Pediatric Tracheotomy Stomal Maturation and Tracheocutaneous Fistulas

OBJECTIVE

The purpose of this study is to determine whether tracheostomy stomal maturation affects the risk of tracheocutaneous fistula (TCF) in children.

METHODS

A retrospective chart review was conducted for all children who both underwent a tracheostomy and were decannulated between 2012 and 2021 at a tertiary children's hospital. Charts were analyzed for demographics, surgical technique, and development of a TCF. TCF was defined as a persistent fistula following 3 months after decannulation.

RESULTS

179 children met inclusion criteria. The median (interquartile range) age at tracheostomy was 1.5 (82.4) months, average (standard deviation [SD]) duration of tracheotomy was 20.0 (20.6) months, and length of follow-up after decannulation (range; SD) was 39.3 (4.4-110.0; 26.7) months. 107 patients (60.0%) underwent stomal maturation and 98 patients developed a TCF (54.7%). Younger age at tracheostomy placement was significantly associated with increased risk of TCF, mean (SD) age 28.4 (51.4) version 80.1 (77.5) months (p < 0.001). Increased duration of tracheostomy was significantly associated with increased risk of TCF, 27.5 (18.4) version 11.0 (18.2) months (p < 0.001). Stomal maturation was not significantly associated with the risk of TCF, including on multivariable analysis adjusting for age at tracheostomy and duration of tracheostomy (p = 0.089).

CONCLUSION

Tracheostomy stomal maturation did not affect the risk of TCF in children, even after adjusting for age and duration of tracheostomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2941-2944, 2024.

The Safety of Pediatric Bedside Tracheostomy

OBJECTIVE

Traditionally, pediatric tracheostomy has been viewed as a technically demanding procedure with a high complication rate, requiring the routine use of a formal operating room. Pediatric bedside tracheostomy in an intensive care unit (ICU) setting has not been widely reported, in contrast to the widespread adult bedside ICU tracheostomy. Transport of these critically ill, multiple life support systems dependent patients can be technically difficult, labor intensive, and potentially risky for these patients. Our study aimed to demonstrate the safety and efficacy of bedside tracheostomy in the pediatric ICU.

MATERIALS AND METHODS

A retrospective analysis of all pediatric patients undergoing tracheostomy at a tertiary care center, between 1st of January 2013 and 31st of December 2019.

RESULTS

During the study period, 117 pediatric patients underwent tracheostomy, 57 (48.7%) were performed bedside while 60 (51.3%) were performed in the operating room. Patients' ages ranged from 2 weeks to 17 years of age, with a median age of 16 months. No case of bedside tracheostomy necessitated a shift to the operating room. There was no difference in 30-day morbidity and mortality between the 2 groups.

CONCLUSIONS

Our results suggest that pediatric open bedside tracheostomy in an ICU setting is a safe procedure, with similar complications and outcomes compared to tracheostomy performed in the operating room.

Neighborhood Socioeconomic Disadvantage and Long-Term Outcomes After Pediatric Tracheostomy

OBJECTIVES

To determine whether long-term outcomes after pediatric tracheostomy are impacted by neighborhood socioeconomic disadvantage.

METHODS

A prospective cohort of children with tracheostomies was followed at an academic pediatric hospital between 2015 and 2020. Patients were grouped into low or high socioeconomic disadvantage using their neighborhood area deprivation index (ADI). Survival and logistic regression analyses determined the relationship between ADI group, decannulation, and mortality.

RESULTS

A total of 260 children were included with a median age at tracheostomy of 6.6 months (interquartile range [IQR], 3.9-42.3). The cohort was 53% male (N = 138), 55% White race (N = 143), and 35% Black or African American (N = 90). Tracheostomy was most frequently indicated for respiratory failure (N = 189, 73%). High neighborhood socioeconomic disadvantage was noted for 66% of children (N = 172) and 61% (N = 158) had severe neurocognitive disability. ADI was not associated with time to decannulation (HR = 0.90, 95% confidence interval [95% CI]: 0.53-1.53) or time to death (HR = 0.92, 95% CI: 0.49-1.72).

CONCLUSIONS

Neighborhood socioeconomic disadvantage was not associated with decannulation or mortality among children with a tracheostomy. These findings suggest that long-term outcomes after pediatric tracheostomy are less dependent on socioeconomic factors in an individual community.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2415-2421, 2024.

A systematic review of antimicrobial therapy in children with tracheostomies

Tracheostomies are indicated in children to facilitate long-term ventilatory support, aid in the management of secretions, or manage upper airway obstruction. Children with tracheostomies often experience ongoing airway complications, of which respiratory tract infections are common. They subsequently receive frequent courses of broad-spectrum antimicrobials for the prevention or treatment of respiratory tract infections. However, there is little consensus in practice with regard to the indication for treatment/prophylactic antimicrobial use, choice of antimicrobial, route of administration, or duration of treatment between different centers. Routine antibiotic use is associated with adverse effects and an increased risk of antimicrobial resistance. Tracheal cultures are commonly obtained from pediatric tracheostomy patients, with the aim of helping guide antimicrobial therapy choice. However, a positive culture alone is not diagnostic of infection and the role of routine surveillance cultures remains contentious. Inhaled antimicrobial use is also widespread in the management of tracheostomy-associated infections; this is largely based on the theoretical benefits of higher airway antibiotic concentrations. The role of prophylactic inhaled antimicrobial use for tracheostomy-associated infections remains largely unproven. This systematic review summarizes the current evidence base for antimicrobial selection, duration, and administration route in pediatric tracheostomy-associated infections. It also highlights significant variation in practice between centers and the urgent need for further prospective evidence to guide the management of these vulnerable patients.

Tracheal A-frame deformity and suprastomal collapse after pediatric tracheostomy

Objectives

To determine the incidence of A-frame deformity and suprastomal collapse after pediatric tracheostomy.

Study design

Retrospective cohort.

Methods

All patients (<18 years) that had a tracheostomy placed at a tertiary institution between 2015 and 2020 were included. Children without a surveillance bronchoscopy at least 6 months after tracheostomy were excluded. Operative reports identified tracheal A-frame deformity or suprastomal collapse.

Results

A total of 175 children met inclusion with 18% (N = 32) developing A-frame deformity within a mean of 35.8 months (SD: 19.4) after tracheostomy. For 18 children (18/32, 56%), A-frame developed within a mean of 11.3 months (SD: 15.7) after decannulation. There were 96 children developing suprastomal collapse (55%) by a mean of 17.7 months (SD: 14.2) after tracheostomy. All suprastomal collapse was identified prior to decannulation. Older age at tracheostomy was associated with a lower likelihood of collapse (OR: 0.92, 95% CI: 0.86-0.99, p = .03). The estimated 5-year incidence of A-frame deformity after tracheostomy was 32.8% (95% CI: 23.0-45.3) and the 3-year incidence after decannulation was 36.1% (95% CI: 24.0-51.8). Highly complex children had an earlier time to A-frame development (p = .04). At 5 years after tracheostomy, the estimated rate of suprastomal collapse was 73.7% (95% CI: 63.8-82.8).

