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de Miranda LDG, Borges LAA, Zavaglia LC, Mesquita TCL, Leite LR, Aguiar LT, de Mendonça Picinin IF. Decannulation protocol in pediatric patients: case series study. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2024; 43:e2023187. [PMID: 39319994 PMCID: PMC11421412 DOI: 10.1590/1984-0462/2025/43/2023187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 05/17/2024] [Indexed: 09/26/2024]
Abstract
OBJECTIVE The aim of this study was to describe the phases of a decannulation protocol and the results from its application in hospitalized children. METHODS This is a retrospective, observational study. Data were collected from medical records of decannulated patients followed up in a pediatric hospital in Belo Horizonte, Minas Gerais between 2011 and 2021. RESULTS Among the children followed up in the service (n=526), 23% (n=120) were successfully decannulated. Children aged between 2 months and 16 years, with a mean age of 4 years, 69% of whom were male, were evaluated. About 75% of the patients have tracheostomy due to upper airway obstruction and 60% of these due to acquired subglottic stenosis. At the beginning of the decannulation protocol, 5.5% of the patients had moderate oropharyngeal dysphagia, while 80.4% had normal swallowing. Correction in the upper airway pre-decannulation was performed in 39.5% of the patients, dilation in 63.8%, and endoscopic correction was performed in 55.3%. After performing the decannulation, none of the patients had complications. CONCLUSIONS The described decannulation protocol is safe, since no complications such as death and need for recannulation happened.
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Affiliation(s)
- Luciana Diniz Gomide de Miranda
- Fundação Hospitalar do Estado de Minas Gerais, Hospital Infantil João Paulo II, Serviço de Assistência Integral à Criança Traqueostomizada, Belo Horizonte, MG, Brazil
| | | | | | - Tereza Cristina Lara Mesquita
- Fundação Hospitalar do Estado de Minas Gerais, Hospital Infantil João Paulo II, Serviço de Assistência Integral à Criança Traqueostomizada, Belo Horizonte, MG, Brazil
| | - Luanna Rodrigues Leite
- Fundação Hospitalar do Estado de Minas Gerais, Hospital Infantil João Paulo II, Serviço de Assistência Integral à Criança Traqueostomizada, Belo Horizonte, MG, Brazil
| | | | - Isabela Furtado de Mendonça Picinin
- Fundação Hospitalar do Estado de Minas Gerais, Hospital Infantil João Paulo II, Serviço de Assistência Integral à Criança Traqueostomizada, Belo Horizonte, MG, Brazil
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil
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Cecil CA, Dziorny AC, Hall M, Kane JM, Kohne J, Olszewski AE, Rogerson CM, Slain KN, Toomey V, Goodman DM, Heneghan JA. Low-Resource Hospital Days for Children Following New Tracheostomy. Pediatrics 2024; 154:e2023064920. [PMID: 39113630 DOI: 10.1542/peds.2023-064920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with new tracheostomy and invasive mechanical ventilation (IMV) require transitional care involving caregiver education and nursing support. To better understand hospital resource use during this transition, our study aimed to: (1) define and characterize low-resource days (LRDs) for this population and (2) identify factors associated with LRD occurrence. METHODS This retrospective cohort analysis included children ≤21 years with new tracheostomy and IMV dependence admitted to an ICU from 2017 to 2022 using the Pediatric Health Information System database. A LRD was defined as a post tracheostomy day that accrued nonroom charges <10% of each patient's accrued nonroom charges on postoperative day 1. Factors associated with LRDs were analyzed using negative binomial regression. RESULTS Among 4048 children, median post tracheostomy stay was 69 days (interquartile range 34-127.5). LRDs were common: 38.6% and 16.4% experienced ≥1 and ≥7 LRDs, respectively. Younger age at tracheostomy (0-7 days rate ratio [RR] 2.42 [1.67-3.51]; 8-28 days RR 1.8 (1.2-2.69) versus 29-365 days; Asian race (RR 1.5 [1.04-2.16]); early tracheostomy (0-7 days RR 1.56 [1.2-2.04]), and longer post tracheostomy hospitalizations (31-60 days RR 1.85 [1.44-2.36]; 61-90 days RR 2.14 [1.58-2.91]; >90 days RR 2.21 [1.71-2.86]) were associated with more LRDs. CONCLUSIONS Approximately 1 in 6 children experienced ≥7 LRDs. Younger age, early tracheostomy, Asian race, and longer hospital stays were associated with increased risk of LRDs. Understanding the postacute phase, including bed utilization, serves as an archetype to explore care models for children with IMV dependence.
