Anja Hanser
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology and Pediatric Intensive Care Medicine, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
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17
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Koenigs MB, Behzadpour HK, Zalzal GH, Preciado DA. Barriers to Decannulation After Double-Stage Laryngotracheal Reconstruction. Laryngoscope 2021; 131:2141-2147. [PMID: 33635575 DOI: 10.1002/lary.29486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES/HYPOTHESIS To identify any potential barriers for decannulation in children undergoing double-staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself. STUDY DESIGN Case series with chart review. METHODS We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR. RESULTS Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log-rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log-rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log-rank), and race/ethnicity (P = .001 Log-rank). CONCLUSION In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2141-2147, 2021.
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Affiliation(s)
- Maria B Koenigs
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Hengameh K Behzadpour
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - George H Zalzal
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Diego A Preciado
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
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18
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Caloway C, Balakrishnan K, Boudewyns A, Chan KH, Cheng A, Daniel SJ, Fayoux P, Garabedian N, Hart C, Moreddu E, Muntz H, Nicollas R, Nuss R, Pransky S, Rahbar R, Russell J, Rutter M, Sidell D, Smith RJ, Soma M, Spratley J, Thompson D, Ward RF, Watters K, Wyatt M, Zalzal G, Hartnick C. International Pediatric Otolaryngology Group (IPOG) survey: Efforts to avoid complications in home tracheostomy care. Int J Pediatr Otorhinolaryngol 2021; 141:110563. [PMID: 33360407 DOI: 10.1016/j.ijporl.2020.110563] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/12/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To provide guidance for home care tracheostomy management in the pediatric population. The mission of the IPOG is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. METHODS Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). RESULTS Survey results provide guidance for caregiver teaching, the reuse of tracheostomies and suction catheters while inpatient and following discharge, acceptable sterilization practices for tracheostomies, tracheitis workup and management, and outpatient follow-up practices. CONCLUSION This presentation of common home tracheostomy care practices are aimed at improving patient-centered care in the pediatric population.
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Affiliation(s)
- Christen Caloway
- Department of Otolaryngology - Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - An Boudewyns
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, University of Antwerp, Belgium
| | | | - Alan Cheng
- The Children's Hospital at Westmead, Sydney, Australia
| | - Sam J Daniel
- Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pierre Fayoux
- Department of Pediatric Otolaryngology-Head Neck Surgery, Jeanne de Flandre Hospital, CHU Lille, Université de Lille, Lille, France
| | - Noel Garabedian
- Pediatric ENT Department, Ho^pital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
| | - Catherine Hart
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eric Moreddu
- Department of Pediatric Otorhinolaryngology - Head and Neck Surgery - La Timone Children's Hospital, Aix-Marseille Universite, Marseille, France
| | - Harlan Muntz
- Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, UT, USA
| | - Richard Nicollas
- Department of Pediatric Otorhinolaryngology - Head and Neck Surgery - La Timone Children's Hospital, Aix-Marseille Universite, Marseille, France
| | - Roger Nuss
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States
| | - Seth Pransky
- Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, United States
| | - John Russell
- Children's Health Ireland (Crumlin), Dublin, Ireland
| | - Mike Rutter
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Richard J Smith
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Jorge Spratley
- Hospital S. João Center, Univ. of Porto Faculty of Medicine, Cintesis, Porto, Portugal
| | - Dana Thompson
- Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | | | - George Zalzal
- Children's National Medical Center, Washington, DC, USA
| | - Christopher Hartnick
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
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19
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Davidson C, Jacob B, Brown A, Brooks R, Bailey C, Whitney C, Chorney S, Lenes-Voit F, Johnson RF. Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients. Laryngoscope 2021; 131:E2469-E2474. [PMID: 33464608 DOI: 10.1002/lary.29402] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity. STUDY DESIGN Retrospective case series. METHODS All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients. RESULTS A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length. CONCLUSIONS Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2469-E2474, 2021.
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Affiliation(s)
- Christian Davidson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Benjamin Jacob
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Ashley Brown
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Rebecca Brooks
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Candace Bailey
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Cindy Whitney
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Stephen Chorney
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Felicity Lenes-Voit
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
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Sachdev A, Chaudhari ND, Singh BP, Sharma N, Gupta D, Gupta N, Gupta S, Chugh P. Tracheostomy in Pediatric Intensive Care Unit-A Two Decades of Experience. Indian J Crit Care Med 2021; 25:803-811. [PMID: 34316177 PMCID: PMC8286380 DOI: 10.5005/jp-journals-10071-23893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective To study the profile, indications, related complications, and predictors of decannulation and mortality in patients who underwent tracheostomy in the pediatric intensive care unit (PICU). Materials and methods Retrospective analysis of prospectively collected data of tracheostomies was done on patients admitted at PICU. Demographics, primary diagnosis, indication of tracheostomy, and durations of endotracheal intubation, mechanical ventilation, and tracheostomy cannulation were recorded. The indication was recorded in one of the four categories—upper airway obstruction (UAO), central neurological impairment (CNI), prolonged mechanical ventilation, and peripheral neuromuscular disorders). Results Two hundred ninety cases were analyzed. UAO (42%) and CNI (48.2%) were main indications in the halves of the study period, respectively. Decannulation was successful in 188 (64.8%) patients. Seventy-seven percentage UAO patients were decannulated successfully [OR (odds ratio); 95% CI (confidence interval), 2.647; 1.182–5.924, p = 0.018]. Age <1 year (0.378; 0.187–0.764; p = 0.007), nontraumatic, noninfectious central neurological diseases (0.398; 0.186–0.855; p = 0.018), and malignancy (0.078; 0.021–0.298; p <0.001), durations of posttracheostomy ventilation (0.937; 0.893–0.983; p = 0.008), and stay in the PICU (0.989; 0.979–0.999; p = 0.029) were predictors of unsuccessful decannulation. There were 91 (31.4%) deaths. Age <1 year (2.39 (1.13–5.05; p = 0.02), malignancy (17.55; 4.10–75.11; p <0.001), durations of posttracheostomy ventilation (1.06; 1.006–1.10; p = 0.028), and hospital stay (1.007; 1.0–1.013; p = 0.043) were independent predictors of mortality. Indication of UAO favored survivor (0.24; 0.09–0.57; p <0.001). Conclusion The indications for tracheostomy in children had changed over the years. Infancy, primary diagnosis, length of posttracheostomy ventilation, and stay in the PICU and hospital were independent predictors of decannulation and mortality. What This Adds Similar to developed countries, the age at the time of tracheostomy and indication are changing. Inability to decannulate and mortality were associated with the age of a child at the time of tracheostomy, indication, medical diagnosis, and duration of postprocedure mechanical ventilation and stay in the hospital. How to cite this article Sachdev A, Chaudhari ND, Singh BP, Sharma N, Gupta D, Gupta N, et al. Tracheostomy in Pediatric Intensive Care Unit—A Two Decades of Experience. Indian J Crit Care Med 2021;25(7):803–811.