Conclusions

Tracheal A-frame deformity is estimated to occur in 36% of children within 3 years after tracheostomy decannulation. Suprastomal collapse, which approaches 74% at 5 years after tracheostomy, is more common when tracheostomy is placed at a younger age. Surgeons caring for tracheostomy-dependent children should recognize acquired airway obstruction and appropriately monitor these outcomes.

Level of evidence

3.

Pediatric Custom Tracheostomies: A Ten-Year Experience

OBJECTIVES

To describe the use of customized and custom tracheostomies at our institution, and to identify trends in patient presentation and tracheostomy design.

METHODS

A retrospective review was conducted for patients at our institution for whom a customized or custom tracheostomy tube was ordered between January 2011 and July 2021. Customized tracheostomy tubes allow for a small selection of alterations to trach design, such as cuff length and flange type. Custom tracheostomies have a unique design created by tracheostomy tube engineers in collaboration with the clinical provider, and are built specifically for a single patient.

RESULTS

A total of 235 patients were included, of whom 220 (93%) received customized tracheostomies and 15 custom (7%). The most common indications for customized tracheostomy were tracheal or stomal breakdown on a standard tracheostomy (n = 73, 33%) and ventilation difficulties (n = 61, 27%). The most frequent customization was shaft length (n = 126, 57%). The most common indication for custom tracheostomies was a persistent air leak on a standard or customized trach (n = 9) and the most frequent designs were custom cuffs (n = 8), flanges (n = 4), and anteriorly curved shafts (n = 4). Patients treated with a customized tracheostomy had a 5-year overall survival of 75.3%, compared to 51.4% for custom.

CONCLUSION

These are the first cohorts of pediatric patients with customized and custom tracheostomies to be described. Modifications to tracheostomies, in particular shaft length and cuff design, can address common complications of extended tracheostomy, and may help improve ventilation in the most challenging cases.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:452-458, 2024.

Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis

Objective

This study aimed to determine the direct costs of pediatric tracheostomy care within a health care system.

Study Design

Prospective analysis.

Setting

Academic children's hospital.

Methods

Costs associated with caring for pediatric tracheostomy patients under 18 years were analyzed between 2015 and 2021. Direct costs were calculated using the Medicare/Medicaid charges-to-costs ratio for various visit types. Costs were estimated using generalized linear equations, accounting for confounders.

Results

A total of 297 children underwent tracheostomy at a median age of 0.94 years. The median follow-up was 2.5 years, resulting in 13,966 visits (mean = 41). The total cost was $321 million. The initial admission accounted for 72% ($231 million) of costs while other inpatient admissions added 24% ($78 million). Emergency department, observation, and outpatient visits comprised 4% of costs. The length of stay (LOS) was the primary cost driver for inpatient visits. Each additional hospital day increased costs by roughly $1195, and each extra admission added about $130,223 after adjusting for confounders. Respiratory failure and infections were the primary reasons for 67% of subsequent admissions.

Conclusion

Pediatric tracheostomy care generated over $300 million in direct costs over 5 years. Inpatient stays constituted 96% of these costs, with the LOS being a major factor. To reduce direct health expenditures for these patients, the focus should be on minimizing admissions.

Survival After Declining Pediatric Tracheostomy Placement

OBJECTIVE

To determine survival among critically ill children when caregivers decline tracheostomy placement.

STUDY DESIGN

Retrospective cohort.

METHODS

All children (<18 years) obtaining a pre-tracheostomy consultation at a tertiary children's hospital between 2016 and 2021 were included. Comorbidities and mortality were compared between children of caregivers that declined or agreed to tracheostomy.

RESULTS

Tracheostomy was declined for 58 children but was placed for 203 children. After consultation, mortality was 52% (30/58) when declining and 21% (42/230) when agreeing to tracheostomy (p < 0.001) at a mean of 10.7 months (standard deviation [SD]: 16) and 18.1 months (SD: 17.1), respectively (p = 0.07). For those declining, 31% (18/58) died during the hospitalization within a mean of 1.2 months (SD: 1.4) while 21% (12/58) died at a mean of 23.6 months (SD: 17.5) after discharge. Among children of caregivers declining tracheostomy, older age (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.74-0.97, p = 0.01) and chronic lung disease (OR: 0.18, 95% CI: 0.04-0.82, P = .03) were associated with lower odds of mortality but sepsis (OR: 9.62, 95% CI: 1.161-57.43, p = 0.01) and intubation (OR: 4.98, 95% CI: 1.24-20.08, p = 0.02) were associated with higher odds of mortality. Median survival after declining tracheostomy was 31.9 months (interquartile range [IQR]: 2.0-50.7) and declining placement was associated with increased mortality risk (hazard ratio [HR]: 4.04, 95% CI: 2.49-6.55, p < 0.001).

CONCLUSION

When caregivers declined tracheostomy placement, less than half of critically ill children in this cohort survived with younger age, sepsis, and intubation associated with higher mortality. This information offers valuable insight for families weighing decisions pertaining to pediatric tracheostomy placement.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3602-3607, 2023.

Factors Affecting the Quality of Life of Parents Caring for Pediatric Patients with a Tracheostomy

Objectives  This study aimed to evaluate factors affecting the quality of life (QOL) of parents of children who underwent placement of a tracheostomy while in the pediatric intensive care unit (PICU) through postdischarge use of a standardized questionnaire, Functional Status Scale (FSS) for patients, and WHOQoL-BREF (a QOL scale) for parents. Methods  The parents were initially contacted by telephone, postdischarge, during which the standardized questionnaire was completed. The functional status of the patients was evaluated using the FSS, and the QOL of parents was determined through use of the WHOQoL-BREF scale. Results  From 2011 to 2021, tracheostomy was performed in 119 PICU patients. Overall, 93 patients were excluded due to death in 66 (56%), decannulation in 24 (20%) and, 3 (2%) were not available for follow-up. The parents of 26 (22%) patients were available for follow-up and for which the standardized questionnaire FSS and WHOQoL-BREF QOL scales were completed. The mean FSS score of the patients was elevated at 17.84. In comparison, reduced mean scores were observed for parental physical health of 20.61, psychological health of 20.57, social health of 11.15, and environmental health of 29.00. As a result, a moderate ( r < 0.80), yet significant ( p ≤ 0.004) negative correlation was found between the FSS scores of patients and the physical, social relationships, environmental, and psychological health QOL scores of parents. Conclusion  This study is unique in that, to our knowledge, it is the first to compare parental QOL with the FSS of pediatric patients who have undergone a tracheostomy while hospitalized in the PICU. Our findings indicate that the parental QOL was reduced in four areas and correlates with an elevation in FSS score (indicating a greater functional disorder) of pediatric patients who had previously undergone a tracheostomy while hospitalized in the PICU.

Long-Term Outcomes of Tracheostomy-Dependent Children

OBJECTIVE

To estimate the 1-, 5-, and 10-year survival and decannulation rates of children with a tracheostomy.

STUDY DESIGN

Ambidirectional cohort.

SETTING

Tertiary children's hospital.

METHODS

All patients (<18 years) that had a tracheostomy placed between 2009 and 2020 were included and followed until 21 years of age, decannulation, or death. The Kaplan-Meier method estimated cumulative probabilities of death and decannulation.