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Affiliation(s)
- Cara A Cecil
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam C Dziorny
- School of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Jason M Kane
- Pritzker School of Medicine, University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Joseph Kohne
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Aleksandra E Olszewski
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Colin M Rogerson
- Division of Critical Care, Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Katherine N Slain
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Vanessa Toomey
- Children's Hospital Los Angeles; University of Southern California Keck School of Medicine, Los Angeles, California
| | - Denise M Goodman
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia A Heneghan
- University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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Sozduyar S, Ergun E, Khalilova P, Gollu G, Ates U, Can OS, Kendirli T, Yagmurlu A, Cakmak M, Kologlu M. Percutaneous Tracheostomy Via Grigg's Technique in Children: Does Age and Size Matter? Laryngoscope 2024. [PMID: 39132833 DOI: 10.1002/lary.31698] [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: 10/17/2023] [Revised: 06/19/2024] [Accepted: 07/12/2024] [Indexed: 08/13/2024]
Abstract
OBJECTIVES Percutaneous tracheostomy is rarely performed in children, especially in infants. In the present study, we aimed to evaluate the complications and outcomes of PT via the Griggs technique according to the age and size of pediatric patients. METHODS This study included 110 PICU patients who underwent PT using the Griggs technique between 2012 and 2020. The patients were divided into six groups according to their age, demographic data, primary disease, mean duration of intubation before PT, mean duration of PICU and hospitalization after PT, complications, and decannulation outcomes were compared between these groups. RESULTS The mean age and mean weight of the patients were 43.6 ± 58.9 months (1 month-207 months) and 14.6 ± 14.9 kg (2.6-65 kg), respectively. Mean intubation times before the procedures were 64.6 ± 40 days and 38.6 ± 37.9. Thirty-seven (33.6%) infants were under 6 months of age(Group 1). There were no intraoperative complications. Tracheostomy site stenosis was significantly greater in Group 1 than in the other age groups (p = 0.032). Granuloma formation and dermatitis incidence were similar in all age groups. CONCLUSION PT is a safe and feasible procedure even in small infants. The accidental decannulation risk is lower than standard tracheostomy. Interacting with rigid bronchoscopy guidance is essential to perform a safer procedure. The first tracheostomy change after PT in small infants under 6 months of age, the possibility of tracheostomy site (stoma) stenosis should be considered. LEVEL OF EVIDENCE Level III Laryngoscope, 2024.
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Affiliation(s)
- Sumeyye Sozduyar
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ergun Ergun
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Pari Khalilova
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gulnur Gollu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ufuk Ates
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ozlem S Can
- Department of Anesthesiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tanil Kendirli
- Department of Pediatric Intensive Care Unit, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Aydin Yagmurlu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Murat Cakmak
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Meltem Kologlu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
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Odetola FO, Gebremariam A. Epidemiology of Acute Respiratory Failure in US Children: Outcomes and Resource Use. Hosp Pediatr 2024; 14:622-631. [PMID: 38953120 DOI: 10.1542/hpeds.2023-007166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/15/2024] [Accepted: 04/08/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVE Acute respiratory failure recalcitrant to conventional management often requires specialized organ-supportive technologies to optimize outcomes. Variation in the availability of these technologies prompted testing of the hypothesis that outcomes and resource use will vary by not only patient characteristics but also hospital characteristics and receipt of organ-supportive technology. METHODS Retrospective study of children 0 to 20 years old hospitalized for acute respiratory failure using the 2019 Kids' Inpatient Database. Multivariable regression models identified factors associated with mortality, length of hospitalization, and costs. RESULTS Of an estimated 75 365 hospitalizations nationally, 97% were to urban teaching hospitals, 57% were of children < 6 years, and 58% were of males. Complex chronic conditions (CCC) existed in 62%, multiorgan dysfunction in 35%, and extreme illness severity in 54%. Mortality was 7%, length of stay 15 days, and hospital costs $77 168. Elevated mortality was associated with cumulative organ dysfunction (odds ratio [OR]:2.31, 95% confidence interval [CI]: 2.22-2.42), CCC (OR: 5.49, 95% CI: 4.73-6.37), transfer, higher illness severity, and cardiopulmonary resuscitation. Lower mortality was associated with extracorporeal membrane oxygenation (OR: 0.36, 95% CI: 0.28-0.47) and new tracheostomy (OR: 0.30, 95% CI: 0.25-0.35). Longer hospitalization was associated with transfer, infancy, CCC, higher illness severity, cumulative organ dysfunction, and urban hospitals. Higher costs accrued with noninfants, cumulative organ dysfunction, private insurance, and urban teaching hospitals. CONCLUSIONS Hospitalizations for pediatric acute respiratory failure incurred substantial mortality and resource consumption. Efforts to reduce mortality and resource consumption should address interhospital transfer, access to organ-supportive technology, and drivers of higher severity-adjusted resource consumption at urban hospitals.
