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Azimzadeh JB, Sidell DR, Balakrishnan K, Mathew R, Asija R, Rutter MJ, Meister KD. Use of temporary tracheostomy occlusion to reduce the risk of sternal wound infection after sternotomy in congenital cardiac surgery. Cardiol Young 2024:1-6. [PMID: 38410052 DOI: 10.1017/s1047951124000106] [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] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To describe a method of reducing the risk of sternal wound infection after sternotomy in children with a pre-existing tracheostomy. To report our outcomes using this method from 1 January, 2013 to 31 August, 2023. METHODS We describe a method for temporarily occluding the tracheal stoma with a removable implant with the primary goal of reducing the risk of sternotomy wound infection by preventing soilage due to tracheostomal secretions. We then performed a retrospective review of all children who underwent temporary tracheostomal occlusion between 1 January, 2013 and 31 August, 2023 at our quaternary care children's hospital. Clinical variables were extracted from the hospital medical records. The rates of antibiotic use and minor and major complications during the period when the stoma plug was in place were recorded. RESULTS Totally, 19 patients underwent tracheal stoma plugging prior to sternotomy and were included in our analysis. There were two cases of sternal wound infection; one case occurred while the stoma plug was in place, and one developed four days following plug removal. There was one minor complication, with one patient requiring stoma revision via serial dilation at bedside at the time of recannulation. There were no deaths. CONCLUSION Temporary occlusion of the tracheal stoma with an impermeable plug is a viable option for reducing the risk of sternal wound infection in children with a pre-existing tracheostomy who are undergoing sternotomy.
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Affiliation(s)
- Julien B Azimzadeh
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Douglas R Sidell
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Karthik Balakrishnan
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
| | - Roshni Mathew
- Department of Pediatric Infectious Diseases, Stanford University, Palo Alto, CA, USA
| | - Ritu Asija
- Department of Pediatric Cardiology, Stanford University, Palo Alto, CA, USA
| | - Michael J Rutter
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kara D Meister
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, CA, USA
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2
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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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3
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Teplitzky TB, Brown AF, Brooks RL, Bailey CH, Whitney C, Sewell A, Kou YF, Johnson RF, Chorney SR. Mortality Among Children with a Tracheostomy. Laryngoscope 2023; 133:403-409. [PMID: 35357004 DOI: 10.1002/lary.30123] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/17/2022] [Accepted: 03/21/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To characterize the cause of death among children with a tracheostomy. STUDY DESIGN Prospective cohort. METHODS All pediatric patients (<18 years) who had a tracheostomy placed at a tertiary care institution between 2015 and 2020 were included. The location and cause of death were recorded along with patient demographics and age. RESULTS A total of 271 tracheostomies were placed with 46 mortalities reviewed for a mortality rate of 16.8%. Mean age at placement was 1.7 years (SD: 3.4) and mean age at death was 2.9 years (SD: 3.5). Most tracheostomies were placed for respiratory failure (N = 33, 72%). The mean time to death after tracheostomy was 1.2 years (SD: 1.2) and 28% (N = 13) occurred during the same admission as placement. Mean time to death after hospital discharge was 1.3 years (SD: 1.3). Etiology of death was respiratory failure (33%, N = 15), cardiopulmonary arrest (15%, N = 7), unknown (43%, N = 20), or secondary to a tracheostomy-related complication for 9% (N = 4). Location of death was in intensive care units for 41% (N = 19) and 30% died at home (N = 14). Comfort care measures were taken for 37% (N = 17). Severe neurological disability (HR: 4.06, p = 0.003, 95% CI: 1.59-10.34) and congenital heart disease (HR: 2.36, p = 0.009, 95% CI: 1.24-4.48) correlated with time to death on Cox proportional hazard modeling. CONCLUSIONS Nearly one-third of children with a tracheostomy who expire will do so during the same admission as tracheostomy placement. Although progression of underlying disease will lead to most deaths, 9% will be a result of a tracheostomy-related complication, which represents a meaningful target for quality improvement initiatives. LEVEL OF EVIDENCE 3 Laryngoscope, 133:403-409, 2023.