RESULTS

A total of 551 children underwent tracheostomy at a median age of 7.2 months (interquartile range [IQR]: 3.8-49.2). Children were followed for a median of 2.1 years (IQR: 0.7-4.2, range 0-11.5). The cumulative probability of mortality at 1 year was 11.9% (95% confidence interval [CI]: 9.4-15.1), at 5 years was 26.1% (95% CI: 21.6-31.3), and at 10 years was 41.6% (95% CI: 32.7-51.8). Ventilator dependence at index discharge (hazard ratio [HR]: 2.04, 95% CI: 1.10-3.81, p = .03), severe neurologic disability (HR: 2.79, 95% CI: 1.61-4.84, p < .001), and cardiac disease (HR: 1.69, 95% CI: 1.08-2.65, p = .02) were associated with time to death. The cumulative probability of decannulation was 10.4% (95% CI: 8.0-13.5), 44.9% (95% CI: 39.4-50.9), and 54.1% (95% CI: 47.4-61.1) at 1 year, 5 years, and 10 years, respectively. Ventilator dependence (HR: 0.43, 95% CI: 0.31-0.60, p < .001), severe neurologic disability (HR: 0.20, 95% CI: 0.14-0.30, p < .001), and tracheostomy indicated for respiratory failure (HR: 0.68, 95% CI: 0.48-0.96, p = .03) correlated with longer decannulation times.

CONCLUSION

After tracheostomy, estimated mortality approaches 42% by 10 years and decannulation approaches 54%. Children with ventilator support at discharge and severe neurological disability had poorer long-term survival and longer times to decannulation.

Pediatric Patients with Tracheostomies and Its Multifacet Association with Lower Airway Infections: An 8-Year Retrospective Study in a Large Tertiary Center

Background: Lower respiratory tract infections frequently complicate the care of children with chronic tracheostomies. Pediatric patients have significantly more risk to have tracheostomy infections than adults. Better understanding of modifiable risk factors for pulmonary exacerbations may improve the care of technology-dependent children. Methods: A retrospective single-center cohort study conducted on children with tracheostomy and chronic home ventilator to determine the incidence of pulmonary exacerbations leading to hospitalizations, emergency room (ER) visits, and antibiotic prescriptions. Oral and nebulized antibiotic prescriptions were collected and correlated to the type of exacerbation. Results: Gram-negative enteric organisms were the most common microbes seen in the lower airways, with Pseudomonas aeruginosa cultured in 86% of the subjects. P. aeruginosa presence predicted a 4-fold increased rate of pulmonary-related hospitalization. In pediatric patients with chronic respiratory failure, 64% of readmissions were pulmonary or tracheostomy related. When compared to standard care subjects on dual agent, alternating monthly nebulized antibiotic therapy (for chronic pseudomonas colonization) experienced 41% fewer hospitalizations [incidence rate ratios (IRR) 0.59 (0.18), P = 0.08], 46% fewer ER visits [IRR 0.56 (0.16), P = 0.04], and 41% fewer pulmonary-related ER visits [IRR 0.59 (0.19), P = 0.94]. Discussion: Children who require artificial airways are at an increased risk for bacterial bronchopulmonary infections. Most notable risk factors for hospitalization in tracheostomized children included neurologic impairment, dysphagia, aspiration, gastrotomy tube dependence, and gastroesophageal reflux disease. Pathogenic microbes such as P. aeruginosa species, certain gram-negative bacteria, candida, and yeast also predicted increased hospitalizations. Use of nebulized antibiotics prophylaxis in a subset of patients predicted lower rates of hospitalization or ER visits. More studies are needed to assess whether there is increased antimicrobial resistance with this strategy, and whether the benefits persist in the long-term nebulized antibiotics utilization.

Pediatric Tracheostomy: A Quality-of-Life Assessment Study in Saudi Arabia

INTRODUCTION

The pediatric population undergoes tracheostomy for a variety of reasons. For a child and their family, having a tracheostomy means learning a new way of life and facing several social, psychological, medical, and economic challenges. Our analysis of the literature indicates that this is the first study of its kind, using the Pediatric Tracheotomy Health Status Instrument (PTHSI) tool to assess the quality of life (QoL) following tracheostomy in pediatric patients and their caregivers in the Kingdom of Saudi Arabia (KSA).

METHODS

This was a descriptive cross-sectional study for tracheostomized children's QoL evaluation. The medical records of the Maternity and Children Hospital, Dammam, KSA, were used to identify the patients and their caregivers. A higher score on the validated PTHSI indicated a better result.

RESULTS

From a total of 56 patients, 24 were included in this study. Based on the PTHSI tool, the overall mean score was 93.3/150 (62.28%) and this indicated a good QoL score. Analysis of the correlation between the PTHSI score and other variables indicated no association between the total PTHSI score and the age or gender of the patient or the duration of the tracheostomy (p-value > 0.05). However, we found families of children with major medical comorbidities had lower scores (p-value = 0.03) and their QoL was affected much more than families of patients who did not have major medical comorbidities.

CONCLUSION

Tracheostomy care for pediatric patients can significantly affect the QoL of patients and their families. Our findings using the validated PTHSI tool showed poorer QoL compared to other studies, suggesting the need for future home care training programs to support tracheostomized children and their families, particularly those with comorbidities, who tend to have lower QoL scores and require more organized support.

Parental Perception and Barriers Regarding COVID-19 Vaccination in Technology Dependent Children

INTRODUCTION

Children who use chronic home mechanical ventilation are at high risk for respiratory infections and mortality. They are also at increased risk for developing severe COVID-19 infection. The primary goal of this study was to evaluate the parental perception of the COVID-19 vaccine in pediatric patients with technology dependence.

METHOD

We conducted a cross-sectional survey at a children's hospital between September 2021 and February 2022. A telephone or in-person interview was conducted to assesss parental attitudes toward the COVID-19 vaccine for their technology-dependent child. Technology-dependent groups included patients requiring (1) invasive mechanical ventilation via tracheostomy and (2) noninvasive mechanical ventilation via a facial interface.

RESULTS

Fourteen of 44 participants (32%) of technology-dependent children were vaccinated for COVID-19 despite high parental vaccination and influenza vaccination rates. Twenty-eight patients (63% of total participants) were tracheostomy dependent. In the tracheostomy group, the COVID-19 vaccine rate was 28% versus 54% in the nontracheostomy group.  Concern for vaccine side effects was the major reason for vaccine hesitancy (53%). More parents of vaccinated children than unvaccinated children were counseled by their primary care provider (85.7% vs. 46.7%; p = .02) or subspecialist (93% vs. 47%; p = .003).

CONCLUSIONS

Our findings suggest counseling by primary care providers and subspecialists is important in overcoming COVID-19 vaccine hesitancy. Social media was identified as a major source of information, particularly among parents of unvaccinated patients.

Outcomes of pediatric tracheostomy after surgery for congenital heart disease: A 20-year experience

Objective

Children with congenital heart defects (CHD) requiring cardiovascular surgery (CVS) rarely require tracheostomy placement; however the mortality rate remains high. The study aimed to analyze the incidence of tracheostomy in children with CHD, and to determine factors contributing to postoperative outcomes, decannulation rates, and mortality.