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Affiliation(s)
- Folafoluwa O Odetola
- Division of Pediatric Critical Care Medicine, Department of Pediatrics
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan
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Bilgin G, Unal F, Yanaz M, Baskan AKILIC, Uzuner S, Ayhan Y, Onay ZR, Kalyoncu M, Tortop DMAVI, Arslan H, Oksay SCAN, Kostereli E, Yazan H, Atag E, Ergenekon AP, Ekizoglu NBAS, Yegit CYILMAZ, Gokdemir Y, Uyan ZS, Kilinc AA, Cokugras H, Eralp EERDEM, Cakir E, Karadag B, Oktem S, Karakoc F, Girit S. Long-term outcomes of standardized training for caregivers of children with tracheostomies: The IStanbul PAediatric Tracheostomy (ISPAT) project. Pediatr Pulmonol 2024; 59:331-341. [PMID: 37983721 DOI: 10.1002/ppul.26749] [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: 01/14/2023] [Revised: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND AND OBJECTIVES: Children with tracheostomies are at increased risk of tracheostomy-related complications and require extra care. Standardized training programs for caregivers can improve tracheostomy care and reduce complications. In this study, we compared caregiver knowledge and skill scores after a standardized theoretical and practical training program on tracheostomy care (IStanbul PAediatric Tracheostomy (ISPAT) project) immediately and 1 year post-training and evaluated how this training affected the children's clinical outcomes. MATERIALS AND METHODS We included 32 caregivers (31 children) who had received standardized training a year ago and administered the same theoretical and practical tests 1 year after training completion. We recorded tracheostomy-related complications and the number and reasons for admission to the healthcare centers. All data just before the training and 1 year after training completion were compared. RESULTS After 1 year of training completion, the median number of correct answers on the theoretical test increased to 16.5 from 12 at pretest (p < 0.001). Compared with pretest, at 1-year post-training practical skills assessment scores, including cannula exchange and aspiration, were significantly higher (both p < 0.001) and mucus plug, bleeding, and stoma infection reduced significantly (p = 0.002, 0.022, and 0.004, respectively). Hands-on-training scores were better than pretest but declined slightly at 1 year compared to testing immediately after training. Emergency admission decreased from 64.5% to 32.3% (p = 0.013). Hospitalization decreased from 61.3% to 35.5% (p = 0.039). CONCLUSION Our findings indicate that caregiver training can lead to a persistent increase in knowledge and skill for as long as 1 year, as well as improvements in several measurable outcomes, although a slight decrease in scores warrants annual repetitions of the training program.
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Affiliation(s)
- Gulay Bilgin
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Fusun Unal
- Faculty of Medicine, Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Muruvvet Yanaz
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Azer K I L I C Baskan
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Selcuk Uzuner
- Faculty of Medicine, Istanbul Bezmialem University, Istanbul, Turkey
| | - Yetkin Ayhan
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Zeynep Reyhan Onay
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Mine Kalyoncu
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Deniz M A V I Tortop
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Huseyin Arslan
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Sinem C A N Oksay
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
| | - Ebru Kostereli
- Faculty of Medicine, Division of Pediatric Pulmonology, Koc University, Istanbul, Turkey
| | - Hakan Yazan
- Health Sciences University, Umraniye Training and Research Hospital, Division of Pediatric Pulmonology, Istanbul, Turkey
| | - Emine Atag
- Faculty of Medicine, Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Almala Pınar Ergenekon
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Nilay B A S Ekizoglu
- Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital, Division of Pediatric Pulmonology, Istanbul, Turkey
| | - Cansu Y I L M A Z Yegit
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Yasemin Gokdemir
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Zeynep Seda Uyan
- Faculty of Medicine, Division of Pediatric Pulmonology, Koc University, Istanbul, Turkey
| | - Ayse Ayzıt Kilinc
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Haluk Cokugras
- Cerrahpasa Faculty of Medicine, Division of Pediatric Pulmonology, Istanbul University, Istanbul, Turkey
| | - Ela E R D E M Eralp
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Erkan Cakir
- Faculty of Medicine, Division of Pediatric Pulmonology, Istinye University, Istanbul, Turkey
| | - Bulent Karadag
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Sedat Oktem
- Faculty of Medicine, Division of Pediatric Pulmonology, Medipol University, Istanbul, Turkey
| | - Fazilet Karakoc
- Faculty of Medicine, Division of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
| | - Saniye Girit
- Faculty of Medicine, Division of Pediatric Pulmonology, Medeniyet University, Istanbul, Turkey
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Liu Y, He Q, Dou Z, Ma K, Chen W, Li S. Management Strategies for Congenital Heart Disease Comorbid with Airway Anomalies in Children. J Pediatr 2024; 264:113741. [PMID: 37726085 DOI: 10.1016/j.jpeds.2023.113741] [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: 03/29/2023] [Revised: 09/03/2023] [Accepted: 09/13/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE To assess management strategies for pediatric patients with the challenging combination of congenital heart diseases (CHDs) and airway anomalies. STUDY DESIGN Patients diagnosed with CHD and airway anomalies in the Pediatric Cardiac Surgery Centre of Fuwai Hospital from January 2016 to December 2020 were included in this retrospective study. Patients were divided into three groups based on different management, including the conservative group, the slide group (slide tracheoplasty), and the suspension group (suspension with external stenting). Patients' data and computed tomography measurements from medical records were reviewed. RESULTS A total of 139 patients were included in the cohort; 107 had conservative airway treatment (conservative group), 15 had slide tracheoplasty (slide group), and 17 had tracheal suspension operation (suspension group). The top three associated intracardiac anomalies were ventricular septal defect (n = 34, 24%), pulmonary artery sling (n = 22, 16%), and tetralogy of Fallot (n = 15, 11%). Compared with patients with conservative airway management (100 minutes [median], 62-152 [IQR]), the extra airway procedure prolonged cardiopulmonary bypass duration, with 202 minutes (IQR, 119-220) for the slide group and 150 minutes (IQR, 125-161) for the suspension group. Patients who underwent slide tracheoplasty required prolonged mechanical ventilation (129 minutes [median], 56-328 [IQR]). Of the total cohort, 6 in-hospital deaths, all in the conservative group, and 8 mid-to long-term deaths, with 6 in the conservative group, occurred. CONCLUSIONS Both conservative and surgical management of CHD patients with airway anomalies have promising outcomes. Extra tracheobronchial procedures, especially the slide tracheoplasty, significantly prolonged cardiopulmonary bypass duration. Based on multidisciplinary team assessment, individualized management strategies should be developed for these patients.