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Affiliation(s)
- Anil Sachdev
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Bhanu P Singh
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | - Nikhil Sharma
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | - Dhiren Gupta
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Gupta
- Department of Pediatric Intensive Care, Sir Ganga Ram Hospital, New Delhi, India
| | - Suresh Gupta
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | - Parul Chugh
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
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21
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Hebbar KB, Kasi AS, Vielkind M, McCracken CE, Ivie CC, Prickett KK, Simon DM. Mortality and Outcomes of Pediatric Tracheostomy Dependent Patients. Front Pediatr 2021; 9:661512. [PMID: 34017809 PMCID: PMC8129024 DOI: 10.3389/fped.2021.661512] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/06/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: To describe clinical factors associated with mortality and causes of death in tracheostomy-dependent (TD) children. Methods: A retrospective study of patients with a new or established tracheostomy requiring hospitalization at a large tertiary children's hospital between 2009 and 2015 was conducted. Patient groups were developed based on indication for tracheostomy: pulmonary, anatomic/airway obstruction, and neurologic causes. The outcome measures were overall mortality rate, mortality risk factors, and causes of death. Results: A total of 187 patients were identified as TD with complete data available for 164 patients. Primary indications for tracheostomy included pulmonary (40%), anatomic/airway obstruction (36%), and neurologic (24%). The median age at tracheostomy and duration of follow up were 6.6 months (IQR 3.5-19.5 months) and 23.8 months (IQR 9.9-46.7 months), respectively. Overall, 45 (27%) patients died during the study period and the median time to death following tracheostomy was 9.8 months (IQR 6.1-29.7 months). Overall survival at 1- and 5-years following tracheostomy was 83% (95% CI: 76-88%) and 68% (95% CI: 57-76%), respectively. There was no significant difference in mortality based on indication for tracheostomy (p = 0.35), however pulmonary indication for tracheostomy was associated with a shorter time to death (HR: 1.9; 95% CI: 1.04-3.4; p = 0.04). Among the co-morbid medical conditions, children with seizure disorder had higher mortality (p = 0.04). Conclusion: In this study, TD children had a high mortality rate with no significant difference in mortality based on indication for tracheostomy. Pulmonary indication for tracheostomy was associated with a shorter time to death and neurologic indication was associated with lower decannulation rates.
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Affiliation(s)
- Kiran B Hebbar
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Ajay S Kasi
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Monica Vielkind
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Courtney E McCracken
- Pediatric Biostatistics Core, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Caroline C Ivie
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Kara K Prickett
- Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Dawn M Simon
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
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22
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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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23
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Caloway C, Yamasaki A, Callans KM, Shah M, Kaplan RS, Hartnick C. Quantifying the benefits from a care coordination program for tracheostomy placement in neonates. Int J Pediatr Otorhinolaryngol 2020; 134:110025. [PMID: 32304856 DOI: 10.1016/j.ijporl.2020.110025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Value-based care models are becoming instrumental in structuring clinical care delivery in our healthcare climate. Our objective was to determine the value associated with implementation of a Family-Centered Care Coordination (FCCC) program for neonates undergoing tracheostomy. METHODS A multi-disciplinary FCCC program was implemented at the Massachusetts Eye and Ear Infirmary and MassGeneral Hospital for Children in January 2013. This program is designed to ensure a safe transition out of the hospital for children undergoing tracheostomy, reduce re-admission rates, and increase caregiver quality of life (QOL). Study participants included neonates undergoing tracheostomy in 2012 and 2015. This retrospective cohort study examined length of stay (LOS), utilized time-driven activity-based costing to estimate the cost of care, assessed caregiver QOL with 1-month Pediatric Tracheostomy Health Status Instrument (PTHSI) scores, and assessed complications with 6-month Medical Complications Associated with Pediatric Tracheostomy (MCAT) scores. RESULTS Following implementation of the FCCC program, average LOS decreased from 30.5 days (range 17-39) to 16.6 days (range 9-23). The largest process improvement (cost reduction of 61%) occurred in the discharge-planning phase. The overall cost per care cycle was reduced by 36%. A large clinically meaningful benefit was demonstrated for PTHSI (effect size 0.80) as well as MCAT scores (effect size 9.35). CONCLUSIONS We demonstrated the higher outcomes, including reductions in caregiver burden and complication rates, and the lower costs associated with implementation of the FCCC program for neonates undergoing tracheostomy.
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Affiliation(s)
- Christen Caloway
- Department of Otolaryngology, Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Alisa Yamasaki
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Kevin M Callans
- Clinical Care Management Unit, Massachusetts General Hospital and Massachusetts Eye, Ear Infirmary, Boston, MA, USA
| | - Mahek Shah
- Harvard Business School, Boston, MA, USA
| | | | - Christopher Hartnick
- Department of Otolaryngology, Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
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24
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Sobotka SA, Lynch E, Peek ME, Graham RJ. Readmission drivers for children with medical complexity: Home nursing shortages cause health crises. Pediatr Pulmonol 2020; 55:1474-1480. [PMID: 32212321 PMCID: PMC7290239 DOI: 10.1002/ppul.24744] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/15/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Children with medical technology dependence (MTD) are frequently readmitted to the hospital. However, due to their medical fragility, it is often difficult to untangle the root causes for readmissions to identify the most effective preventive approaches. We sought to explore environmental and family factors driving hospital readmissions for children with MTD. DESIGN Semi-structured, in-person interviews were conducted with state-wide care coordinators for children with MTD in Illinois with at least 1 year of experience. Interview topics related to children with MTD transitioning from hospital-to-home, essential supports for living in the community, and factors which influenced and prevented hospital readmission. The interview guide served as an initial codebook which was iteratively modified as themes emerged. RESULTS Fifteen care coordinators with on average 6.6 years of experience were interviewed. They described that lack of home nursing was one of the primary drivers of readmissions due to parental exhaustion and lack of medical expertize in the home. Unavoidable medical admissions, a lack of a plan for emergencies, and home environmental factors also contributed to readmissions. CONCLUSION Hospital readmission is an expected occurrence for children with MTD, yet still may be substantially reduced through consistent, quality home health nursing to bolster family capacity and allow for respite from constant caregiving. Improved incentives for the home health workforce to increase manpower would be ultimately offset by reduced hospitalizations for children with MTD. Additionally, more research is needed to understand which home nursing structures and skills optimally support families in the reality of manpower scarcity.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Emma Lynch
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Monica E Peek
- Section of General Internal Medicine, Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Robert J Graham
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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25
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Kana LA, Shuman AG, Helman J, Krawcke K, Brown DJ. Disparities and ethical considerations for children with tracheostomies during the COVID-19 pandemic. J Pediatr Rehabil Med 2020; 13:371-376. [PMID: 33104051 DOI: 10.3233/prm-200749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic is exacerbating longstanding challenges facing children with tracheostomies and their families. Myriad ethical concerns arising in the long-term care of children with tracheostomies during the COVID-19 pandemic revolve around inadequate access to care, healthcare resources, and rehabilitation services. Marginalized communities such as those from Black and Hispanic origins face disproportionate chronic illness because of racial and other underlying disparities. In this paper, we describe how these disparities also present challenges to children who are technology-dependent, such as those with tracheostomies and discuss the emerging ethical discourse regarding healthcare and resource access for this population during the pandemic.
