Early Use of Anti-influenza Medications in Hospitalized Children With Tracheostomy

BACKGROUND

Early administration of anti-influenza medications is recommended for all children hospitalized with influenza. We investigated whether early use of anti-influenza medications is associated with improved outcomes in children with tracheostomy hospitalized with influenza.

METHODS

We performed a multicenter retrospective cohort study through the Pediatric Health Information System database for patients aged 30 days to 19 years who were discharged between October 1, 2007, and September 30, 2015 with diagnostic codes for both influenza and tracheostomy. Our primary predictor was receipt of anti-influenza medications on hospital day 0 or 1. We used propensity score matching to adjust for confounding by indication. Primary outcomes were length of stay (LOS) and 30-day all-cause revisit rate (emergency department visit or hospital admission).

RESULTS

Of 1436 discharges screened, 899 met inclusion criteria. The median admission age was 5 years (interquartile range: 2-10). The majority had multiple complex chronic conditions (median 3; interquartile range: 3-4) and technology dependence, such as gastrostomy tube (73.6%). After matching 772 unique admissions by propensity score, LOS was shorter for the cohort receiving early anti-influenza medications (6.4 vs 7.5 days; P = .01) without increase in revisit rate (27.5% vs 24.1%; P = .28). More than 80% in both cohorts received empirical antibiotics, and the duration of antibiotic therapy was similar (5.0 vs 5.6 days; P = .11).

CONCLUSIONS

Early use of anti-influenza medications in children with tracheostomy hospitalized with influenza is associated with shorter LOS, but these children continue to receive antibiotics despite identification and treatment of their viral infections.

Management trends of infantile hemangioma: A national perspective

INTRODUCTION

The primary management of infantile hemangioma (IH) has changed since 2008, with the initiation of propranolol. The change that propranolol has affected on resource utilization is unknown.

MATERIALS AND METHODS

The Kids' Inpatient Database (KID) in 2003, 2006, 2009, and 2012 was queried for ICD-9 codes for IH in children under age three. The number of patients undergoing the following procedures of interest: tracheostomy, tracheoscopy and laryngoscopy with biopsy, and excision of skin lesion were evaluated. Data was analyzed for demographics and details on the admission. Trends were identified. Weighted statistical analyses were performed with SAS 9.4.

RESULTS

The number of qualified admissions significantly increased over the years (9271 in 2003-12029 in 2012, OR 1.042 per year increase, p < 0.001). The mean age at admission ranged from 26 to 28 days but did not vary over time (p = 0.54). The percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the percentage undergoing tracheoscopy and laryngoscopy with biopsy significantly decreased from 7.29% in 2003 to 4.20% in 2012 (p = 0.011) among those with IH of unspecified or other sites. The percentage undergoing skin lesion excision also significantly decreased from 1.87% in 2003 to 1.03%, in 2012 (p = 0.0038) among those with IH of skin and subcutaneous tissue. These findings suggest a potential impact of propranolol. After adjusting for inflation, the total hospital charges increased from a mean of $17,838 in 2003 to an adjusted mean of $41,306 in 2012 (p < 0.0001).

CONCLUSIONS

Total admissions and hospital charges in children with IH has increased from 2003 to 2012. The percentage of patients undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision significantly decreased in 2012 compared to 2003, suggesting a potential impact of propranolol. Further studies are needed to examine these changes more closely.

Analysis of extracellular brain chemistry during percutaneous dilational tracheostomy: A retrospective study of 19 patients

OBJECTIVE

The purpose of this study was to analyze changes in brain tissue chemistry around percutaneous dilational tracheostomy (PDT) in patients with acute brain injury (ABI) in a retrospective single-center analysis.

PATIENTS AND METHODS

We included 19 patients who had continuous monitoring of brain tissue chemistry and intracranial pressure (ICP) during a 20h period before and after PDT. Different microdialysis parameters (lactate, pyruvate, lactate pyruvate ratio (LPR), glycerol and glutamate) and values of ICP, cerebral perfusion pressure (CPP) and brain tissue oxygenation (PBrO₂) were recorded per hour. Mean values were compared between a 10h period before PDT (prePDT) and after PDT (postPDT).

RESULTS

Mean values of cerebral lactate, pyruvate, LPR, glycerol and glutamate did not differ significantly between prePDT and postPDT. In addition, the rate of patients, which exceeded the known threshold was similar between prePDT and postPDT. Only one patient showed a strong increase of cerebral glycerol during the postPDT period, but analysis of subcutaneous glycerol could exclude an intracerebral event. ICP, CPP and PBrO₂ did not exhibit significant changes.

CONCLUSIONS

We could exclude the occurrence of cerebral metabolic crisis and the excess release of cerebral glutamate and glycerol in a series of 19 patients. Our results support the safety of PDT in patients with ABI.