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Affiliation(s)
- Yuze Liu
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qiyu He
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zheng Dou
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Kai Ma
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Pediatric Cardiac Surgery Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Fox MT, Meyer-Macaulay C, Roberts H, Lipsitz S, Siegel BD, Mastropietro C, Graham RJ, Moynihan KM. Tracheostomy Timing During Pediatric Cardiac Intensive Care: Single Referral Center Retrospective Cohort. Pediatr Crit Care Med 2023; 24:e556-e567. [PMID: 37607094 DOI: 10.1097/pcc.0000000000003345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES To describe associations between the timing of tracheostomy and patient characteristics or outcomes in the cardiac ICU (CICU). DESIGN Single-institution retrospective cohort study. SETTING Freestanding academic children's hospital. PATIENTS CICU patients with tracheostomy placed between July 1, 2011, and July 1, 2020. INTERVENTIONS We compared patient characteristics and outcomes between early and late tracheostomy based on the duration of positive pressure ventilation (PPV) before tracheostomy placement, fitting a receiver operating characteristic curve for current survival to define a cutoff. MEASUREMENTS AND MAIN RESULTS Sixty-one patients underwent tracheostomy placement (0.5% of CICU admissions). Median age was 7.8 months. Eighteen patients (30%) had single ventricle physiology and 13 patients (21%) had pulmonary vein stenosis (PVS). Primary indications for tracheostomy were pulmonary/lower airway (41%), upper airway obstruction (UAO) (31%), cardiac (15%), neuromuscular (4%), or neurologic (4%). In-hospital mortality was 26% with 41% survival at the current follow-up (median 7.8 [interquartile range, IQR 2.6-30.0] mo). Late tracheostomy was defined as greater than or equal to 7 weeks of PPV which was equivalent to the median PPV duration pre-tracheostomy. Patients with late tracheostomy were more likely to be younger, have single ventricle physiology, and have greater respiratory severity. Patients with early tracheostomy were more likely to have UAO or genetic comorbidities. In multivariable analysis, late tracheostomy was associated with 4.2 times greater mortality (95% CI, 1.9-9.0). PVS was associated with higher mortality (adjusted hazard ratio [HR] 5.2; 95% CI, 2.5-10.9). UAO was associated with lower mortality (adjusted HR 0.2; 95% CI, 0.1-0.5). Late tracheostomy was also associated with greater cumulative opioid exposure. CONCLUSIONS CICU patients who underwent tracheostomy had high in-hospital and longer-term mortality rates. Tracheostomy timing decisions are influenced by indication, disease, genetic comorbidities, illness severity, and age. Earlier tracheostomy was associated with lower sedative use and improved adjusted survival. Tracheostomy placement is a complex decision demanding individualized consideration of risk-benefit profiles and thoughtful family counseling.
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Affiliation(s)
- Miriam T Fox
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Pediatrics, Boston Medical Center, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Colin Meyer-Macaulay
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Children's Health, Delaware Valley, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hanna Roberts
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Bryan D Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Chris Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Robert J Graham
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
| | - Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
- Faculty of Medicine and Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
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MacLean JE, Fauroux B. Long-term non-invasive ventilation in children: Transition from hospital to home. Paediatr Respir Rev 2023; 47:3-10. [PMID: 36806331 DOI: 10.1016/j.prrv.2023.01.002] [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: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023]
Abstract
Long-term non-invasive ventilation (NIV) is an accepted therapy for sleep-related respiratory disorders and respiratory insufficiency or failure. Increase in the use of long-term NIV may, in part, be driven by an increase in the number of children surviving critical illness with comorbidities. As a result, some children start on long-term NIV as part of transitioning from hospital to home. NIV may be used in acute illness to avoid intubation, facilitate extubation or support tracheostomy decannulation, and to avoid the need for a tracheostomy for long-term invasive ventilation. The decision about whether long-term NIV is appropriate for an individual child and their family needs to be made with care. Preparing for transition from the hospital to home involves understanding how NIV equipment is obtained and set-up, education and training for parents/caregivers, and arranging a plan for clinical follow-up. While planning for these transitions is challenging, the goals of a shorter time in hospital and a child living well at home with their family are important.
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Affiliation(s)
- Joanna E MacLean
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Canada; Women and Children's Health Research Institute, University of Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Brigitte Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, Necker University Hospital, AP-HP, Paris, France; Université de Paris, EA 7330 VIFASOM, F-75004 Paris, France
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Rodriguez AM, Schain K, Jayakar P, Wright MS, Chowdhury S, Salyakina D. Report of two cases of Schaaf-Yang syndrome: Same genotype and different phenotype. Clin Case Rep 2023; 11:e7753. [PMID: 37529132 PMCID: PMC10387585 DOI: 10.1002/ccr3.7753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023] Open
Abstract
We report two, genotypically identical but phenotypically distinct cases of Schaaf-Yang syndrome and propose the early use of Genome Sequencing in patients with nonspecific presentations to facilitate the early diagnosis of children with rare genetic diseases and improve overall health care outcomes.