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Affiliation(s)
- Taylor B Teplitzky
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ashley F Brown
- Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
| | - Rebecca L Brooks
- Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
| | - Candice H Bailey
- Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
| | - Cindy Whitney
- Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
| | - Ashley Sewell
- Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Medical Center Dallas, Department of Pediatric Otolaryngology, Children's Health Airway Management Program, Dallas, Texas, USA
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4
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The Prevalence of Congenital Anomalies of the Airway or Lung in Infants with Hypoplastic Left Heart Syndrome and Differences in Midterm Outcomes: A National Pediatric Cardiology Quality Improvement Collaborative Registry Analysis. Pediatr Cardiol 2023; 44:86-94. [PMID: 35731252 DOI: 10.1007/s00246-022-02949-2] [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: 02/17/2022] [Accepted: 05/31/2022] [Indexed: 01/24/2023]
Abstract
Infants with single ventricle physiology and congenital anomalies of the airway and/or lung are potentially poor candidates for staged palliation. The prevalence and midterm outcomes for patients with anomalies of the airway or lung with hypoplastic left heart syndrome are unknown. We performed an analysis of data in infants with hypoplastic left heart syndrome from the National Pediatric Cardiology Quality Improvement Collaborative registry. The prevalence of congenital anomalies of the airway or lung in the registry was determined. Clinical characteristics and midterm outcomes were compared between infants with hypoplastic left heart syndrome with and without anomalies of the airway or lung. Fifty-seven (2.3%) of 2467 infants with hypoplastic left heart syndrome enrolled in the registry had congenital airway or lung anomalies. Infants congenital anomalies of the airway or lung had significantly lower transplant-free survival at 1 year (49.5 vs 77.2%, p < 0.001). Infants with airway or lung anomalies had longer combined hospital length of stay for stage 1 and stage 2 palliation (102 vs 65.1 days, p < 0.001) and underwent more major procedures (2.04 vs 0.93 procedures, p < 0.001) than those without. There was no difference in the number of interstage readmissions (1.85 vs 1.89, p = 0.87) or need for non-oral feeding supplementation (71.4 vs 54.5%, p = 0.12) between groups. Infants enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry with hypoplastic left heart syndrome and anomalies of the airway or lung have increased morbidity and mortality at 1 year compared to those with hypoplastic left heart syndrome alone.
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5
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Villafranco N, Chartan C, Varghese NP, Coleman RD. Tracheostomy in Pulmonary Hypertension: Not for the Faint of Heart. Pediatr Crit Care Med 2022; 23:754-756. [PMID: 36053037 DOI: 10.1097/pcc.0000000000003021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Natalie Villafranco
- Department of Pediatrics, Division of Pulmonary Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Corey Chartan
- Department of Pediatrics, Division of Pulmonary Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX.,Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nidhy P Varghese
- Department of Pediatrics, Division of Pulmonary Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ryan D Coleman
- Department of Pediatrics, Division of Pulmonary Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX.,Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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6
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Schoeneberg L, Prodhan P, Spray B, Akmyradov C, Zakaria D. Risk Factors for Increased Post-operative Length of Stay in Children with Coarctation of Aorta. Pediatr Cardiol 2021; 42:1567-1574. [PMID: 34052859 DOI: 10.1007/s00246-021-02641-x] [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: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
Coarctation of the aorta is a relatively common congenital heart disease occurring in 0.4-0.6 per 1000 live births with a low mortality rate. This is a retrospective study, with data abstracted from the Pediatric Health Information System database (PHIS). The study sample included pediatric patients less than or equal to 3 months of age discharged from a PHIS participating hospital between January 1, 2004 and December 31, 2018 who underwent surgical repair of isolated COA. The primary outcome for the study was post-operative hospital length of stay (PH-LOS), and the secondary outcome was in-hospital mortality. Patient demographics, comorbidities, procedures, and outcomes were assessed for statistical differences between eras. A total of 5354 patients were included in the study. The study highlights an increasing trend in PH-LOS and NICU hospital length of stay (NICU-LOS) across the investigated eras. Prematurity (before 37 weeks gestation) was an independent risk factor associated with both longer post-operative length of the stay and higher mortality. In addition, congenital anomalies, respiratory and abdominal surgeries have a significant impact on the post-operative hospital stay. In conclusion, this study is the largest published systematic assessment of PH-LOS in patients with isolated COA repair during infancy to date and identifies independent risk factors of increased PH-LOS.