Experimental Assessment and Future Applications of the Shikani Tracheostomy Speaking Valve

PURPOSE

Tracheostomy speaking valve use may increase airflow resistance and work of breathing. It remains unclear which valve offers the best performance characteristics. We compared the performance characteristics of the Shikani speaking valve (SSV; unidirectional-flow ball valve) with those of the Passy-Muir valve (PMV; bias-closed flapper valve).

METHOD

Airflow resistance was measured for both the SSV and the PMV at 8 flow amplitudes and in 3 orientations (-15°, 0°, +20°) in the bias-open and bias-closed configurations.

RESULTS

Significantly lower airflow resistance was observed for the SSV (bias open) compared with the PMV at -15° (p < .001), 0° (p < .001), and +20° (p = .006) from the horizon. No significant difference was observed between the PMV and the SSV (bias-closed) configuration at any of the tested angles. A nonsignificant trend toward decreased airflow resistance was observed between the SSV bias-open and bias-closed configurations at each of the angles tested.

CONCLUSIONS

The SSV demonstrated lower airflow resistance compared with the PMV across 8 flow amplitudes in the bias-open configuration at -15°, 0°, and +20° from the horizon. Further investigation is needed to determine the clinical impact of these findings on patient comfort, work of breathing, phonation, and airway protection during swallowing.

Tracheostomy after severe ischemic stroke: a population-based study

BACKGROUND

Stroke can result in varying degrees of respiratory failure. Some patients require tracheostomy in order to facilitate weaning from mechanical ventilation, long-term airway protection, or a combination of the two. Little is known about the rate and predictors of this outcome in patients with severe stroke. We aim to determine the rate of tracheostomy after severe ischemic stroke.

METHODS

Using the Nationwide Inpatient Sample database from 2007 to 2009, patients hospitalized with ischemic stroke were identified based on validated International Classification of Diseases, 9th revision, Clinical Modification codes. Next, patients with stroke were stratified based on whether they were treated with or without decompressive craniectomy, and the rate of tracheostomy for each group was determined. A logistic regression analysis was used to identify predictors of tracheostomy after decompressive craniectomy. Survey weights were used to obtain nationally representative estimates.

RESULTS

In 1,550,000 patients discharged with ischemic stroke nationwide, the rate of tracheostomy was 1.3% (95% confidence interval [CI], 1.2-1.4%), with a 1.3% (95% CI, 1.1-1.4%) rate in patients without decompressive craniectomy and a 33% (95% CI, 26-39%) rate in the surgical treatment group. Logistic regression analysis identified pneumonia as being significantly associated with tracheostomy after decompressive craniectomy (odds ratio, 3.95; 95% CI, 1.95-6.91).

CONCLUSIONS

Tracheostomy is common after decompressive craniectomy and is strongly associated with the development of pneumonia. Given its impact on patient function and potentially modifiable associated factors, tracheostomy may warrant further study as an important patient-centered outcome among patients with stroke.

Current trends in paediatric tracheostomies

OBJECTIVE

In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis.

METHODS

Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004.

RESULTS

Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months.

CONCLUSIONS

Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients.

Paediatric tracheostomy in Hospital University Kebangsaan Malaysia - a changing trend

Indication for pediatric tracheostomy has changed. Upper airway obstruction secondary to infectious disorders is no longer the commonest indication. The aim of this study was to establish data on indications, outcome and complications of pediatric tracheostomy. A retrospective analysis of pediatric tracheostomies carried out between March 2002 to March 2004 was done. Eighteen patients were identified. The commonest indication was prolonged ventilation (94.5%) followed by pulmonary toilet (5.5%). None was performed for upper airway obstruction. Postoperative complications were encountered in six patients (33.3%), the commonest being accidental decannulation notably in children less than six years of age. Twelve patients (66.6%) were successfully decannulated. The mortality rate was 16.6%. All death were non tracheostomy related. The commonest indication for tracheostomy was prolonged ventilation and tracheostomy in children is relatively safe despite complications.

Recent developments in percutaneous tracheostomy: improving techniques and expanding roles

PURPOSE OF REVIEW

The purpose of this review is to provide an update of recent developments pertaining to the use of percutaneous tracheostomy. Percutaneous tracheostomy has been established as an alternative to open surgical tracheostomy, but many key questions about the optimal use of this procedure remain unanswered.

RECENT FINDINGS

Issues in percutaneous tracheostomy that have been addressed in the recent literature include the optimal method, timing, use of percutaneous tracheostomy in emergencies, safety in high-risk populations, confirmation of tracheal puncture, and outcomes.