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Affiliation(s)
- Lulia A Kana
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrew G Shuman
- University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Helman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kelly Krawcke
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David J Brown
- University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.,Office for Health Equity and Inclusion, Michigan Medicine, Ann Arbor, MI, USA
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26
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Sobotka SA, Lynch E, Quinn MT, Awadalla SS, Agrawal RK, Peek ME. Unmet Respite Needs of Children With Medical Technology Dependence. Clin Pediatr (Phila) 2019; 58:1175-1186. [PMID: 31502488 PMCID: PMC7232777 DOI: 10.1177/0009922819870251] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children with medical technology dependency (MTD) require a medical device to compensate for a vital body function and substantial nursing care. As such, they require constant high-level supervision. Respite care provides caregivers with a temporary break, and is associated with reduced stress; however, there are often barriers. The study utilizes mixed methodology with the National Survey of Children with Special Health Care Needs (NS-CSHCN) and semistructured interviews with state-wide care coordinators to understand the gap for respite care services. Fifty-nine percent of parents who needed respite care received none. Parents of older children with MTD were more likely to report respite needs. Care coordinators described that home health shortages created barriers to respite care utilization, and the lack of respite care can lead to hospital readmission. Although respite care is a vital resource to support families of children with MTD, it is infrequently available, which can have severe consequences.
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Affiliation(s)
| | - Emma Lynch
- The University of Chicago, Chicago, IL, USA
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27
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McKelvie BL, Lobos AT, Chan J, Momoli F, McNally JD. High Rate of Medical Emergency Team Activation in Children with Tracheostomy. J Pediatr Intensive Care 2019; 9:27-33. [PMID: 31984154 DOI: 10.1055/s-0039-1695733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022] Open
Abstract
Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.
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Affiliation(s)
- Brianna L McKelvie
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, Western University, Children's Hospital-London Health Sciences Centre, London, Ontario, Canada
| | - Anna-Theresa Lobos
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jason Chan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - James Dayre McNally
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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28
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Seligman KL, Liming BJ, Smith RJH. Pediatric Tracheostomy Decannulation: 11-Year Experience. Otolaryngol Head Neck Surg 2019; 161:499-506. [PMID: 30987524 DOI: 10.1177/0194599819842164] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the successful decannulation rate with a published pediatric tracheostomy decannulation protocol. STUDY DESIGN Case series with chart review. SETTING A single tertiary care institution. SUBJECTS AND METHODS A chart review was performed for patients aged ≤5 years who underwent tracheostomy. Extracted data included demographic data, indication for tracheostomy, age at tracheostomy and decannulation, comorbidities, and surgical complications. Records were searched for documentation of early decannulation failure (within 1 month of decannulation) or late failure (within 1 year). RESULTS Forty patients with a tracheostomy aged ≤5 years underwent attempted decannulation during the 11-year study period. Seventeen patients were excluded from the study for documentation of nonprotocol decannulation. The final study population of 23 patients underwent a total of 27 decannulations, 26 of which were performed by protocol. Of the 26 protocol decannulations, 22 were successful, for a failure rate of 15%. CONCLUSION Twenty-six protocol decannulations were attempted among 23 patients, 4 of which were unsuccessful for an overall failure rate of 15%. This result is consistent with rates reported in other published decannulation protocols. We believe that our protocol minimizes resource utilization in its use of pulse oximetry over polysomnography, while maximizing patient safety and success through the use of capping trials for very young and very small pediatric patients.
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Affiliation(s)
- Kristen L Seligman
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Bryan J Liming
- 2 Department of Otolaryngology-Head and Neck Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Richard J H Smith
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa, USA
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29
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Sobotka SA, Gaur DS, Goodman DM, Agrawal RK, Berry JG, Graham RJ. Pediatric patients with home mechanical ventilation: The health services landscape. Pediatr Pulmonol 2019; 54:40-46. [PMID: 30461228 PMCID: PMC7286281 DOI: 10.1002/ppul.24196] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 10/29/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Children with invasive home mechanical ventilation (HMV) are a growing population with complex health service needs. Single institution studies provide insight into successful program structures and outcomes. Our study objectives were to assess health service structures, providers, and programs caring for this population throughout the U.S., and to understand barriers to high-quality care. DESIGN Using purposeful sampling with capture-recapture and snowball sampling methods, we identified key informants for care of the U.S. pediatric HMV population. Informants received web-based surveys with two reminders. Survey domains included respondent characteristics, HMV team composition, and barriers to care. RESULTS Survey response was 71% with 101 completed. Respondents caring for patients in 45 states included physicians (61%), nurses (20%), therapists (12%), case managers (4%), and social workers (2%). Half (53%) of physicians were fellowship trained, most commonly pulmonology (22%) and critical care medicine (13%). The majority (65%) of providers described a dedicated HMV service. The majority (61%) of respondents from a HMV service provided both inpatient and outpatient care. Nearly all respondents (96%) described an inadequate supply of home nurses and 88% reported inadequate respite facilities. CONCLUSIONS Children with HMV assistance receive care from a diverse group of providers with varied team structure. Heterogeneity may reflect patient diversity and provider interest, increasing efficacy but challenging standardization nationwide. Despite team structure variability, similar home care difficulties were universally experienced. Data suggest that the home nursing shortage is a national impediment to quality and efficient discharge with limited community-based support for this vulnerable population.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois
| | | | - Denise M Goodman
- Division of Pediatric Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rishi K Agrawal
- Division of Hospital-Based Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Robert J Graham
- Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
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30
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Nackers A, Ehlenbach M, Kelly MM, Werner N, Warner G, Coller RJ. Encounters From Device Complications Among Children With Medical Complexity. Hosp Pediatr 2018; 9:6-15. [PMID: 30530805 DOI: 10.1542/hpeds.2018-0103] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Children with medical complexity (CMC) are commonly assisted by medical devices to support essential body functions, although complications may lead to preventable emergency department (ED) and hospital use. Our objective was to identify predictors of device-complicated ED visits and hospitalizations. METHODS This single-center retrospective cohort study included patients referred to a Pediatric Complex Care Program between April 1, 2014, and April 30, 2016, assisted by at least 1 medical device. Hospitalizations and ED visits in the year before enrollment were rated for likelihood for being due to device complications. Interrater reliability among 3 independent reviewers was assessed. Bivariate followed by multivariate logistic regression clustered by patient helped us identify associations between demographic, clinical, and device characteristics associated with device-complicated ED or hospital encounters. RESULTS Interrater reliability was high (κ = 0.92). Among 98 CMC, device-complicated encounters represented 17% of 258 hospitalizations and 31% of 228 ED visits. Complications of 3 devices (central venous catheters, enteral tubes, and tracheostomy tubes) accounted for 13% of overall hospitalizations and 28% of overall ED visits. Central venous catheter presence (adjusted odds ratio [aOR] 3.2 [95% confidence interval (CI) 1.1-9.5]) was associated with device-complicated ED visits. Gastrojejunostomy/jejunostomy tube presence (aOR 3.3 [95% CI 1.5-7.5]) or tracheostomies with (aOR 8.1 [95% CI 2.3-28.5]) or without (aOR 4.5 [95% CI 1.7-7.5]) ventilator use was associated with device-complicated hospitalizations. Clinical variables were poor predictors of device-complicated encounters. CONCLUSIONS Device-complicated ED visits and hospitalizations comprised a substantial proportion of total hospital and ED use. Developing interventions to prevent device complications may be a promising strategy to reduce overall CMC use.