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Affiliation(s)
- Laura Schoeneberg
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA
| | - Parthak Prodhan
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA
| | - Beverly Spray
- Arkansas Children's Research Institute (Biostatistics), Little Rock, USA
| | - Chary Akmyradov
- Arkansas Children's Research Institute (Biostatistics), Little Rock, USA
| | - Dala Zakaria
- Department of Pediatrics (Cardiology and Pediatric Intensive Care), University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 1 Children's Way, Slot 512-1, Little Rock, AR, 72202, USA.
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7
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Overfeeding and obesity in young children with positive pressure ventilation via tracheostomy following cardiac surgery. Cardiol Young 2020; 30:1397-1404. [PMID: 32741396 DOI: 10.1017/s1047951120002073] [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] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Infants with CHD requiring positive pressure ventilation via tracheostomy are especially vulnerable to malnutrition following cardiac surgery. Current post-operative feeding recommendations may overestimate the caloric needs. DESIGN We retrospectively studied infants requiring tracheostomy after cardiac surgery. Anthropometric and nutritional data were collected, including caloric goals, weight-for-age z score, length-for-age z score, and weight-for-length z score. Changes in anthropometrics over time were compared to ascertain the impact of nutritional interventions. Data were shown as mean ± standard deviation. RESULTS Nineteen infants with CHD required tracheostomy at 160 ± 109 days (7-364 days), 13 had reparative surgery, and 6 had palliative surgery for single ventricle. The indications for tracheostomy consisted of airway abnormality/obstruction (n = 13), chronic respiratory failure (n = 7), and/or vocal cord paresis (n = 2). Initial maintenance nutritional target was set at 100-130 cal/kg per day. Fourteen patients (73.7%) became obese (maximum weight-for-length z score: 2.59 ± 0.47) under tracheostomy and gastrostomy feeding, whereas five patients did not (weight-for-length z score: 0.2 ± 0.83). Eight obese patients (weight-for-length z score: 2.44 ± 0.85) showed effective reduction of obesity within 6 months (weight-for-length z score: 0.10 ± 0.20; p < 0.05 compared with pre-adjustment) after appropriate feeding adjustment (40-90 cal/kg per day). Overall mortality was high (31.6%) in this population. CONCLUSION Standard nutritional management resulted in overfeeding and obesity in young children with CHD requiring positive pressure ventilation via tracheostomy. Optimal nutritional management in this high-risk population requires close individualised management by multidisciplinary teams.
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8
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Han SM, Watters KF, Hong CR, Edwards EM, Knell J, Morrow KA, Soll RF, Jaksic T, Horbar JD, Modi BP. Tracheostomy in Very Low Birth Weight Infants: A Prospective Multicenter Study. Pediatrics 2020; 145:peds.2019-2371. [PMID: 32098788 DOI: 10.1542/peds.2019-2371] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In this study, we benchmark outcomes and identify factors associated with tracheostomy placement in infants of very low birth weight (VLBW). METHODS Data were prospectively collected on infants of VLBW (401-1500 g or gestational age of 22-29 weeks) born between 2006 and 2016 and admitted to 796 North American centers. Length of stay (LOS), mortality, associated surgical procedures, and comorbidities were assessed, and infants who received tracheostomy were compared with those who did not. Multivariable logistic regressions were performed to identify risk factors for tracheostomy placement and for mortality in those receiving tracheostomy. RESULTS Of 458 624 infants of VLBW studied, 3442 (0.75%) received tracheostomy. Infants with tracheostomy had a median (interquartile range) LOS of 226 (168-304) days and a mortality rate of 18.8%, compared with 58 (39-86) days and 8.3% for infants without tracheostomy. Independent risk factors associated with tracheostomy placement included male sex, birth weight <1001 g, African American non-Hispanic maternal race, chronic lung disease (CLD), intraventricular hemorrhage, patent ductus arteriosus ligation, and congenital neurologic, cardiac, and chromosomal anomalies. Among infants who received tracheostomy, male sex, birth weight <751 g, CLD, and congenital anomalies were independent predictors of mortality. CONCLUSIONS Infants of VLBW receiving tracheostomy had twice the risk of mortality and nearly 4 times the initial LOS of those without tracheostomy. CLD and congenital anomalies were the strongest predictors of tracheostomy placement and mortality. These benchmark data on tracheostomy in infants of VLBW should guide discussions with patient families and inform future studies and interventions.