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Affiliation(s)
- Ana Maria Rodriguez
- Division of Genetics and MetabolismNicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
| | - Katherine Schain
- Division of Genetics and MetabolismNicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
| | - Parul Jayakar
- Division of Genetics and MetabolismNicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
| | - Meredith S. Wright
- Rady Children's Institute for Genomic MedicineSan DiegoCaliforniaUSA
- Keck Graduate InstituteClaremontCaliforniaUSA
| | - Shimul Chowdhury
- Rady Children's Institute for Genomic MedicineSan DiegoCaliforniaUSA
| | - Daria Salyakina
- Personalized Medicine & Health Outcomes Research, Nicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
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10
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He Q, Liu Y, Dou Z, Ma K, Li S. Congenital heart diseases with airway stenosis: a predictive nomogram to risk-stratify patients without airway intervention. BMC Pediatr 2023; 23:351. [PMID: 37438689 DOI: 10.1186/s12887-023-04160-5] [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: 05/15/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND This study focused on congenital heart disease (CHD) patients complicated with airway stenosis (AS) without airway intervention and aimed to identify the patients with potential risks. METHODS Patients diagnosed with CHD and AS were enrolled in this retrospective study. The primary outcome was defined as a postoperative mechanical ventilation duration of more than two weeks. We constructed a prediction model to predict the risk of prolonged mechanical ventilation (PMV). RESULTS A total of 185 patients diagnosed with CHD and AS in Fuwai Hospital from July 2009 to December 2022 were included in the study. Weight at CHD surgery, cardiopulmonary bypass (CPB) duration, complex CHD and comorbid tracheobronchomalacia were identified as risk factors and included in the model. The ROC curve showed a good distinguishing ability, with an AUC of 0.847 (95% CI: 0.786-0.908). According to the optimal cut-off value of the ROC curve, patients were divided into high- and low-risk groups, and the subsequent analysis showed significant differences in peri-operative characteristics and in-hospital deaths. CONCLUSIONS With the predictive model, several factors could be used to assess the risky patients with PMV. More attention should be paid to these patients by early identification and routine surveillance.
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Affiliation(s)
- Qiyu He
- Pediatric Cardiac Surgery Centre, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Yuze Liu
- Pediatric Cardiac Surgery Centre, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Zheng Dou
- Pediatric Cardiac Surgery Centre, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Kai Ma
- Pediatric Cardiac Surgery Centre, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China
| | - Shoujun Li
- Pediatric Cardiac Surgery Centre, National Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, China.
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11
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Samornpitakul P, Watcharaporn W, Setabutr D. Increased Intervals Between Paediatric Tracheostomy Tube Changes: Is it a Safe Technique? Indian J Otolaryngol Head Neck Surg 2023; 75:503-507. [PMID: 37275110 PMCID: PMC10234948 DOI: 10.1007/s12070-022-03302-y] [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: 06/05/2022] [Accepted: 11/20/2022] [Indexed: 12/14/2022] Open
Abstract
To evaluate the safety of changing tracheostomy tubes every three months in paediatric patients and determine the occurrence of tube-related complications. Retrospective observational chart review was completed from 2018 to 2021 at a tertiary medical centre in Thailand. Tube associated complications were assessed with regards to interval length between tracheostomy tube changes. The rate of complication was compared with previous studies. Out of a total of 108 visits, the average interval between each tube change was 87 days. Of all encounters, 6.48% resulted in a tube-related complication. Of these seven visits, two had an admission for a respiratory infection within 30 days, three experienced accidental decannulation and two resulted in excess granulation tissue formation. A p-value of 0.8 was obtained from a chi-squared test. An interval of 90-days between paediatric tracheostomy tube changes does not increase the rate of tracheostomy tube related complications. This interval may be practical for those in resource limited settings.