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Affiliation(s)
- Allison Nackers
- Department of Pediatrics, School of Medicine and Public Health
| | - Mary Ehlenbach
- Department of Pediatrics, School of Medicine and Public Health
| | - Michelle M Kelly
- Department of Pediatrics, School of Medicine and Public Health.,Center for Quality and Productivity Improvement, and
| | - Nicole Werner
- Center for Quality and Productivity Improvement, and.,Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Gemma Warner
- Department of Pediatrics, School of Medicine and Public Health
| | - Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health,
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31
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Sakai M, Kou YF, Shah GB, Johnson RF. Tracheostomy demographics and outcomes among pediatric patients ages 18 years or younger-United States 2012. Laryngoscope 2018; 129:1706-1711. [DOI: 10.1002/lary.27463] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 05/23/2018] [Accepted: 07/02/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Mark Sakai
- University of Texas Southwestern Medical School; Dallas Texas
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery; Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center; Dallas Texas
| | - Gopi B. Shah
- Department of Otolaryngology-Head and Neck Surgery; Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center; Dallas Texas
- Department of Pediatric Otolaryngology; Children's Health, Children's Medical Center Dallas; Dallas Texas U.S.A
| | - Romaine F. Johnson
- Department of Otolaryngology-Head and Neck Surgery; Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center; Dallas Texas
- Department of Pediatric Otolaryngology; Children's Health, Children's Medical Center Dallas; Dallas Texas U.S.A
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32
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Can FK, Anıl AB, Anıl M, Gümüşsoy M, Çitlenbik H, Kandoğan T, Zengin N. The outcomes of children with tracheostomy in a tertiary care pediatric intensive care unit in Turkey. Turk Arch Pediatr 2018; 53:177-184. [PMID: 30459517 DOI: 10.5152/turkpediatriars.2018.6586] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/14/2018] [Indexed: 11/22/2022]
Abstract
Aim We aimed to describe which clinical characteristics were associated with the outcome of tracheostomy in our tertiary care pediatric intensive care unit. Material and Methods This was a retrospective review of medical records of pediatric patients who underwent tracheostomy in our Pediatric Intensive Care unit from 2008 to 2014 in Turkey. Results Sixty-three patients were included the study. The median age of patients was 11 (range, 1-195) months. Twenty-five (39.7%) patients were female. The tracheostomy rate was 8.5% over a six-year period. Forty-nine (77.7%) patients were able to be discharged and sent home. The decannulation rate was 12.6% (n=8). The indications for tracheostomy were upper airway obstruction (n=9) and prolonged mechanical ventilation (n=54). The median intubation period before tracheostomy was 32 (range, 1-122) days and the median duration of pediatric intensive care unit stay after tracheostomy was 37 days. A total of 21 (52.5%) patients were weaned off mechanical ventilation. The rate of successful weaning from mechanical ventilation was higher in patients with upper airway obstruction than in those in the prolonged mechanical ventilation group (p=0.021). The complication rate was 25.3% in the pediatric intensive care unit and 11.1% at home. Conclusions Tracheostomy seems safe and improves pediatric patients' outcomes. The most important factor that affects the prognosis of children who underwent tracheostomy is the indication for tracheostomy. The outcomes are always better if the tracheostomy has been performed because of upper airway obstruction. Performing tracheostomy helps weaning from and off ventilator support and finally the discharge of patients with prolonged mechanical ventilation from the pediatric intensive care unit setting.
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Affiliation(s)
- Fulya Kamit Can
- Unit of Pediatric Intensive Care, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Ayşe Berna Anıl
- Unit of Pediatric Intensive Care, Katip Çelebi Univercity School of Medicine, İzmir, Turkey
| | - Murat Anıl
- Clinic of Child Emergency Service, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Murat Gümüşsoy
- Department of Otorhinolaryngology, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Hale Çitlenbik
- Unit of Pediatric Intensive Care, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Tolga Kandoğan
- Department of Otorhinolaryngology, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Neslihan Zengin
- Unit of Pediatric Intensive Care, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
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Querney J, Ethier JL. Tracheostomy reversal years after patient lost to follow-up. J Otolaryngol Head Neck Surg 2018; 47:46. [PMID: 30001737 PMCID: PMC6044025 DOI: 10.1186/s40463-018-0291-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 07/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Pediatric tracheostomies occur for various reasons, including prologned intubation, and require a multidisciplinary approach with routine follow-up. Case presentation This report reviews the history and clinical outcome of a 29 year old female patient who was lost to follow-up for nearly two decades after a pediatric tracheostomy. When she presented to the Otolaryngology service as an adult the original indication for tracheostomy had resolved and decannulation was initiated, but a profound psychological dependence had developed. Conclusion This case outlines the importance of regular follow-up for tracheostomy patients, as well as health care barriers faced in remote rural communities.
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Affiliation(s)
- Jill Querney
- University of Alberta, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada.
| | - Jean-Luc Ethier
- Timmins and District Hospital, Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON, P3E 2C6, Canada
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Yu H, Mamey MR, Russell CJ. Factors associated with 30-day all-cause hospital readmission after tracheotomy in pediatric patients. Int J Pediatr Otorhinolaryngol 2017; 103:137-141. [PMID: 29224755 PMCID: PMC5728177 DOI: 10.1016/j.ijporl.2017.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine factors associated with post-tracheotomy hospital readmission within 30 days of discharge. METHODS Children 18 years and younger who underwent tracheotomy at Children's Hospital Los Angeles (CHLA) between 1/1/2005 and 12/31/2013 with at least 30 days of follow-up at CHLA were identified through ICD-9 procedure codes. Patient characteristics and covariates were obtained by linking manual chart review and administrative data. We used multivariate logistic regression to identify the independent association between risk factors and the primary outcome of 30-day all-cause same-hospital readmission. RESULTS Of the 273 patients included, the median age at admission was 6 months [interquartile range (IQR): 1-51 months]. Among this primarily male (60.8%) and Hispanic (66.3%) cohort with a high proportion of discharge on positive pressure ventilation (47.1%), the 30-day readmission rate was 22% (n = 60). Of the readmissions, 92% (n = 55) were unplanned and 64% (n = 35) were associated with acute respiratory illnesses. Multivariate regression analysis demonstrated that, among patients ≤12 months, discharge on positive pressure ventilation [adjusted odds ratio (aOR) = 2.88, 95% confidence interval (CI) = 1.19-6.97] was associated with increased odds of readmission, while gastrostomy tube placement during the tracheotomy hospitalization (aOR = 0.42, 95% CI = 0.19-0.96) and prematurity (aOR = 0.35, 95% CI = 0.15-0.83) were associated with decreased odds of readmission. In patients >1 year of age, increased length of hospitalization (aOR = 1.01 per hospital day, 95% CI = 1-1.02) and presence of comorbid malignancy (aOR = 6.03, 95% CI = 1.25-29.16) were associated with increased odds of readmission. CONCLUSIONS Over one-fifth of children undergoing tracheotomy had an unplanned hospital readmission within 30 days after discharge. Because the majority of readmissions were unplanned and due to acute respiratory illnesses, future research should investigate how discharge procedures and improved care coordination may lower readmission rates in high-risk patients (e.g., patients discharged on positive pressure ventilation).