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Affiliation(s)
- Sam M Han
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | - Karen F Watters
- Department of Otolaryngology and Communication Enhancement, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Charles R Hong
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | - Erika M Edwards
- University of Vermont, Burlington, Vermont; and.,Vermont Oxford Network, Burlington, Vermont
| | - Jamie Knell
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | | | - Roger F Soll
- University of Vermont, Burlington, Vermont; and.,Vermont Oxford Network, Burlington, Vermont
| | - Tom Jaksic
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | - Jeffrey D Horbar
- University of Vermont, Burlington, Vermont; and.,Vermont Oxford Network, Burlington, Vermont
| | - Biren P Modi
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
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9
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Paes B, Saleem M, Kim D, Lanctôt KL, Mitchell I. Respiratory illness and respiratory syncytial virus hospitalization in infants with a tracheostomy following prophylaxis with palivizumab. Eur J Clin Microbiol Infect Dis 2019; 38:1561-1568. [DOI: 10.1007/s10096-019-03588-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/13/2019] [Indexed: 11/28/2022]
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10
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Risk factors and outcomes of tracheostomy after prolonged mechanical ventilation in pediatric patients with heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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11
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Strang AR, Briddell JW, Barth PC, Shah UK, Chidekel A. Risk factor analysis for mortality among infants requiring tracheostomy. Pediatr Pulmonol 2018; 53:1115-1121. [PMID: 29862662 DOI: 10.1002/ppul.24064] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 05/05/2018] [Indexed: 11/08/2022]
Abstract
INTRODUCTION An increasing number of tracheostomies are performed in infants with complex comorbidities including bronchopulmonary dysplasia (BPD) and congenital heart disease (CHD). With this shift in indications, there is an urgent need to characterize outcomes in this population. METHODS This 5-year retrospective chart review assessed rates of 12-month mortality in infants who were ≤12 months of age at the time of tracheostomy at a tertiary care pediatric hospital and risk factors associated with death. Patient characteristics evaluated included chronologic age and post-menstrual age at tracheostomy placement, gestational age and weight, sex, ethnicity, indication for tracheostomy, and comorbidities including BPD, CHD, subglottic stenosis (SGS), craniofacial syndromes, and chromosomal trisomy syndromes. Subgroup analysis was performed in infants with CHD. RESULTS One hundred thirty-two tracheostomies were performed during the study period with an overall 12-month mortality of 14.4% (19/132). Mortality was increased in patients with CHD (35%) and decreased in patients with SGS (3.7%). No other patient characteristics were associated with differences in mortality. There was a trend towards improved mortality outcomes among patients born at earlier gestational ages. CONCLUSIONS Among infants with tracheostomy in this cohort, overall mortality rates were relatively low but not insignificant. CHD was associated with increased mortality; however, children with SGS showed more favorable outcomes. Other patient characteristics were not associated with differences in mortality. These data clarify outcomes in a group of infants with tracheostomy.