Methods

Retrospective case series of children ≤18 years old with CHD status post-CVS who underwent tracheostomy placement between January 1, 2001 and December 31, 2020. Variables analyzed included demographic information, presence of comorbidities including prematurity, respiratory diseases, presence of genetic syndromes, decannulation status, type of repair (univentricular vs. biventricular), and need for cardiopulmonary bypass. Adverse events analyzed included all-cause mortality, development of mediastinitis, fatal decannulation, and persistence of tracheocutaneous fistula.

Results

Fifty-one patients were analyzed. The incidence of tracheostomy was 0.8%. Median age at tracheostomy was 5.3 months. The 5-year survival estimate was 56.3% (95% confidence interval 43.6%, 72.6%). Age ≤6 months at the time of tracheostomy placement (p = .03), and the presence of tracheomalacia (p = .04) were factors significantly associated with 5-year survival. Two patients (3.9%) experienced fatal decannulation, and one patient (2.0%) developed postoperative mediastinitis. The 10-year decannulation rate estimate was 47.8% (30.5%, 63.2%). Seven patients (13.7%) had a persistent tracheocutaneous fistula.

Conclusions

This study corroborates high mortality rates in this population. Factors associated with improved survival were younger age at the time of tracheostomy and presence of tracheomalacia. Decannulation rates were low, but estimates improved over 10 years. Further studies are needed to determine optimal indications and timing for tracheostomy placement in this patient population.

Level of Evidence

4.

Accidental Tracheostomy Decannulations in Children-A Prospective Cohort Study of Inpatients

OBJECTIVES

To determine the incidence of tracheostomy accidental decannulations (AD) among pediatric inpatients and identify risks for these events.

STUDY DESIGN

Prospective cohort.

METHODS

All tracheostomy patients (≤18 years) admitted at a tertiary children's hospital between August 2018 and April 2021 were included. AD were recorded and patient harm was classified as no harm/minor, moderate, or severe. Monthly AD incidence was described as events per 1000 tracheostomy-days.

RESULTS

One-hundred seventeen AD occurred among 67 children with 33% (22/67) experiencing multiple events (median: 2.5 events, range: 2-10). Mean age at AD was 4.7 years (SD: 4.4). AD resulted from patient movement (32%, 37/117), performing tracheostomy care (27%, 31/117), repositioning or transporting (15%, 17/117), or unclear reasons (27%, 32/117). A parent or guardian was involved in 28% (33/117) of events. Nearly all AD resulted in no more than minor harm (84%, 98/117) but moderate (12%, 14/117) and severe (4%, 5/117) events did occur. There were no deaths. Tracheostomy care or repositioning were frequently responsible in acute versus subacute events (48% vs. 26%, p = 0.04). Mean monthly AD incidence was 4.7 events per 1000 tracheostomy-days (95% CI: 3.7-5.8) and after implementation of safety initiatives, the mean rate decreased from 5.9 events (95% CI: 4.2-7.7) to 3.7 events (95% CI: 2.5-5.0) per 1000 tracheostomy-days (p = 0.04).

CONCLUSIONS

AD in children occur at nearly 5 events per 1000 tracheostomy-days and often result in minimal harm. Quality initiatives targeting patient movement, provider education, and tracheostomy care might reduce the frequency of these complications.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:963-969, 2023.

Mortality Among Children with a Tracheostomy

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.

Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation

OBJECTIVES

To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence.

STUDY DESIGN

Prospective cohort.

METHODS

All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation.

RESULTS

A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p = 0.049) with failure to spontaneously close.

CONCLUSIONS

Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:417-422, 2023.

Hospital Admissions in Pediatric Patients With Tracheostomies Based on Rurality and Insurance Status

OBJECTIVE

Determine whether rurality or public insurance status is associated with greater 30-day readmission after tracheostomy in pediatric patients.

STUDY DESIGN

Retrospective cohort.

SETTING

Pediatric Health Information System (PHIS) Database.

METHODS

Patients within PHIS who underwent tracheostomy from 2013 to 2017 were included. Rural status was defined by rural-urban commuting area codes. Insurance status was based on the primary payer. All-cause 30-day readmissions and tracheostomy-related readmissions were recorded. Multivariate logistic regression was performed to test for differences in readmissions between cohorts.

RESULTS

Among patients, 1092 were rural, and 4329 were publicly insured, with no significant association between rurality and insurance. Compared to nonrural patients, rural patients were more frequently white, less frequently ventilator dependent, and more likely discharged home rather than to a care facility. Publicly insured patients were more frequently non-white. Twenty-eight percent of patients were readmitted within 30 days of discharge. Odds of 30-day readmission were lower in rural patients (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.68-0.95, p = .01) but higher in publicly insured (OR: 1.24, 95% CI: 1.09-1.42, p = .001) controlling for age at tracheostomy, sex, race, and ventilator dependence. The odds of tracheostomy-related admission did not differ by rurality but were higher in publicly insured children (1.39, 95% CI: 1.03-1.88, p = .03).

CONCLUSION

Readmission within 30 days following tracheostomy was more likely in publicly insured patients and less likely in rural patients. These findings help identify at-risk patients when considering discharge planning and follow-up. More work is needed to understand long-term tracheostomy outcomes in these groups.

Airway multidrug-resistant organisms in a population of tracheostomy and chronic ventilator-dependent children at a tertiary care pediatric hospital

OBJECTIVE/BACKGROUND

Children with tracheostomies are at an increased risk of bacterial respiratory tract infections. Infections caused by multidrug-resistant organisms (MDROs) are more difficult to treat and can result in severe complications. This study aimed to investigate the risk factors and sequelae of MDRO positivity in tracheostomy and chronic ventilator-dependent children.

METHODS

We performed a retrospective chart review of 75 tracheostomy and chronic ventilator-dependent children at St. Louis Children's Hospital. Data on demographics, respiratory cultures, hospitalizations, emergency department (ED) visits, and antibiotic usage were collected. We determined the frequency of MDRO positivity and compared the number of hospitalizations, number of ED visits, and antibiotic usage in patients with and without MDRO-positive cultures. Patient clinical variables were analyzed before and after MDRO acquisition.

RESULTS

We found 75.7% (56/74) of our participants had an MDRO-positive culture, with methicillin-resistant Staphylococcus aureus (MRSA, n = 36, 64%) and Pseudomonas aeruginosa (n = 8, 14%) being the most commonly detected organisms. Participants with a greater number of annual nonpulmonary admissions (odds ratio [OR] = 1.99, 95% confidence interval [CI] (1.21-3.29), p = 0.008], inpatient antibiotic courses [OR = 1.27, 95% CI (1.07-1.50), p = 0.006], total antibiotic courses [OR = 1.26, 95% CI (1.08-1.48), p = 0.004], and chronic antibiotic use [OR = 2.31, 95% CI (1.12-4.74), p = 0.03] were at an increased risk for MDRO positivity. Those who were MDRO-positive had more pulmonary admissions following MDRO acquisition compared those who were MDRO-negative [p = 0.005] but not more antibiotic usage or ED visits.