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Affiliation(s)
- Helena Yu
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mary Rose Mamey
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Logan LK, Gandra S, Mandal S, Klein EY, Levinson J, Weinstein RA, Laxminarayan R. Multidrug- and Carbapenem-Resistant Pseudomonas aeruginosa in Children, United States, 1999-2012. J Pediatric Infect Dis Soc 2017; 6:352-359. [PMID: 27856730 PMCID: PMC5907855 DOI: 10.1093/jpids/piw064] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 09/27/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa is a common cause of healthcare-associated infection. Multidrug-resistant (MDR) (>3 classes) and carbapenem-resistant (CR) P aeruginosa are significant threats globally. We used a large reference-laboratory database to study the epidemiology of P aeruginosa in children in the United States. METHODS Antimicrobial susceptibility data from the Surveillance Network were used to phenotypically identify MDR and CR P aeruginosa isolates in children aged 1 to 17 years between January 1999 and July 2012. Logistic regression analysis was used to calculate trends in the prevalence of MDR and CR P aeruginosa. Isolates from infants (<1 year old) and patients with cystic fibrosis were excluded. RESULTS Among the isolates tested, the crude proportion of MDR P aeruginosa increased from 15.4% in 1999 to 26% in 2012, and the proportion of CR P aeruginosa increased from 9.4% in 1999 to 20% in 2012. The proportion of both MDR and CR P aeruginosa increased each year by 4% (odds ratio [OR], 1.04 [95% confidence interval (CI), 1.03-1.04] and 1.04 [95% CI, 1.04-1.05], respectively). In multivariable analysis, both MDR and CR P aeruginosa were more common in the intensive care setting, among children aged 13 to 17 years, in respiratory specimens, and in the West North Central region. In addition, resistance to other antibiotic classes (aminoglycosides, fluoroquinolones, cephalosporins, and piperacillin-tazobactam) often used to treat P aeruginosa increased. CONCLUSIONS Rates of MDR and CR P aeruginosa infection in children are rising nationally. Aggressive prevention strategies, including instituting antimicrobial stewardship programs in pediatric settings, are essential for combating antimicrobial resistance.
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Affiliation(s)
- Latania K Logan
- Departments of Pediatrics
- Section of Pediatric Infectious Diseases, Rush Medical College, Rush University Medical Center, Chicago, Illinois
- Cook County Health and Hospitals System, Chicago, Illinois
| | - Sumanth Gandra
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | | | - Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Washington, DC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jordan Levinson
- Center for Disease Dynamics, Economics & Policy, Washington, DC
| | - Robert A Weinstein
- Internal Medicine, Division of Infectious Diseases
- Cook County Health and Hospitals System, Chicago, Illinois
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, Washington, DC
- Public Health Foundation of India, New Delhi
- Princeton University, Princeton, New Jersey
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Hartnick C, Diercks G, De Guzman V, Hartnick E, Van Cleave J, Callans K. A quality study of family-centered care coordination to improve care for children undergoing tracheostomy and the quality of life for their caregivers. Int J Pediatr Otorhinolaryngol 2017; 99:107-110. [PMID: 28688550 DOI: 10.1016/j.ijporl.2017.05.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/31/2017] [Indexed: 11/18/2022]
Abstract
IMPORTANCE Approximately 4000 U.S. children undergo tracheostomy yearly [1], and these surgeries often result in hospital re-admissions that have definite cost and caregiver burdens due to complications that are avoidable with proper training and support. OBJECTIVE To assess the impact of a Family-Centered Care Coordination (FCCC) program on the quality of care received by children undergoing tracheostomy and their caregivers. DESIGN Caregivers of children undergoing tracheostomies from January 2012 to January 2013 and then a different set of caregivers of children undergoing tracheostomies from January 2015 to January 2016 completed both the Pediatric Tracheostomy Health Status Instrument (PTHSI) 1 month after discharge and the Medical Complications Associated with Pediatric Tracheostomy (MCAT) questionnaire 6 months after initial tracheostomy. To assess complication rates, these same sets of caregivers were asked to complete the MCAT and only those who provided complete medical data for all 6 months were included for comparative analysis. SETTING The PTHSI and MCAT were administered at Massachusetts Eye and Ear in a hospital setting. PARTICIPANTS Ten caregivers of children undergoing tracheostomies completed the PTHSI before FCCC program implementation and12 caregivers then completed the PTHSI after FCCC implementation. For each of the 2 groups, 5 caregivers provided complete data on the MCAT questionnaires. EXPOSURES FCCC is a collection of programs, policies, and tools designed to ensure safe transition home for children undergoing tracheostomies, reduce re-admission rates, and minimize "caregiver burden". MAIN OUTCOMES AND MEASURES The PTHSI is a validated caregiver quality of life instrument that was supplemented by the MCAT which records post-discharge medical issues following tracheostomy that relate specifically to the tracheotomy placement. RESULTS The time to first follow-up appointment decreased from 6.4 weeks (SD = 1.52) to 6 days (SD = 0.18) with FCCC implementation. The total MCAT scores decreased from 15.2 (SD = 1.1) to 1.3 (SD = 1.3) (Wilcoxon sum rank test: P < 0.016) whereas neither PTHSI scores (P = 0.32) nor the specific caregiver burden domain (P = 0.18) demonstrated a significant change. CONCLUSIONS and Relevance: By reducing the time to first follow-up after tracheostomy and by optimizing caregiver tracheostomy tube care and teaching, children's quality of care and caregiver burden can be significantly improved.
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Affiliation(s)
- Christopher Hartnick
- Massachusetts Eye and Ear, Boston, MA, United States; Massachusetts General Hospital for Children, Boston, MA, United States.
| | | | | | | | | | - Kevin Callans
- Massachusetts Eye and Ear, Boston, MA, United States; Massachusetts General Hospital for Children, Boston, MA, United States
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Russell CJ, Mack WJ, Schrager SM, Wu S. Care Variations and Outcomes for Children Hospitalized With Bacterial Tracheostomy-Associated Respiratory Infections. Hosp Pediatr 2017; 7:16-23. [PMID: 27998905 DOI: 10.1542/hpeds.2016-0104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Identify hospital-level care variations and association with length of stay (LOS) and hospital revisit in children with tracheostomies hospitalized for bacterial respiratory tract infections (bRTIs). METHODS A multicenter, retrospective cohort study that used the Pediatric Health Information System database between 2007 and 2014 of patients with tracheostomies aged ≤18 years with a primary diagnosis of bRTI (eg, tracheitis) or a primary diagnosis of a bRTI symptom (eg, cough) and a secondary diagnosis of bRTI. Primary outcomes were LOS and 30-day all-cause revisit rates. Secondary outcomes included hospital-level diagnostic testing and anti-Pseudomonas antibiotic use. We used mixed-effects negative binomial (for LOS) and logistic (for revisit) regression to explore the relationship between hospital-level diagnostic test utilization and the outcomes. RESULTS Data representing 4137 unique patients with a median age of 3 years (interquartile range: 1-9 years) were included. Median LOS was 4 days (interquartile range: 3-8 days), and the 30-day revisit rate was 24.9%. Use of diagnostic testing and empirical anti-Pseudomonas antibiotics varied significantly among hospitals (all P values <.001). After adjusting for patient and hospital characteristics, compared with low test utilization hospitals, there were no differences in 30-day all-cause revisit rates in moderate (adjusted odds ratio: 1.19; 95% confidence interval [CI]: 0.93-1.52) or high (adjusted odds ratio: 1.07; 95% CI: 0.82-1.39) utilization hospitals. LOS in hospitals with moderate (% difference: -0.8%; 95% CI: -14.4-14.9%) or high (% difference: 13.9%; 95% CI: -0.7-30.6%) test utilization was not significantly longer. CONCLUSIONS Given that care variations were not associated with outcomes, future research should focus on standardizing diagnosis and treatment of bRTIs and readmission prevention in this population.