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Affiliation(s)
- Abigail R Strang
- Division of Pulmonary Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Jenna W Briddell
- Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Patrick C Barth
- Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.,Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Udayan K Shah
- Division of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.,Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Aaron Chidekel
- Division of Pulmonary Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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12
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Evaluating the Use of a Stability Guideline for Long-Term Ventilator-Dependent Children Discharging to Home: A Quality Improvement Project. J Pediatr Health Care 2017; 31:648-653. [PMID: 28760317 DOI: 10.1016/j.pedhc.2017.04.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/23/2017] [Accepted: 04/21/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Defining stability before discharge for children with severe chronic lung disease requiring home ventilation has historically been dependent on an individual provider's opinion. METHODS An institutional guideline based on expert opinion was used for patients who were first discharged home on mechanical ventilation. A retrospective review determined if the guideline was used. Electronic medical record changes were initiated to improve compliance with the guideline. RESULTS The retrospective review showed that the guideline is documented in less than one third of patients, and 36% of patients met the requirements of the guideline before discharge. Following these results, electronic medical record documentation was changed. DISCUSSION Results showed a low utilization rate for the discharge home guideline for patients receiving long-term ventilation. Utilization of electronic medical record charting can improve the tracking of stability guidelines and provide the opportunity to further define stability in ventilator-dependent children.
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13
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McPherson ML, Shekerdemian L, Goldsworthy M, Minard CG, Nelson CS, Stein F, Graf JM. A decade of pediatric tracheostomies: Indications, outcomes, and long-term prognosis. Pediatr Pulmonol 2017; 52:946-953. [PMID: 28263440 DOI: 10.1002/ppul.23657] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 11/03/2016] [Accepted: 11/27/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To define the mortality and long-term outcomes of children undergoing tracheostomy. DESIGN Retrospective chart and Texas Department of Health Bureau of Vital Statistics review of patients admitted to a Pediatric Intensive Care Unit who underwent a tracheostomy between 2001 and 2011. Mortality and decannulation rates were compared based on tracheostomy indication and age. SUBJECTS A total of 426 patients admitted to a Pediatric Intensive Care Unit in a large tertiary children's hospital. RESULTS The median patient age was 1.5 years (3 days-24 years). Primary indications for tracheostomy included (a) airway obstruction, (b) congenital neurologic disease, (c) acquired neurologic disease, (d) congenital respiratory disease, and (e) acquired respiratory disease. Overall, 98 patients (23%) died during the study period, and 75th percentile survival time was 5.9 years (95%CI: 3-8). Patients undergoing a tracheostomy for airway obstruction were the least likely to die; while patients with acquired neurologic disease were most likely to die. A total of 163 patients (38%) were decannulated, and 50% were decannulated at 1.2 years (95%CI: 0.9-1.5). Patients with congenital neurologic disease were the least likely to undergo decannulation. Over half of the patients were discharged from the hospital requiring some form of mechanical respiratory support in addition to their tracheostomy. CONCLUSIONS In this largest cohort of long-term follow-up to date, we have shown the overall risk of mortality varied according to the indication for the tracheostomy. We were unable to determine exact causes of death. The likelihood of being decannulated also correlates with the underlying indication for the tracheostomy. Pediatr Pulmonol. 2017; 52:946-953. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mona L McPherson
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Lara Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Michelle Goldsworthy
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Charles G Minard
- Baylor College of Medicine, Dan L. Duncan Institute for Clinical and Translation Research, Houston, Texas
| | - Cynthia S Nelson
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Fernando Stein
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Jeanine M Graf
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
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Outcomes of Tracheostomy in Children Requiring Surgery for Congenital Heart Disease. Pediatr Cardiol 2017; 38:296-301. [PMID: 27872994 DOI: 10.1007/s00246-016-1512-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
Outcomes after discharge in children requiring tracheostomy after cardiac surgery have not been fully described. A retrospective, single-center study was performed on all children <18 years of age requiring both tracheostomy and surgery for congenital heart disease from January 2002 to May 2015. Forty-six tracheostomies were placed after surgery and four before. Single-ventricle anatomy was present in 12 (33%) patients. Incidence of tracheostomy after heart surgery increased from 0.8% the first half of the study period to 2% the second half. Median time between cardiac surgery and tracheostomy was 58 days. The most common indication for tracheostomy was multifactorial (30%) followed by airway malacia (22%). Median length to follow-up for survivors was 3.9 years (range 0.4-11.8 years). Survival to hospital discharge was 72%, and intermediate survival was 48%. Survival in those with systemic to pulmonary artery shunts at the time of tracheostomy was 22% compared to 59% for those with biventricular anatomy. Heart failure and multiple indications for tracheostomy were associated with worse outcome. There was no difference in survival for those discharged with a ventilator compared to those that were not. The most common cause of death after discharge was tracheostomy tube dislodgement/obstruction, accounting for 5 of 11 that died. Survival with a tracheostomy after cardiac surgery is poor, and children with systemic to pulmonary artery shunts are at especially high risk of death.