CONCLUSION

Frequent antibiotic usage and hospitalizations increase the risk of MDRO acquisition in children with tracheostomies and ventilator-dependence. Further antibiotic stewardship may help prevent resistant infections in technology-dependent children.

Collaborative decision-making: A framework for decision-making about life-sustaining treatments in children with medical complexity

OBJECTIVE

Caregivers of children with medical complexity (CMC) face decisions about life-sustaining treatments (LST) like tracheostomy. We sought to develop a clinically relevant and realistic model for decision-making about tracheostomy placement that might apply to other LST in CMC.

DESIGN

This qualitative study, conducted between 2013 and 2015, consisted of 41 interviews with 56 caregivers of CMC who had received tracheostomies and 5 focus groups of 33 healthcare providers (HCPs) at a tertiary-care children's hospital in North Carolina. Participants were asked about their perspectives on the tracheostomy decision-making process. Data were transcribed, and coded. Using thematic content analysis, we inductively developed a tracheostomy decision-making framework and process.

RESULTS

Many factors influenced caregivers' decisions, including children's well-being and caregivers' values, faith, knowledge, experience, emotional state, and social factors; preserving the child's life was the most important. HCPs consider many clinical and nonclinical factors; recommending tracheostomy for children with limited survival, perceived poor functioning and quality of life, and progressive conditions is ethically difficult. The framework of tracheostomy decision-making has inter-related caregiver- and HCP-level factors that influence the process. The framework contains elements not captured in a shared decision-making model, but better fits a collaborative decision-making (CDM) model. The tracheostomy CDM process that emerged from the data has two nonsequential components that HCPs could use: (1) gaining understanding and (2) holding decision-making conversations.

CONCLUSIONS

CDM could be a useful model for clinicians guiding families about tracheostomy for CMC. The applicability of CDM for decision-making about other LSTs needs further exploration.

Assessing Radiology Practice Patterns for Obtaining MRI in Pediatric Patients with MR-Conditional Tracheostomy Tubes

OBJECTIVES

Silicone tracheostomy tubes are a popular choice for pediatric patients with chronic tracheostomies due to their pliability and increased comfort. However, the presence of wire reinforcement causes them to be labeled "MR-conditional." The objective of this study was to understand practice patterns across radiology departments for obtaining MRI in children with MR-conditional tracheostomy tubes.

METHODS

A survey consisting of 7 questions aimed at determining a facility's protocol for obtaining MRI in children with tracheostomy tubes was developed and administered via telephone to MRI technologists at US children's hospitals.

RESULTS

182 children's hospitals were identified and 59 responses were obtained across 30 states (32.4%). 19 sites (32%) were excluded as they were unable to perform MRI. All 40 facilities reported that they have a standard questionnaire for medical implants, however only 20 reported that tracheostomy tubes are included on that questionnaire (50%). 6 (15%) reported all MR-conditional tubes are changed to MR-safe ones. Of the remaining 34, protocols were as follows: 1 (2.9%) scans patients with conditional tubes for a maximum of 15 minutes, 5 (14.7%) only use a 1.5T magnet, and 28 (82.3%) reported following the manufacturer conditions. In terms of artifact, 3 sites change MR-conditional tubes to MR-safe if scanning the head, neck, chest, or abdomen (8.8%), 6 (17.6%) change the tube if scanning the head or neck, 15 (44.1%) change the tube only if scanning the neck, and 10 (29.4%) were not aware of issues with artifact.

CONCLUSION

Based on this survey of MRI technologists at US children's hospitals, there is no unified protocol for obtaining MRI in pediatric patients with MR-conditional tracheostomy tubes. A lack of standardized protocols may be contributing to unnecessary tracheostomy changes. Future research includes clearly defining the anatomical regions affected by wire-related artifact and developing a standardized MRI protocol for these patients.

Emergency Department Visits and Hospitalizations After Pediatric Tracheostomy

OBJECTIVE

To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy.

METHODS

A prospective cohort of children (<18 years) with a tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits).

RESULTS

A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory-related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18-3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35-5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47-10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy-related complications, which accounted for 4.8% of all encounters. A sub-analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure.

CONCLUSION

Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy-related visits are uncommon, strategies to anticipate and decrease respiratory-related admissions may have the most impact.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Impact of Language and Ethnicity on Pediatric Tracheostomy Outcomes

OBJECTIVE

To compare outcomes after tracheostomy between children from Spanish- and English-speaking families.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care children's hospital.

METHODS

All children <18 years of age who had a tracheostomy placed between 2014 and 2020 were included. Comorbidities and postsurgical outcomes were compared between (1) children whose families preferred speaking Spanish or identified as Hispanic/Latino and (2) children from English-language or non-Hispanic families.

RESULTS

A total of 339 children met inclusion, with 11% (37/339) from families identifying Spanish as their primary language and 33% (112/339) identifying as Hispanic. Spanish-speaking families were more likely to have tracheostomy-dependent children with cardiac conditions (65% vs 42%, P = .008) and high complexity (72% vs 49%, P = .007). Outcomes were similar regardless of language preference, with 45% (153/339) still tracheostomy dependent, 28% (94/339) decannulated, and 6.8% (23/339) deceased at a median follow-up of 1.77 years (interquartile range, 0.65-3.43). Severe neurocognitive disabilities were similar between Spanish- and English-language families (P > .05). Spanish language was not associated with times to decannulation or death in univariate or multiple regression models. A sensitivity analysis of self-identified Hispanic or Latino patients did not show significant differences for time to decannulation, death, or neurocognitive disability rates (P > .05).

CONCLUSION

Spanish language and Hispanic ethnicity appear to have minimal impact on pediatric tracheostomy outcomes.

Effects of tracheostomy on mothers of children with cerebral palsy

OBJECTIVE

We aimed to investigate psychosocial changes such as burnout, caregiver burden, depression, and coping in mothers of children with cerebral palsy (CP) after tracheostomy placement.

DESIGN

A total of 48 children with CP and chronic respiratory insufficiency and their mothers participated in the study. The children with tracheostomy were classified as T (+) (n = 26) and those who did not have tracheostomy were classified as T (-) (n = 22). The patients with tracheostomy through invasive mechanical ventilation were classified as TIV (+). The data about the clinical conditions of the patients and the sociodemographic characteristics of the mothers were recorded. Zarit caregiver burden, Maslach burnout, Beck depression, and Coping Orientation to Problems Experienced (COPE) questionnaires were applied to all mothers.

FINDINGS

Beck depression score was 14 ± 8.24 in T (+) group and 16.09 ± 9.65 in T (-) group (p = .576). There was no significant difference between the T (+) and T (-) groups in the Maslach burnout inventory, Zarit caregiver burden scale, and their subgroups. The first two methods from the COPE scales were identical. In the T (+) group, the third coping method was found as "planning" and in the T (-) group as "active coping". Maslach burnout inventory, Zarit 1, and Zarit 2 scores were higher in patients with only tracheostomy compared to those with TIV (p = .002, p = .018, p = .021).

CONCLUSION

In the study presented, the placement of tracheostomy in children with CP does not increase mother's depression tendencies and mood changes.