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Affiliation(s)
- Pheemaphol Samornpitakul
- Chulabhorn International College of Medicine, Thammasat University, Khlong Nueng, Pathum Thani 12120 Thailand
| | - Warisra Watcharaporn
- Chulabhorn International College of Medicine, Thammasat University, Khlong Nueng, Pathum Thani 12120 Thailand
| | - Dhave Setabutr
- Chulabhorn International College of Medicine, Thammasat University, Khlong Nueng, Pathum Thani 12120 Thailand
- Department of Otolaryngology Head and Neck Surgery, Thammasat University Hospital, Khlong Nueng, Pathum Thani 12120 Thailand
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12
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Killien EY, Grassia KL, Butler EK, Mooney SJ, Watson RS, Vavilala MS, Rivara FP. Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers. J Trauma Acute Care Surg 2023; 94:615-623. [PMID: 36730091 PMCID: PMC10038845 DOI: 10.1097/ta.0000000000003848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults. METHODS We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care. RESULTS Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]). CONCLUSION Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kalee L. Grassia
- Department of Pediatric Critical Care Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Surgery, University of Montreal, Montreal, Quebec, Canada
| | - Stephen J. Mooney
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
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13
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Timing of Tracheostomy in Critically Ill Infants and Children With Respiratory Failure: A Pediatric Health Information System Study. Pediatr Crit Care Med 2023; 24:e66-e75. [PMID: 36508241 DOI: 10.1097/pcc.0000000000003120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Tracheostomy placement in infants and children with respiratory failure has steadily increased over time, yet there is no consensus for optimal timing. We sought to: 1) describe tracheostomy timing and associated demographic and clinical characteristics in a large ICU cohort and 2) compare clinical outcomes between subgroups based on tracheostomy timing. DESIGN Retrospective observational study using the Pediatric Health Information System (PHIS). SETTING Neonatal ICUs and PICUs in the United States. PATIENTS PHIS was queried for patients less than 18 years who underwent tracheostomy from 2010 to 2020. Patients were included if admitted to an ICU with need for mechanical ventilation (MV) prior to tracheostomy in the same hospitalization. Patients were categorized as early tracheostomy (ET) (placement at MV day ≤ 14), late tracheostomy (LT) (MV days 15-60), and extended tracheostomy (ExT) (MV day > 60). Primary endpoints included demographic and clinical characteristics. Secondary endpoints included patient outcomes: in-hospital mortality, length of stay (LOS), hospital-acquired pneumonia (HAP), and hospital costs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixteen thousand one hundred twenty-one patients underwent tracheostomy at 52 children's hospitals. Ten thousand two hundred ninety-five had complete data and were included in the analysis. Thirty-nine percent (4,006/10,295) underwent ET, 40% (4,159/10,295) underwent LT, and 21% (2,130/10,295) underwent ExT. Majority of patients in all subgroups had complex chronic conditions. Median age was significantly different between subgroups with ET being the oldest ( p < 0.001). A multivariable regression analysis showed that ET was associated with lower in-hospital mortality ( p < 0.001), shorter hospital LOS ( p < 0.001), shorter ICU LOS ( p < 0.001), shorter post-tracheostomy LOS ( p < 0.001), decreased HAP ( p < 0.001), and lower hospital costs ( p < 0.001) compared with those who underwent LT or ExT. CONCLUSIONS In a large cohort of pediatric patients with respiratory failure, tracheostomy placement within 14 days of MV was associated with improved in-hospital outcomes. ET was independently associated with decreased mortality, LOS, HAP, and hospital costs.
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14
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Schemm J, Danis DO, Howard D, Rodriguez E, Dong K, Fazelpour S, Levi JR. Open and percutaneous pediatric tracheostomy: comorbidities and in-hospital mortality. ANNALS OF PEDIATRIC SURGERY 2023. [DOI: 10.1186/s43159-023-00239-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Abstract
Background
Tracheostomy procedures are used to establish a surgical airway in patients when non-invasive methods fail to offer adequate support. In pediatric patients, this procedure is relatively rare, and data on patients is scarce, limiting the ability of physicians to contextualize patient outcomes and identify those most at risk. This can be crucial, as research has shown that early tracheostomy in pediatric patients may improve clinical outcomes. The objective of this study is to characterize the comorbidities of pediatric patients undergoing open and percutaneous tracheostomies and examine their association with in-hospital mortality, as well as to compare patient demographics and comorbidity frequency between the two approaches. The 2016 Kids’ Inpatient Database was used to identify patients younger than 21 with ICD-CM-10 codes for open or percutaneous tracheostomies to determine demographic characteristics and identify the most frequent comorbidities in these patient cohorts.
Results
A weighted total of 5229 cases were analyzed. Congenital cardiopulmonary defects, newborn respiratory diseases, and traumatic lung or brain injury were the most common comorbidities for tracheostomy patients. In open tracheostomies, there was an increased likelihood of in-hospital mortality in patients aged less than one (OR = 2.2; 95% CI, 1.6–3.0) and in patients with atrial septal defects (OR = 1.9; 95% CI, 1.5–2.5), patent ductus arteriosus (OR = 2.5, 95% CI, 2.0–3.3), bronchopulmonary dysplasia (OR = 2.1; 95% CI, 1.6–2.8), and acute kidney injury (OR = 5.6, 95% CI, 4.3–7.2). Trauma-related comorbidities were more common in patients who underwent percutaneous procedures and were not associated with an increased likelihood of mortality. Patient age < 1 was associated with an increased risk of in-hospital mortality in both the open (OR = 2.2; 95% CI, 1.6–3.0) and percutaneous (OR = 2.3, 95% CI (1.3–3.9) approaches.
Conclusion
There are many indications for pediatric tracheostomy, and patients often present with complicated disease profiles and complicated courses of care. Broadly, we found that congenital cardiopulmonary defects were associated with a higher likelihood of in-hospital patient mortality, especially in younger patients undergoing an open-approach procedure. Patients undergoing a percutaneous-approach procedure were more likely to have trauma-related comorbidities such as pneumothorax or brain hemorrhage that were not associated with in-hospital mortality.