SUMMARY

Recent literature suggests that percutaneous tracheostomy is safe to use in an expanding population of patients, including patients with airway compromise and thrombocytopenia. Several methods seem to be safe alternatives to that originally described. Capnography has arisen as an alternative to bronchoscopy for confirmation of tracheal puncture. Recent evidence highlights that although tracheostomy may improve short-term outcome, these critically ill patients have a significant long-term risk of poor outcome. This must be taken into consideration when this procedure is offered.

Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993–2002

OBJECTIVE

Patients who require tracheostomy for prolonged mechanical ventilation have poor outcomes and high costs of care. However, recent longitudinal trends relevant to these patients and their care have not been described. We aimed to describe trends in the annual incidence and timing of tracheostomy for prolonged mechanical ventilation, as well as prolonged mechanical ventilation patient resource utilization and overall in-hospital mortality.

DESIGN AND SETTING

Retrospective review of the North Carolina Hospital Discharge Database, a comprehensive record of all state nonfederal, nonpsychiatric hospital discharges between 1993 and 2002.

PATIENTS

Patients were 9,794 medical and surgical patients >/=18 yrs of age with International Classification of Diseases, Ninth Revision, Clinical Modification code 96.72 (mechanical ventilation for >96 hrs) and Diagnosis Related Group code 483 (tracheostomy except for face, neck, and mouth diagnoses).

INTERVENTIONS

None.

MEASUREMENTS

Incidence rates adjusted for annual population growth, mechanical ventilation days until tracheostomy placement, length of stay, and hospital charges and payments adjusted by the medical component of the Consumer Price Index.

MAIN RESULTS

Between 1993 and 2002, the incidence of tracheostomy for prolonged mechanical ventilation increased across all age groups from 8.3 of 100,000 to 24.2 of 100,000 (p < .001), although most significantly among patients <55 yrs of age. During this period, a decrease was seen in mortality (from 39% to 25%), median mechanical ventilation days to tracheostomy placement (from 12 to 10 days), and median length of stay (from 47 to 33 days). By 2002, patients were almost three times less likely to be discharged to home independently although twice as likely to be sent to a skilled nursing facility. Although prolonged mechanical ventilation patients with tracheostomies represented only 7% of all who required mechanical ventilation, their total charges during the study period were 1.74 billion dollars-22% of all mechanical ventilation patient charges.

CONCLUSION

The incidence of tracheostomy for prolonged mechanical ventilation increased by nearly 200% during the past decade in North Carolina, exceeding changes in the overall incidence of respiratory failure three-fold. Although in-hospital mortality, length of stay, and charges per patient fell over time, the overall resource utilization of prolonged mechanical ventilation patients increased dramatically.

Tracheostomy in preterm infants: current trends

OBJECTIVE

To study the indications for and outcomes of tracheostomy in a population of preterm infants.

DESIGN

Retrospective analysis of case records.

SETTING

Two university-affiliated tertiary care children's hospitals. Patients We identified premature infants who required tracheostomies from January 1, 1997, through January 31, 2001. Information on weight, gestational age, comorbid conditions, indication for tracheostomy, and outcomes was collected. Infants were divided by birth weight into group 1 (<1000 g; n = 19 [very low birth weight]) and group 2 (> or =1000 g; n = 14). Comorbid conditions were scored and a total score was calculated for each patient.

RESULTS

Group 1 had a higher incidence of patent ductus arteriosus, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity. The incidence of congenital or genetic defects was equal in groups 1 and 2 (11 infants [58%] and 8 infants [57%], respectively). Group 1 had a higher average number of failed extubations (5.17 vs 3.18) and a higher oxygen requirement (48.7% vs 30.3%) compared with group 2. Weight at tracheostomy was essentially equal in groups 1 and 2 (3.6 vs 3.7 kg). Subglottic stenosis and laryngotracheomalacia were equally common findings in groups 1 and 2. The average comorbidity score for group 1 was higher than that for group 2 (6.7 vs 2.8). The most common indication for tracheostomy was ventilatory dependence (n = 24 [73%]), compared with airway obstruction (n = 6 [18%]) and pulmonary toilet (n = 3 [9%]). Overall, 6 patients (18%) had a complication related to the tracheostomy.

CONCLUSIONS

Severity of pulmonary disease was the most significant factor associated with the need for tracheostomy in preterm infants. A tracheostomy can safely be performed in these infants with minimal morbidity.