Pediatric Tracheostomy Outcomes After Development of a Multidisciplinary Airway Team: A Quality Improvement Initiative

Objectives

To analyze a multidisciplinary tracheostomy team's effect on length of stay and cost.

Methods

An airway management program using a balanced scorecard was created to track key performance measures. Interventions included weekly rounding, standardized placement, postoperative care, and caregiver education. Process measures included time to first education, speech-language pathology consultation rates, and pretracheostomy consultations. Outcome measures focused on the total length of stay, 30-day revisit rates after discharge, accidental decannulation rate, and standardized cost. Regression analysis was used to predict the program's effect on length of stay and total cost.

Results

In total, 239 children met inclusion. The mean time to first education class was reduced from 13.7 to 1.9 days (P < .001). The speech-language pathology consultation rate increased from 68% to 95% (P < .001), and the presurgical consultation rate with the tracheostomy team increased from 14% to 93% (P < .001). The length of stay decreased from 133 to 96 days (P = .006). Total costs were lower for short admissions but higher for prolonged admissions. Revisits within 30 days remained stable over time (18%).

Discussion

Establishing a multidisciplinary tracheostomy team results in improvements in quality metrics when caring for children with tracheostomies. Controlling for associated factors showed the mean length of stay decreased significantly in the first full year of program implementation. Cost analysis estimated significant reductions for tracheostomy patients spending less time in the hospital.

Implications for Practice

A airway management program can positively affect tracheostomy processes and outcomes.

Pediatric Tracheostomy-Related Complications: A Cross-sectional Analysis

OBJECTIVE

To determine the rate of tracheostomy-related complications in pediatric patients from nationally representative databases.

STUDY DESIGN

Cross-sectional analysis.

SETTING

2016 Kids' Inpatient Database and 2016 Nationwide Readmission Database.

METHODS

All pediatric tracheostomy procedures were included. Complication type, admission outcomes, and readmission rates were recorded with a logistic regression analysis to determine patient characteristics associated with complications.

RESULTS

An estimated 5309 tracheostomies were performed among pediatric patients in 2016, 8% (n = 432) of whom developed tracheostomy-related complications. This group was younger (4.7 vs 8.7 years, P < .001) and required longer hospital admissions (68.7 vs 33.2 days, P < .001) than children without tracheostomy-related complications. Mean costs ($459,324 vs $397,937, P < .001) and mean total charges ($1,573,964 vs $1,099,347, P < .001) were increased if a tracheostomy-related complication occurred. These events occurred more often in those with bronchopulmonary dysplasia (24% vs 12%, P < .001), heart disease (24% vs 12%, P = .001), gastroesophageal reflux disease (31% vs 19%, P < .001), short gestational age (24% vs 14%, P < .001), and subglottic stenosis (9.9% vs 5.4%, P = .001). The estimated 30-day readmission rate was 24% (SE, 1.7%) but did not increase after tracheostomy complications (27% vs 15%, P = .04). Tracheostomy-related complications were predicted by gastroesophageal reflux disease (odds ratio [OR], 1.50; 95% CI, 1.14-1.97; P = .004), younger age (OR, 1.12; 95% CI, 1.04-1.22; P = .002), and lengthier hospitalization (OR, 1.00; 95% CI, 1.00-1.01; P < .001) on multiple logistic regression analysis.

CONCLUSION

Tracheostomy-related complications occur in approximately 8% of pediatric patients and are higher in younger children or those with longer admission lengths. These data have implications for benchmarking standards of posttracheostomy complications across institutions.

Validation of the Seattle Suprastomal Safety Score (5S): A Novel Measure in Pediatric Tracheostomy-Dependent Patients

OBJECTIVE

Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an instrument with 2 domains: collapse and granulation.

STUDY DESIGN

Cross-sectional repeated testing survey.

SETTING

Electronic survey.

METHODS

A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains.

RESULTS

ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation.

CONCLUSION

The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients.

Comparing decannulation failures and successes in pediatric tracheostomy: An 18-year experience

OBJECTIVES

There is a paucity of published literature identifying patients at higher risk of decannulation failure. The purpose of this study is to evaluate patient factors that may predict successful decannulation of pediatric tracheostomy patients and analyze factors contributing to tracheostomy decannulation failures.

METHODS

A retrospective chart review of tracheostomy outcomes was conducted at a pediatric referral hospital. Successful and failed decannulations were compared using the following patient variables: age at tracheostomy, sex, ethnicity, gestational age and weight, the primary indication for tracheostomy, comorbidities, age at decannulation attempt, polysomnography data, and status of airway before decannulation as assessed endoscopically by airway team.

RESULTS

Four hundred thirty-nine tracheostomies were performed over the 18-year period with 173 decannulation attempts. The overall rate of successful decannulation on the first attempt was 91.9% (159 of 173), with an eventual decannulation success rate of 97.1% (168 of 173). Compared with failed decannulations, the patients with successful decannulations had a shorter duration of tracheostomy and no medical comorbidities. Gestational age and weight approached, but did not achieve, statistical significance. After 25 months with a tracheostomy, approximately 50% of patients are decannulated with very few decannulations occurring after 75 months. The overall mortality rate in this cohort was 18.6% (78 of 420) with a tracheostomy-related mortality rate of 0.95% (4 of 420).

CONCLUSIONS

The decannulation protocol at this institution is successful nearly 92% of the time. Fewer medical comorbidities, shorter duration of tracheostomy placement, and older gestational age may improve the likelihood of successful decannulation. Future studies are needed to determine the optimal timing and workup to evaluate patients for decannulation.

Early Tracheostomy Change in Neonates: Feasibility and Benefits

OBJECTIVES

To compare outcomes of early and late tracheostomy change in neonatal patients. Early tracheostomy change (ETC) occurred 3 to 4 days after surgery, and late tracheostomy change (LTC) occurred 5 to 7 days after surgery.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary neonatal/pediatric intensive care unit.

METHODS

A retrospective review of patients who underwent tracheostomy from 2015 to 2019 was performed for infants <1 year old. Data were recorded regarding age at tracheostomy, days until tracheostomy tube change, postoperative complications, and total number of days on sedative or paralytic drugs.

RESULTS

Forty-six patients were included: 18 (39%) were male, with a mean age of 140 days (SD, 78). Of these, 28 (61%) received ETC. There were no accidental decannulation events in either group. Wound breakdown developed in 4 (14%) patients with ETC versus 5 (28%) with LTC (P = .3). Use of FlexTend tracheostomy tubes was associated with decreased odds of breakdown (odds ratio, 0.03; P = .01). Postoperatively, 46 (100%) patients received sedation, and 12 (26%) received paralysis. Mean duration of paralysis was 0.5 days in ETC as opposed to 2.2 days in LTC (P = .02) on univariate analysis, but the significance was not maintained on multivariate regression (P = .07).

CONCLUSIONS

ETC appears to be feasible in children less than a year of age. There does not appear to be an increased risk of accidental decannulation events or false passage tracts. Further investigations are warranted to investigate safety and possible impact on wound breakdown.