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15
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Yogo N, Sasaki T, Kozumi M, Kinoshita Y, Muto Y, Hirai K, Yoshino Y. Oral to nasal endotracheal tube exchange using tracheal tube guide and video laryngoscope in a pediatric patient with facial burns: a case report. Int J Emerg Med 2022; 15:42. [PMID: 36064321 PMCID: PMC9442961 DOI: 10.1186/s12245-022-00451-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background Airway management in children with severe burns is difficult because of airway edema and prolonged duration of ventilatory management. There is insufficient evidence to suggest that tracheostomy is beneficial for children. Case presentation A male child aged 1 year and 4 months was injured when he accidentally fell into a bathtub filled with boiling water. Furthermore, 85% of the burnt area, including the face and neck, consisted of second-degree burns; hence, oral tracheal intubation and resuscitative infusion were required. In this case, the patient was safely switched from oral to nasotracheal intubation using a tracheal tube guide and video laryngoscope, without the use of a bronchoscope, and ventilatory management could be continued for 2 weeks. Conclusion Oral to nasal endotracheal tube exchange using a tracheal tube guide and video laryngoscope may be useful not only for pediatric burn patients but also for adult patients who need to be safely switched from oral to nasotracheal intubation.
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Affiliation(s)
- Naoki Yogo
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan. .,Division of Pediatric Emergency and Critical Care, Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamineminami, Higashi-ku, Kumamoto, 861-8520, Japan.
| | - Taeko Sasaki
- Department of Trauma Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Masato Kozumi
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Yuya Kinoshita
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Yuichiro Muto
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.,Division of Pediatric Emergency and Critical Care, Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamineminami, Higashi-ku, Kumamoto, 861-8520, Japan
| | - Katsuki Hirai
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.,Division of Pediatric Emergency and Critical Care, Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamineminami, Higashi-ku, Kumamoto, 861-8520, Japan
| | - Yuichiro Yoshino
- Department of Dermatology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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17
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Kohne JG, MacLaren G, Rider E, Carr B, Mallory P, Gebremariam A, Friedman M, Barbaro RP. Tracheostomy Practices and Outcomes in Children During Respiratory Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2022; 23:268-276. [PMID: 35081085 PMCID: PMC9197266 DOI: 10.1097/pcc.0000000000002902] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Children receiving prolonged extracorporeal membrane oxygenation (ECMO) support may benefit from tracheostomy during ECMO by facilitating rehabilitation; however, the procedure carries risks, especially hemorrhagic complications. Knowledge of tracheostomy practices and outcomes of ECMO-supported children who undergo tracheostomy on ECMO may inform decision-making. DESIGN Retrospective cohort study. SETTING ECMO centers contributing to the Extracorporeal Life Support Organization registry. PATIENTS Children from birth to 18 years who received ECMO support for greater than or equal to 7 days for respiratory failure from January 1, 2015, to December 31, 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three thousand six hundred eighty-five children received at least 7 days of ECMO support for respiratory failure. The median duration of ECMO support was 13.0 days (interquartile range [IQR], 9.3-19.9 d), and inhospital mortality was 38.7% (1,426/3,685). A tracheostomy was placed during ECMO support in 94/3,685 (2.6%). Of those who received a tracheostomy on ECMO, the procedure was performed at a median 13.2 days (IQR, 6.3-25.9 d) after initiation of ECMO. Surgical site bleeding was documented in 26% of children who received a tracheostomy (12% after tracheostomy placement). Among children who received a tracheostomy, the median duration of ECMO support was 24.2 days (IQR, 13.0-58.7 d); inhospital mortality was 30/94 (32%). Those that received a tracheostomy before 14 days on ECMO were older (median age, 15.8 yr [IQR, 4.7-15.5] vs 11.7 yr [IQR, 11.5-17.3 yr]; p =0.002) and more likely to have been supported on venovenous-ECMO (84% vs 52%; p = 0.001). Twenty-two percent (11/50) of those who received a tracheostomy before 14 days died in the hospital, compared with 19/44 (43%) of those who received a tracheostomy at 14 days or later (p = 0.03). CONCLUSIONS Tracheostomies during ECMO were uncommon in children. One in four patients who received a tracheostomy on ECMO had surgical site bleeding. Children who had tracheostomies placed after 14 days were younger and had worse outcomes, potentially representing tracheostomy as a "secondary" strategy for prolonged ECMO support.
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Affiliation(s)
- Joseph G. Kohne
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
- Pediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, Australia
| | - Erica Rider
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
| | | | | | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | - Ryan P Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
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18
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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] [MESH Headings] [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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19
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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20
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Leonard JA, Mamidi IS, Mudd P, Espinel A. Pediatric tracheostomy surveillance. Pediatr Pulmonol 2021; 56:3047-3050. [PMID: 34185970 DOI: 10.1002/ppul.25515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 05/16/2021] [Indexed: 12/26/2022]
Abstract
We report an unusual case of a 14-month-old ex-28 week, ventilator-dependent male with a history of bronchopulmonary dysplasia and tracheostomy at 2 months of age. Lost to follow-up, at age 9 months, he presented to the emergency department with worsening respiratory distress. The patient was taken to the operating room at which time direct visualization of the airway demonstrated a mass filling the entire glottic inlet without supraglottic or pharyngeal mucosal attachments. The solid, nonvascular, mass appeared to be emanating from a suprastomal site. Excision proved to relieve the airway obstruction and postoperatively the patient has thrived.