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Affiliation(s)
- Christopher J Russell
- Department of Pediatrics and .,Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Wendy J Mack
- Division of Biostatistics, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Susan Wu
- Department of Pediatrics and.,Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Akangire G, Manimtim W, Nyp M, Townley N, Dai H, Norberg M, Taylor JB. Factors leading to rehospitalization for tracheostomized and ventilator-dependent infants through 2 years of age. J Perinatol 2017; 37:857-863. [PMID: 28425979 DOI: 10.1038/jp.2017.54] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/07/2017] [Accepted: 03/22/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To identify factors leading to readmission for tracheostomized, ventilator-dependent infants <2 years of age. STUDY DESIGN Retrospective cohort study of 117 tracheostomized, ventilator-dependent infants followed through 2 years of age. RESULTS Home ventilator use (at hospital discharge, 6 and 12 months of age), inhaled steroid use (at 12 and 24 months of age), oxygen dependence (at 6 and 12 months of age) and tracheostomy (at discharge, 6 and 12 months of age) were increased risks for rehospitalization. Equipment malfunction throughout the first 2 years also contributed to readmissions. Viral infection, with rhinovirus/enterovirus the most commonly identified pathogen, was the most common etiology for rehospitalization. Diuretic use and initial comorbid diagnoses were not associated with increased risk of rehospitalization. CONCLUSION The risk for rehospitalization for infants requiring tracheostomy and ventilator support was affected by prolonged oxygen use, prolonged ventilator dependence, inhaled steroid use and equipment malfunction, and was equally distributed throughout the first 2 years of life.
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Affiliation(s)
- G Akangire
- Center for Infant Pulmonary Disorders, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - W Manimtim
- Center for Infant Pulmonary Disorders, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - M Nyp
- Center for Infant Pulmonary Disorders, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - N Townley
- Center for Infant Pulmonary Disorders, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - H Dai
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - M Norberg
- Center for Infant Pulmonary Disorders, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - J B Taylor
- Center for Infant Pulmonary Disorders, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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Starplasty tracheostomy: case series and literature review. Eur Arch Otorhinolaryngol 2017; 274:2261-2266. [PMID: 28175990 DOI: 10.1007/s00405-017-4464-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/12/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center. METHODS A retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012. RESULTS Among the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3-207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred. CONCLUSIONS In our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.
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Abstract
This mixed methods study explored stress in families whose children were hospitalized in the pediatric intensive care unit (PICU) for more than one week. The study aim was to describe sources of stress for families whose children require extended hospitalization in the PICU. Data collection included semi-structured interviews and completion of the Family Inventory of Life Events and Family System Stressor Strength Inventory. Themes reported in this paper are separation, not knowing, and the child's illness and distress. Additional research is needed to validate these findings in families of other cultures and structures, and in other PICUs.
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41
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Lee JH, Koo CH, Lee SY, Kim EH, Song IK, Kim HS, Kim CS, Kim JT. Effect of early vs. late tracheostomy on clinical outcomes in critically ill pediatric patients. Acta Anaesthesiol Scand 2016; 60:1281-8. [PMID: 27377041 DOI: 10.1111/aas.12760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/29/2016] [Accepted: 05/31/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Few studies investigated the optimal timing for tracheostomy and its influence on the clinical outcomes in critically ill pediatric patients. This study evaluated the differences in clinical outcomes between early and late tracheostomy in pediatric intensive care unit (ICU) patients. METHODS We assessed 111 pediatric patients. Patients who underwent a tracheostomy within 14 days of mechanical ventilation (MV) were assigned to the early tracheostomy group, whereas those who underwent tracheostomy after 14 days of MV were included in the late tracheostomy group. Clinical outcomes, including mortality, duration of MV, length of ICU and hospital stays, and incidence of ventilator-associated pneumonia (VAP) were compared between the groups. RESULTS Of the 111 pediatric patients, 61 and 50 were included in the early and late tracheostomy groups, respectively. Total MV duration and the length of ICU and hospital stay were significantly longer in the late tracheostomy group than in the early tracheostomy group (all P < 0.01). The VAP rate per 1000 ventilator days before tracheostomy was 2.6 and 3.8 in the early and late tracheostomy groups, respectively. There were no significant differences in mortality rate between the groups. No severe complications were associated with tracheostomy itself. CONCLUSIONS Tracheostomy performed within 14 days after the initiation of MV was associated with reduced duration of MV and length of ICU and hospital stay. Although there was no effect on mortality rate, children may benefit from early tracheostomy without severe complications.
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Affiliation(s)
- J.-H. Lee
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - C.-H. Koo
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - S.-Y. Lee
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - E.-H. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - I.-K. Song
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - H.-S. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - C.-S. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - J.-T. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
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Neonates and Infants Discharged Home Dependent on Medical Technology: Characteristics and Outcomes. Adv Neonatal Care 2016; 16:379-389. [PMID: 27275531 DOI: 10.1097/anc.0000000000000314] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Preterm neonates and neonates with complex conditions admitted to a neonatal intensive care unit (NICU) may require medical technology (eg, supplemental oxygen, feeding tubes) for their continued survival at hospital discharge. Medical technology introduces another layer of complexity for parents, including specialized education about neonatal assessment and operation of technology. The transition home presents a challenge for parents and has been linked with greater healthcare utilization. PURPOSE To determine incidence, characteristics, and healthcare utilization outcomes (emergency room visits, rehospitalizations) of technology-dependent neonates and infants following initial discharge from the hospital. METHODS This descriptive, correlational study used retrospective medical record review to examine technology-dependent neonates (N = 71) upon discharge home. Study variables included demographic characteristics, hospital length of stay, and type of medical technology used. Analysis of neonates (n = 22) with 1-year postdischarge data was conducted to identify relationships with healthcare utilization. Descriptive and regression analyses were performed. FINDINGS Approximately 40% of the technology-dependent neonates were between 23 and 26 weeks' gestation, with birth weight of less than 1000 g. Technologies used most frequently were supplemental oxygen (66%) and feeding tubes (46.5%). The mean total hospital length of stay for technology-dependent versus nontechnology-dependent neonates was 108.6 and 25.7 days, respectively. Technology-dependent neonates who were female, with a gastrostomy tube, or with longer initial hospital length of stay were at greater risk for rehospitalization. IMPLICATIONS FOR PRACTICE Assessment and support of families, particularly mothers of technology-dependent neonates following initial hospital discharge, are vital. IMPLICATIONS FOR RESEARCH Longitudinal studies to determine factors affecting long-term outcomes of technology-dependent infants are needed.