Using Narratives to Correct Forecasting Errors in Pediatric Tracheostomy Decision Making

PURPOSE

Parents who face goals-of-care tracheostomy decisions may lack an understanding of challenges affecting their child's and family's long-term quality of life (QOL) to accurately forecast possible outcomes for decision making. We sought to examine whether and how parents' narratives of the child's and family's long-term QOL influence parental tracheostomy decisions and forecasting.

METHOD

We recruited US adult Amazon Mechanical Turk participants (N = 1966) who self-reported having a child (<6 y old) or planning a pregnancy within 5 y. Participants read a vignette about making a tracheostomy decision for their hypothetical neurologically impaired baby. They were randomized to 1 of the following 4 conditions: 1) Baby QOL narratives, 2) Family QOL narratives, 3) Baby QOL + Family QOL narratives, and 4) control: no narratives. They then made a decision about whether or not to pursue tracheostomy, forecasted their concerns about the baby's and family's QOL, reported their values and social norm beliefs about tracheostomy, comfort care, and parental medical decision making, and completed individual differences scales and demographics.

RESULTS

Controlling for individual characteristics, participants in the Baby QOL and Baby QOL + Family QOL conditions were less likely to choose tracheostomy as compared with the control (odds ratio [OR] = 0.38 and 0.25, respectively, P < 0.001). Fewer participants in the Family QOL condition chose tracheostomy compared with the control, but this difference was not statistically significant (OR = 0.70, P = 0.11). Moreover, narratives increased pessimistic forecasting, which was associated with less interest in tracheostomy.

CONCLUSION

Narratives clarifying long-term implications of pursuing tracheostomy have the potential to influence forecasting and decisions. Narrative-based interventions may be valuable in other situations in which forecasting errors are common.

The Impact of Socioeconomic Status on Time to Decannulation Among Children With Tracheostomies

OBJECTIVE

To determine if time to tracheostomy decannulation differs among children by socioeconomic status.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary pediatric medical center.

METHODS

Patients (≤21 years old) who underwent tracheostomy from January 1, 2011, to December 31, 2016. Patients were divided into 2 groups based on their socioeconomic status (SES), low SES and high SES. Principal components analysis was used to create an index for SES using census data obtained by the US Census Bureau's American Community Survey 5 year data profile from 2013 to 2017. Statistical analysis was performed using a χ² for categorical variables and Wilcoxon rank-sum test for continuous variables. A general linear model was constructed to control for clinical factors to understand the independent effect of SES on time to decannulation.

RESULTS

In total, 215 patients were included; of these patients, 111 patients (52%) were included in the high-SES group and 104 patients (48%) were included in the low-SES group. There was a significant difference in the time to decannulation for children based on SES status, with those children in the low-SES group taking on average 10 months longer to decannulate (38.7 vs 28.0 months, P = .0007). Median follow-up was 44.1 months (interquartile range, 29.6-61.3 months).

CONCLUSION

Health care disparities appear to exist among children undergoing decannulation of their tracheostomy tube. Patients with lower SES had a significantly longer time to decannulation than those with higher SES.

Transition From an ICU Ventilator to a Portable Home Ventilator in Children

BACKGROUND

The transition from an ICU ventilator to a portable home ventilator (PHV) for children requiring long-term mechanical ventilation is a crucial step in preparing for discharge home and may not be successful on the first attempt. A review of this process at our institution revealed that some children required multiple trials before they were able to tolerate a PHV. A protocol was developed to standardize the transition process and reduce the number of failed attempts. Key features of the protocol included a transition readiness assessment and criteria for changing to the PHV.

METHODS

A retrospective chart review was completed to evaluate the process of changing to a PHV before and after the protocol was in place during the time period of 2011-2018. Primary outcome measures included the number of transition attempts and the length of time to achieve successful transition. A successful transition attempt was defined as the ability to tolerate a PHV for 14 d.

RESULTS

The study included 56 children ≤ 3 y old with a tracheostomy who required long-term ventilator support. The majority of subjects were from the neonatal ICU and had a diagnosis of bronchopulmonary dysplasia. There was a significant decrease in the number of attempts (P = .005) and in the length of time (P = .01) to successfully transition to a PHV for those who underwent the protocol.

CONCLUSIONS

The process of changing from an ICU ventilator to a PHV in children requiring long-term mechanical ventilation was improved through the use of a standardized protocol. Both the number of failed attempts and the length of time to achieve successful transition were reduced when the protocol was applied. Further study is needed to evaluate other medical and nonmedical factors that may affect successful transition to a PHV.

Disparities and ethical considerations for children with tracheostomies during the COVID-19 pandemic

The COVID-19 pandemic is exacerbating longstanding challenges facing children with tracheostomies and their families. Myriad ethical concerns arising in the long-term care of children with tracheostomies during the COVID-19 pandemic revolve around inadequate access to care, healthcare resources, and rehabilitation services. Marginalized communities such as those from Black and Hispanic origins face disproportionate chronic illness because of racial and other underlying disparities. In this paper, we describe how these disparities also present challenges to children who are technology-dependent, such as those with tracheostomies and discuss the emerging ethical discourse regarding healthcare and resource access for this population during the pandemic.

Epidemiology of Pediatric Tracheostomy and Risk Factors for Poor Outcomes: An 11-Year Single-Center Experience

OBJECTIVE

Children with long-term tracheostomies are at higher risk of complications. This study aims to describe the epidemiology, outcomes, and factors associated with successful decannulation in children undergoing tracheostomy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary hospital.

SUBJECTS AND METHODS

A retrospective analysis was conducted on pediatric tracheostomies performed from 2006 to 2016. Demographics, preexisting comorbidities, indications for tracheostomy, and pretracheostomy ventilatory requirements were collected. A multivariate regression model with covariates of age, failure to thrive (FTT), and comorbidities was used to identify factors associated with successful decannulation. Secondary outcomes were ventilation and oxygen requirements at hospital discharge, hospital and intensive care unit length of stay, and complications.

RESULTS

In total, 105 patients received a tracheostomy at a median age of 8.0 months (interquartile range, 2.0-45.0). The most common indication was anatomic airway obstruction (55 of 105, 52.5%). Forty-four (41.9%) patients had preexisting FTT. In-hospital mortality was 14 of 105 (13.3%). None were directly related to tracheostomy. At discharge, 40 of 91 (44.0%) and 12 of 91 (13.2%) required home mechanical ventilation and supplemental oxygen, respectively. Forty-one (39%) patients underwent successful decannulation at a median 408 days (interquartile range, 170-1153) posttracheostomy. On adjusted analysis, unsuccessful decannulation was more common in patients with FTT and neurologic comorbidities. Postoperative complications were more common in younger patients and those with a longer time to decannulation.

CONCLUSION

Neurologic comorbidities and FTT were risk factors for unsuccessful decannulation after pediatric tracheostomy. Nutritional interventions may have a role in improving long-term outcomes following pediatric tracheostomies and should be investigated in future studies.

Boot Camp for Caregivers of Children With Medically Complex Conditions

BACKGROUND

The safe transition of children with complex medical conditions who are dependent on technology from hospital to home requires that caregivers receive specialized training from qualified health care professionals. Inadequate caregiver training can lead to discharge delays and hospital readmissions, often resulting in caregiver distress.