Evolution in the utilization of the mechanical ventilation in the critical care unit

Use of mechanical ventilation has increased in recent years and constitutes a major therapeutic modality in the intensive care unit (ICU). In the recent years, changes in the ventilatory modes, in the ventilatory strategies and in the weaning from mechanical ventilation have occurred. We have compared the data obtained from the Spanish ICUs in studies that were carried out in three periods of the nineties, with the aim to test whether the aforementioned innovations have modified the clinical practice. We analyzed demographic data, primary reason for mechanical ventilation, ventilatory parameters, mode of weaning and performance of tracheostomy. It was observed a decrease in the percentage of patients receiving mechanical ventilation. There was a significant trend to ventilate older patients over the course of the decade. In the mode of ventilation, we observed a significant decrease in the use of the synchronized intermittent mandatory ventilation with a increment in the use of assist-control ventilation. We did not find differences in the ventilatory settings. Concerning to weaning, over the course of the decade occurred an increase in use of pressure support ventilation and spontaneous breathing trial, being this method the most frequently used at the end of the decade. The performance of the tracheostomy has been lesser and earlier over the time. The results obtained suggest that findings from research on mechanical ventilation are incorporated into clinical practice at a very slow pace whereas the evidence obtained from the clinical trials about weaning has had a better reception.

Surgical airway management in the intensive care unit

Despite having been a known surgical procedure for over 5000 years, the specifics of how, when, and why to perform a surgical airway are still debated. With new procedures, equipment, and techniques, operative airway management is becoming more complex. New methods of surgical airway management have to be evaluated against the gold standard, which will always be the open tracheostomy performed in the operating room. Unlike Dr. Jackson in 1909, surgeons today have to evaluate these new procedures not only by their efficacy but also by their cost effectiveness.

Percutaneous or surgical tracheostomy: a meta-analysis

OBJECTIVE

To compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996.

DATA SOURCES

Publications obtained through a MEDLINE database search with a Boolean combination (tracheostomy or tracheotomy) and complications, with constraints for human studies and English language.

STUDY SELECTION

Publications addressing all peri- and postoperative complications. Studies limited to specific tracheostomy complications or containing insufficient details were excluded. Two authors independently selected the publications.

DATA EXTRACTION

A list of relevant surgical variables and complications was compiled. Complications were divided into peri- and postoperative groups and further subclassified into severe, intermediate, and minor groups. Because most studies of percutaneous tracheostomy were published after 1985, surgical tracheostomy studies were divided into two periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed independently by three investigators, and rare discrepancies were resolved through discussion and data reexamination.

DATA SYNTHESIS

Earlier surgical tracheostomy studies (n = 17; patients, 4185) have the highest rates of both peri- (8.5%) and postoperative (33%) complications. Comparison of recent surgical (n = 21; patients, 3512) and percutaneous (n = 27; patients, 1817) tracheostomy trials shows that perioperative complications are more frequent with the percutaneous technique (10% vs. 3%), whereas postoperative complications occur more often with surgical tracheotomy (10% vs. 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%), which were higher with the percutaneous technique. Heterogeneity analysis of complication rates shows higher heterogeneity in older and surgical trials.

CONCLUSIONS

Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, perioperative deaths and cardiorespiratory arrests. Postoperative complication rates are higher with surgical tracheostomy.

Percutaneous tracheostomy

Percutaneous dilational tracheostomy (PDT) originated in the USA and now an increasing number of UK centres are adopting the technique. It compares favourably with traditional surgical tracheostomy; PDT can be performed more satisfactorily at the bedside, avoiding the transport of critically ill patients to the operating theatre. It is a more rapid and convenient technique and evidence increasingly suggests that it is associated with significantly fewer and less severe complications. If early reports are confirmed by larger, carefully controlled trials, it is likely that PDT will largely replace conventional surgical techniques for the provision of tracheostomy in the critically ill. An improved risk-benefit ratio of PDT may favour earlier conversion of translaryngeal intubation to tracheostomy.

The 1991 Fraser Gurd Lecture: evolution of airway control in the management of injured patients

The evolution of methods for airway control has been an important factor in improving overall trauma care. Many important advances have been made in technique, tubes, and timing. Current methods of airway control are listed in Table 2 and are categorized as emergency or elective. It is always assumed that basic life support techniques will be in place before this hierarchic scheme for airway control is used. Unfortunately, hypoxemia continues to be a factor in preventable trauma deaths. There is much to be done in the future to further improve airway management in injured patients. There is an immediate need to assess methods of airway control in the pre-hospital phase using a randomized clinical trial. The ideal tube for cricothyroidotomy, tracheostomy, or endotracheal intubation remains to be designed. There is a need for further multicenter trials on the timing of tracheostomy in the critical care unit. The role of differential ventilators in the management of unilateral pulmonary parenchymal injury requires clinical validation. Intravascular membrane oxygenators have been proposed in advanced pulmonary insufficiency in a ventilated patient. Thus, while many important strides have been made in airway management following trauma, there remain great challenges in addressing the persistent problem of systemic hypoxemia after multiple injuries.