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Affiliation(s)
- James A Leonard
- Deparment of Otolaryngology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Ishwarya S Mamidi
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Pamela Mudd
- Division of Pediatric Otolaryngology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Alexandra Espinel
- Division of Pediatric Otolaryngology, Children's National Medical Center, Washington, District of Columbia, USA
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Location, Location, Location…Determines Tracheostomy Timing? Learning From Our Adult Colleagues, Yet Again. Pediatr Crit Care Med 2021; 22:674-676. [PMID: 34192732 DOI: 10.1097/pcc.0000000000002705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Takia L, Jayashree M. Tracheostomy in Critically Ill Children-Bypassing the Hurdle and Running into More! Indian J Pediatr 2021; 88:429-430. [PMID: 33738771 PMCID: PMC7971382 DOI: 10.1007/s12098-021-03716-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Lalit Takia
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Muralidharan Jayashree
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Update on Pediatric Tracheostomy: Indications, Technique, Education, and Decannulation. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021; 9:188-199. [PMID: 33875932 PMCID: PMC8047564 DOI: 10.1007/s40136-021-00340-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 12/23/2022]
Abstract
Purpose of Review Tracheostomy in a child demands critical pre-operative evaluation, deliberate family education, competent surgical technique, and multidisciplinary post-operative care. The goals of pediatric tracheostomy are to establish a safe airway, optimize ventilation, and expedite discharge. Herein we provide an update regarding timing, surgical technique, complications, and decannulation, focusing on a longitudinal approach to pediatric tracheostomy care. Recent Findings Pediatric tracheostomy is performed in approximately 0.2% of inpatient stays among tertiary pediatric hospitals. Mortality in children with tracheostomies ranges from 10–20% due to significant comorbidities in this population. Tracheostomy-specific mortality and complications are now rare. Recent global initiatives have aimed to optimize decision-making, lower surgical costs, reduce the length of intensive care, and eliminate perioperative wound complications. The safest road to tracheostomy decannulation in children remains to be both patient and provider dependent. Summary Recent literature provides guidance on safe, uncomplicated, and long-term tracheostomy care in children. Further research is needed to help standardize decannulation protocols.
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Has the Time Come to Reconsider the Indication for Tracheostomy in the Early Pediatric Age, Especially in the First 3 Years? Crit Care Med 2020; 48:268-270. [PMID: 31939804 DOI: 10.1097/ccm.0000000000004146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Brenner MJ, Pandian V, Milliren CE, Graham DA, Zaga C, Morris LL, Bedwell JR, Das P, Zhu H, Lee Y. Allen J, Peltz A, Chin K, Schiff BA, Randall DM, Swords C, French D, Ward E, Sweeney JM, Warrillow SJ, Arora A, Narula A, McGrath BA, Cameron TS, Roberson DW. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth 2020; 125:e104-e118. [PMID: 32456776 DOI: 10.1016/j.bja.2020.04.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 01/15/2023] Open
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The author replies. Crit Care Med 2020; 48:e430. [PMID: 32301781 DOI: 10.1097/ccm.0000000000004300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tripathi S, Swayampakula AK, Deshpande GG, Astle M, Wang Y, Welke KF. Illustration of the current practice and outcome comparison of early versus late tracheostomy after pediatric ECMO. Int J Artif Organs 2020; 43:726-734. [PMID: 32228203 DOI: 10.1177/0391398820913571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Pediatric extracorporeal membrane oxygenation typically necessitates protracted ventilator support, yet not much is known about the use of tracheostomy in the pediatric subpopulation. The study was designed with an objective to quantify the prevalence of tracheostomy in children with respiratory/cardiac failure requiring extracorporeal membrane oxygenation and to compare outcomes for patients undergoing early, late, and no tracheostomy. METHODS Data of patients <18 years of age who underwent extracorporeal membrane oxygenation for respiratory/cardiac failure between 2009 and 2015 were obtained from the Virtual Pediatric Systems (VPS, LLC) Database. Patients who underwent post-operative cardiac ECMO were excluded. Early versus late tracheostomy was defined as ⩽21 or >21 days after intensive care unit admission. RESULTS Data were analyzed for 2127 patients meeting inclusion and exclusion criteria. Five percent (107/2127) underwent a tracheostomy. Of these, 28% (30/107) underwent early and 72% (77/107) late tracheostomy. A higher mortality was found in the no tracheostomy group (41.3%) compared to early (13.3%) and late tracheostomy (14.3%) groups. Late tracheostomy was associated with 2.4 times the expected intensive care unit length of stay and 1.87 times the expected ventilator days as compared to patients with no tracheostomy. Early tracheostomy was associated with a shorter intensive care unit length of stay (p value < 0.001) and ventilator days (p value = 0.04) compared to late tracheostomy and no difference with the no tracheostomy group. CONCLUSIONS Late tracheostomy (>21 days) is associated with worse outcomes in the cohort of children who underwent Pediatric extracorporeal membrane oxygenation compared to patients who did not undergo tracheostomy. Early tracheostomy is associated with shorter intensive care unit stay and ventilator duration when compared to late tracheostomy.
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Affiliation(s)
| | | | | | - Michele Astle
- OSF Children's Hospital of Illinois, Peoria, IL, USA
| | - Yanzhi Wang
- OSF Children's Hospital of Illinois, Peoria, IL, USA
| | - Karl F Welke
- Department of Surgery, Levine Children's Hospital, Charlotte, NC, USA
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