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Sobotka SA, Hird-McCorry LP, Goodman DM. Identification of Fail Points for Discharging Pediatric Patients With New Tracheostomy and Ventilator. Hosp Pediatr 2016; 6:552-557. [PMID: 27538680 DOI: 10.1542/hpeds.2015-0277] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES The core mission of the Pulmonary Habilitation Program is to train and prepare caregivers for the care of a ventilated child in the home. It exists within a free-standing children's hospital. The program is supported by a multidisciplinary staff and serves ∼100 children. Through standardizing electronic documentation with process-specific tracking for the discharge process, the Pulmonary Habilitation Program team sought to identify intervention opportunities for more efficient and effective discharges. METHODS The process of discharge was described using an iterative process, with the multidisciplinary team and discharge milestones noted in the medical chart. RESULTS Several nonmedical factors contribute to prolonged hospital stays, including parent training, approval from the state agency for home care, and staffing of home nursing. Children had median lengths of stay of 141 days (interquartile range, 68 to 177). CONCLUSIONS As a result of this initial investigation, application to the state agency and training for caregivers have been initiated sooner, when a tracheostomy is first placed.
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Affiliation(s)
- Sarah A Sobotka
- Department of Pediatrics, University of Chicago, Chicago, Illinois;
| | | | - Denise M Goodman
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Shimizu J, Taga T, Kishimoto T, Ohta M, Tagawa K, Kunitsu T, Yamane T, Tsujita Y, Kubota Y, Eguchi Y. Airway obstruction caused by rapid enlargement of cervical lymphangioma in a five-month-old boy. Clin Case Rep 2016; 4:896-8. [PMID: 27648270 PMCID: PMC5018596 DOI: 10.1002/ccr3.659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/13/2016] [Accepted: 07/24/2016] [Indexed: 11/06/2022] Open
Abstract
Cervical lymphangioma can cause airway obstruction secondary to enlargement following infection. Physicians should be aware that the airway obstruction can progress rapidly when patients with cervical lymphangioma have respiratory symptoms. Sclerotherapy for lymphangioma can cause both transient swelling and airway obstruction; thus, prophylactic and elective tracheostomy should be considered.
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Affiliation(s)
- Junji Shimizu
- Department of Emergency and Intensive Care Unit Shiga University of Medical Science Otsu Shiga Japan
| | - Takashi Taga
- Department of Pediatrics Shiga University of Medical Science Otsu Shiga Japan
| | - Takuma Kishimoto
- Department of Emergency and Intensive Care Unit Shiga University of Medical Science Otsu Shiga Japan
| | - Motoki Ohta
- Department of Pediatrics Shiga University of Medical Science Otsu Shiga Japan
| | - Kouji Tagawa
- Department of Pediatrics Shiga University of Medical Science Otsu Shiga Japan
| | - Tomoaki Kunitsu
- Department of Pediatrics Shiga University of Medical Science Otsu Shiga Japan
| | - Tetsunobu Yamane
- Department of Emergency and Intensive Care Unit Shiga University of Medical Science Otsu Shiga Japan
| | - Yasuyuki Tsujita
- Department of Emergency and Intensive Care Unit Shiga University of Medical Science Otsu Shiga Japan
| | - Yoshihiro Kubota
- Department of Pediatric Surgery Shiga University of Medical Science Otsu Shiga Japan
| | - Yutaka Eguchi
- Department of Emergency and Intensive Care Unit Shiga University of Medical Science Otsu Shiga Japan
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Dal'Astra APL, Quirino AV, Caixêta JADS, Avelino MAG. Tracheostomy in childhood: review of the literature on complications and mortality over the last three decades. Braz J Otorhinolaryngol 2016; 83:207-214. [PMID: 27256033 PMCID: PMC9442684 DOI: 10.1016/j.bjorl.2016.04.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/04/2016] [Accepted: 04/07/2016] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Tracheostomy is a procedure with unique characteristics when used on pediatric patients due to the greater technical difficulty and higher morbidity and mortality rates relative to the procedure in adults. In recent decades, there have been significant changes in the medical care available to children, particularly for those who need intensive care. Surgical conditions have also improved, and there has been an advent of new equipment and medications. These advances have brought changes to both tracheostomy indications and tracheostomy complications. OBJECTIVE To perform a review of the articles published over the last three decades on the complications and mortality associated with tracheostomies in children. METHODS Articles were selected from the Cochrane, Latin American and Caribbean Health Sciences Literature, SciELO, National Library of Medicine (Medline Plus), and PubMed online databases. The articles selected had been published between January 1985 and December 2014, and the data was compared using the Chi-square test. RESULTS A total of 3797 articles were chosen, 47 of which were used as the basis for this review. When the three decades were evaluated as a whole, an increase in tracheostomies in male children under one year of age was found. The most common complications during the period analyzed in descending order of frequency were granuloma, infection, and obstruction of the cannula, accidental decannulation, and post-decannulation tracheocutaneous fistula. In the second and third decades of the review, granulomas represented the most common complication; in the first decade of the review, pneumothoraces were the most common. Mortality associated with tracheostomy ranged from 0% to 5.9%, while overall mortality ranged from 2.2% to 59%. In addition, the review included four studies on premature and/or very underweight infants who had undergone tracheostomies; the studies reported evidence of higher mortality in this age group to be largely associated with underlying diseases. CONCLUSION Improved surgical techniques and intensive care, the creation of new medications, and vaccines have all redefined the main complications and the mortality rates of tracheostomy in children. It is a safe procedure that increases chances of survival in those who require the prolonged use of mechanical ventilation.
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Groenendijk I, Booth J, van Dijk M, Argent A, Zampoli M. Paediatric tracheostomy and ventilation home care with challenging socio-economic circumstances in South Africa. Int J Pediatr Otorhinolaryngol 2016; 84:161-5. [PMID: 27063774 DOI: 10.1016/j.ijporl.2016.03.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Children discharged home with a tracheostomy need a safe home environment and access to health care. We described the indications, clinical characteristics, socio-economic circumstances and outcomes of children enroled in a tracheostomy home care programme in South Africa. METHODS We performed a retrospective chart review of children receiving a tracheostomy and enroled in the Breatheasy programme at the Red Cross War Memorial Children's Hospital, Cape Town. Medical and background characteristics were recorded. Influences of socio-economic variables and underlying medical conditions on length of hospital stay, unplanned readmissions and mortality in the first year after discharge were evaluated. RESULTS In the period 2008-2012, 157 patients were discharged home with a tracheostomy. Median hospital stay after tracheostomy insertion was significantly longer when parents had incomplete schooling compared to completed secondary school or higher education; 30 days (IQR 21-53) versus 23 days (IQR 16-33), respectively. Unplanned readmissions in the first year were documented for 72 patients (45.9%). The risk for unplanned readmission was 2.6 times higher in families with substance abuse the risk of respiratory infections was two-fold in case of household cigarette smoke exposure (OR 2.3.) Tracheostomy-related mortality was low (1.2%). An underlying medical condition was the only independent significant risk factor for mortality (OR 5.1, 95% CI 1.8-14.3). CONCLUSION This study demonstrates that despite difficult socio-economic circumstances, home ventilation of children with a tracheostomy is safe, provided caregivers are adequately trained and supported.