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15
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Prodhan P, Agarwal A, ElHassan NO, Bolin EH, Beam B, Garcia X, Gaies M, Tang X. Tracheostomy Among Infants With Hypoplastic Left Heart Syndrome Undergoing Cardiac Operations: A Multicenter Analysis. Ann Thorac Surg 2016; 103:1308-1314. [PMID: 27865477 DOI: 10.1016/j.athoracsur.2016.09.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 09/02/2016] [Accepted: 09/07/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Less than 2.7% of infants undergoing congenital heart disease operations have difficulty weaning from invasive mechanical ventilation. In such instances, clinicians may choose to perform tracheostomy. Limited literature has examined tracheostomy placement specifically in infants with hypoplastic left heart syndrome (HLHS). This study evaluated the risk factors for tracheostomy placement in infants with HLHS and examined the outcomes of these infants before their first hospital discharge. METHODS This retrospective analysis of the Pediatric Heath Information System data set included infants with HLHS who underwent stage 1 Norwood operation, a hybrid procedure, or heart transplant from 2004 through 2013. RESULTS We identified 5721 infants with HLHS, and 126 underwent tracheostomy placement. Infants in the tracheostomy group had more morbidities and a higher mortality rate across the study period. Diagnosis of chromosomal abnormalities, anomalies of the trachea and esophagus, larynx, diaphragm and nervous system, bilateral vocal cord paralysis, and necrotizing enterocolitis, and procedures including extracorporeal membrane oxygenation support, cardiac catheterization, and gastrostomy tube were independently associated with tracheostomy placement in the study population. Despite an overall increase in rates of tracheostomy performed in infants with HLHS during the study period, the mortality rate did not improve among tracheostomy patients. CONCLUSIONS Several risk factors were identified in infants with HLHS in whom a tracheostomy was placed during their first hospitalization. Despite an overall increase in rates of tracheostomies during the study period, the mortality rate did not improve among these patients. Appropriate family counseling and thorough preoperative case selection is suggested when discussing possible tracheostomy placement in infants with HLHS.
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Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas; Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas.
| | - Amit Agarwal
- Pulmonary Medicine, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Nahed O ElHassan
- Neonatology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Elijah H Bolin
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Brandon Beam
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Xiomara Garcia
- Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas; Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Michael Gaies
- Pediatric Cardiology, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Xinyu Tang
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
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16
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Funamura JL, Yuen S, Kawai K, Gergin O, Adil E, Rahbar R, Watters K. Characterizing mortality in pediatric tracheostomy patients. Laryngoscope 2016; 127:1701-1706. [DOI: 10.1002/lary.26361] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Jamie L. Funamura
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Sonia Yuen
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Ozgul Gergin
- Department of Otolaryngology; Umraniye Education and Research Hospital; Istanbul Turkey
| | - Eelam Adil
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Karen Watters
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
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17
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Romano JC. Invited Commentary. Ann Thorac Surg 2016; 101:2292-3. [PMID: 27211939 DOI: 10.1016/j.athoracsur.2016.02.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 02/25/2016] [Accepted: 02/26/2016] [Indexed: 11/20/2022]
Affiliation(s)
- Jennifer C Romano
- Department of Cardiac Surgery and Pediatrics, University of Michigan Medical Center, 11-733 C.S. Mott Children's Hospital, 1540 E Hospital Dr, SPC 4204, Ann Arbor, MI 48109-4204.
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