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Affiliation(s)
- Ilse Groenendijk
- Intensive Care Unit and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jane Booth
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Monique van Dijk
- Intensive Care Unit and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Andrew Argent
- Division of Paediatric Critical Care and Children's Heart Disease, School of Child and Adolescent Health University of Cape Town; and Paediatric Intensive Care Unit Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Marco Zampoli
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Watters K, O'Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy. Laryngoscope 2016; 126:2611-2617. [PMID: 27060012 DOI: 10.1002/lary.25972] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/18/2016] [Accepted: 02/16/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children. STUDY DESIGN Retrospective cohort study. METHODS Children (0-16 years) in Medicaid from 10 states undergoing tracheostomy in 2009, identified with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes and followed through 2011, were selected using the Truven Health Medicaid Marketscan Database (Truven Health Analytics, Inc., Ann Arbor, MI). Patient demographic and clinical characteristics were assessed with likelihood of death and tracheostomy complication using chi-square tests and logistic regression. Healthcare use and spending across the care continuum (hospital, outpatient, community, and home) were reported. RESULTS A total of 502 children underwent tracheostomy in 2009, with 34.1% eligible for Medicaid because of disability. Median age at tracheostomy was 8 years (interquartile range 1-16 years), and 62.7% had a complex chronic condition. Two-year rates of in-hospital mortality and tracheostomy complication were 8.9% and 38.8%, respectively. In multivariable analysis, the highest likelihood of mortality occurred in children age < 1 year compared with 13+ years (odds ratio [OR] 7.3; 95% confidence interval [CI], 3.2-17.1); the highest likelihood of tracheostomy complication was in children with a complex chronic condition versus those without a complex chronic condition (OR 3.3; 95% CI, 1.1-9.9). Total healthcare spending in the 2 years following tracheostomy was $53.3 million, with hospital, home, and primary care constituting 64.4%, 9.4%, and 0.5% of total spending, respectively. CONCLUSION Mortality and morbidity are high, and spending on primary and home care is small following tracheostomy in children with Medicaid. Future studies should assess whether improved outpatient and community care might improve their health outcomes. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2611-2617, 2016.
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Affiliation(s)
- Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts.
| | - Margaret O'Neill
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Hannah Zhu
- Department of Pediatrics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Robert J Graham
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Matthew Hall
- Children's Hospital Association, Overland Park, KS, U.S.A
| | - Jay Berry
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Abode KA, Drake AF, Zdanski CJ, Retsch-Bogart GZ, Gee AB, Noah TL. A Multidisciplinary Children's Airway Center: Impact on the Care of Patients With Tracheostomy. Pediatrics 2016; 137:e20150455. [PMID: 26755695 DOI: 10.1542/peds.2015-0455] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children with complex airway problems see multiple specialists. To improve outcomes and coordinate care, we developed a multidisciplinary Children's Airway Center. For children with tracheostomies, aspects of care targeted for improvement included optimizing initial hospital discharge, promoting effective communication between providers and caregivers, and avoiding tracheostomy complications. METHODS The population includes children up to 21 years old with tracheostomies. The airway center team includes providers from pediatric pulmonology, pediatric otolaryngology/head and neck surgery, and pediatric gastroenterology. Improvement initiatives included enhanced educational strategies, weekly care conferences, institutional consensus guidelines and care plans, personalized clinic schedules, and standardized intervals between airway examinations. A patient database allowed for tracking outcomes over time. RESULTS We initially identified 173 airway center patients including 123 with tracheostomies. The median number of new patients evaluated by the center team each year was 172. Median hospitalization after tracheostomy decreased from 37 days to 26 days for new tracheostomy patients <1 year old discharged from the hospital. A median of 24 care plans was evaluated at weekly conferences. Consensus protocol adherence increased likelihood of successful decannulation from 68% to 86% of attempts. The median interval of 8 months between airway examinations aligned with published recommendations. CONCLUSIONS For children with tracheostomies, our Children's Airway Center met and sustained goals of optimizing hospitalization, promoting communication, and avoiding tracheostomy complications by initiating targeted improvements in a multidisciplinary team setting. A multidisciplinary approach to management of these patients can yield measurable improvements in important outcomes.
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Affiliation(s)
- Kathleen A Abode
- University of North Carolina Health Care System, Chapel Hill, North Carolina; and Division of Pulmonology, Department of Pediatrics, and
| | - Amelia F Drake
- Division of Pulmonology, Department of Pediatrics, and Division of Pediatric Otolaryngology, Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Carlton J Zdanski
- Division of Pulmonology, Department of Pediatrics, and Division of Pediatric Otolaryngology, Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Amanda B Gee
- Division of Pulmonology, Department of Pediatrics, and
| | - Terry L Noah
- Division of Pulmonology, Department of Pediatrics, and
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McCrory MC, Lee KJ, Scanlon MC, Wakeham MK. Predictors of need for mechanical ventilation at discharge after tracheostomy in the PICU. Pediatr Pulmonol 2016; 51:53-9. [PMID: 25823590 DOI: 10.1002/ppul.23195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/21/2015] [Accepted: 02/23/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objective of this study was to determine factors predictive of need for mechanical ventilation (MV) upon discharge from the pediatric intensive care unit (PICU) among patients who receive a tracheostomy during their stay. METHODS This was a retrospective cohort study using the Virtual PICU Systems (VPS) database. Patients <18 years old admitted between 2009-2011 who required MV for at least 3 days and received a tracheostomy during their PICU stay were included. RESULTS A total of 680 pediatric patients from 74 PICUs were included, of whom 347 (51%) remained on MV at the time of PICU discharge. Neonates (30/38, 79%) and infants (129/203, 64%) required MV at PICU discharge after tracheostomy more often than adolescents (66/141, 47%) and children (122/298, 41%). Time on MV pre-tracheostomy was longer among those who required MV at discharge (median 18.3 vs. 13.8 days, P < 0.0001); however, number of failed extubations was similar (median 1 for both groups, P = 0.97). On mixed-effects multivariable regression analysis, the age categories of neonate (OR 2.9, 95%CI 1.1-7.6, P = 0.03), and infant (OR 1.7, 95%CI 1.1-2.8, P = 0.03), and ventilator days prior to tracheostomy (OR 1.01, 95%CI 1.0-1.02, P = 0.01) were significantly associated with increased odds of MV upon PICU discharge, while being a trauma admission was associated with decreased odds (OR 0.45, 95%CI 0.28-0.73, P = 0.001). CONCLUSIONS Younger patients and those with prolonged courses of MV prior to tracheostomy are more likely to continue to need MV upon PICU discharge.
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Affiliation(s)
- Michael C McCrory
- Section on Pediatric Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - K Jane Lee
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew C Scanlon
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Martin K Wakeham
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
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Optimizing Timing of Tracheostomy Placement in the PICU: Why Defining Success Will Require a Longer View. Pediatr Crit Care Med 2015; 16:686-7. [PMID: 26335124 DOI: 10.1097/pcc.0000000000000468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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