OBJECTIVE

To determine the effectiveness of a structured boot camp-style predischarge training program for caregivers of pediatric patients with complex medical conditions.

METHODS

We conducted a quasi-experimental interventional study to compare outcomes before and after implementation of the training program, which involved 34 caregivers. Pre-boot camp data were collected retrospectively from the medical records of 34 control patients.

RESULTS

After program implementation, statistically significant decreases were found in mean unit length of stay (92 vs 60 days; P = .02), mean discharge training days (60 vs 16 days; P < .001), and median total parental stress score, expressed as a percentile (49 vs 45; P < .001). More than 90% of caregiver participants were very satisfied with the program. On the basis of minimal length of stay limits, cost savings were estimated at between $53 300 and $69 900 per patient.

CONCLUSION

The results of this study indicate that the training program is a valuable tool to track and verify caregiver education, reduce hospital length of stay, increase caregiver satisfaction, decrease caregiver stress, and reduce medical costs.

Pediatric Tracheostomy Decannulation: 11-Year Experience

OBJECTIVE

To determine the successful decannulation rate with a published pediatric tracheostomy decannulation protocol.

STUDY DESIGN

Case series with chart review.

SETTING

A single tertiary care institution.

SUBJECTS AND METHODS

A chart review was performed for patients aged ≤5 years who underwent tracheostomy. Extracted data included demographic data, indication for tracheostomy, age at tracheostomy and decannulation, comorbidities, and surgical complications. Records were searched for documentation of early decannulation failure (within 1 month of decannulation) or late failure (within 1 year).

RESULTS

Forty patients with a tracheostomy aged ≤5 years underwent attempted decannulation during the 11-year study period. Seventeen patients were excluded from the study for documentation of nonprotocol decannulation. The final study population of 23 patients underwent a total of 27 decannulations, 26 of which were performed by protocol. Of the 26 protocol decannulations, 22 were successful, for a failure rate of 15%.

CONCLUSION

Twenty-six protocol decannulations were attempted among 23 patients, 4 of which were unsuccessful for an overall failure rate of 15%. This result is consistent with rates reported in other published decannulation protocols. We believe that our protocol minimizes resource utilization in its use of pulse oximetry over polysomnography, while maximizing patient safety and success through the use of capping trials for very young and very small pediatric patients.

The Financial Impact of a Hospital-Based Care Coordination Program for Children With Special Health Care Needs

Care coordination programs are important in caring for medically complex pediatric patients, particularly for children with special health care needs. This study is a retrospective financial analysis of a hospital-based care coordination program involving one procedural subgroup of children with special health care needs: those receiving pediatric tracheostomy. Hospital records were reviewed for patients who received a tracheostomy at a large Midwestern U.S. hospital from 1999 through 2015. The population was divided into two subgroups: patients who received a tracheostomy before the development of a care coordination program and patients who received a tracheostomy after enrollment in the care coordination program. Patient records were reviewed for length of stay, readmissions related to respiratory and tracheostomy management, and total hospital charges. Enrollment in a care coordination program for the pediatric tracheostomy patient resulted in a decrease in mean length of stay and reduced hospital charges and a slight increase in readmissions. Further analysis using larger sample sizes and multiple centers is necessary to determine whether such outcomes are the direct result of enrollment in a care coordination program.

Factors associated with successful decannulation in pediatric tracheostomy patients

OBJECTIVES

To investigate the outcome of pediatric tracheostomy and identify predictive factors for successful decannulation.

METHODS

We performed a retrospective chart review of a series of 42 consecutive patients of less than 24 months of age who underwent a tracheostomy between 2012 and 2015.

RESULTS

Successful decannulation was achieved in 11 patients (26%). Thirty-one patients (74%) remained tracheostomy-dependent. Of the 11 patients who were successfully decannulated, 10 (91%) had only structural disorders and nine (82%) were able to walk unassisted; importantly, nine (82%) were able to swallow following decannulation. In contrast, of the 31 patients who did not tolerate decannulation, 21 (68%) had functional disorders and 18 (58%) were unable to walk unassisted; 20 (65%) of the tracheostomy-dependent patients were unable to swallow after undergoing surgery.

CONCLUSION

Following pediatric tracheostomy procedures, patients with solely structural disorders were significantly more likely to be successfully decannulated compared to patients with functional disorders. Furthermore, the capacity to walk unassisted and swallow after surgery is associated with positive outcomes for decannulation. Our results suggest that an objective evaluation of the ability to walk unassisted, and to ingest food, may be useful for predicting the outcome and effects of tracheostomy procedures and decannulation in children.

Impact of functional status and medical comorbidities on tracheostomy decannulation in pediatric patients

To determine if medical or functional factors influence the ability of a pediatric patient with a tracheostomy to tolerate decannulation. Retrospective evaluation of patients at a tertiary Children's Hospital undergoing evaluation with capped tracheostomy polysomnogram (cPSG) for possible tracheostomy decannulation. Charts were reviewed for demographic information, functional status, cPSG characteristics, and success or failure of decannulation. Statistical analysis was performed to determine which patient factors were predictive of successful decannulation. A total of 139 sleep studies were analyzed in 104 unique children followed for at least 1 year after a cPSG was performed to determine readiness for decannulation. At 1 year after most recent PSG, 79.8% of children were decannulated. There was no significant association between any single comorbid condition and the ability to decannulate. There was no association between individual or total functional status score and successful decannulation. Patients with at least 3 comorbid conditions investigated and a total functional score less than 7 were less likely to be decannulated successfully than other patients (71% vs. 93%, p= 0.04). Functional status and comorbid conditions do not independently predict successful decannulation. Regular multi-disciplinary team reevaluation is indicated in patients with lower functional status, as removal of tracheostomy tube may be successfully accomplished.

[Pediatric tracheostomy: a ten-year analysis in the Intensive Care Unit of Sancti Spiritus “José Martí” Pediatric Teaching Hospital]

INTRODUCTION

There has been a significant change in the role of pediatric tracheostomy over the last twenty years. Obstruction of the upper airway caused by infectious agents is no longer the leading cause of tracheostomy in children. Structural anomalies of the upper airway as well as the need for prolonged ventilator assistance have become the most frequent indication for pediatric tracheostomy.

OBJECTIVE

The purpose of this paper is to assess the incidence, indications, complications, and role in mortality of tracheostomy in our pediatric population.

METHODS

A retrospective descriptive study of pediatric patients who underwent tracheostomy was conducted between 1999 and 2008 in the Pediatric Intensive Care Unit of the José Martí de Sancti Spiritus Pediatric Teaching Hospital in Cuba.

RESULTS

Tracheostomy was performed in 14 patients during the period of the study (0.5% of admitted patients). Nine of them (64.2%) were younger than one year. The most frequent indication for the procedure was the need for prolonged mechanical ventilation in patients with neurologic disorders in 10 patients (71.42%). Upper airway malformations and acute infections were infrequent indications for tracheostomy. The most frequent complications were infectious in 10 patients (71.4%) and obstruction in four patients (28.5%). The following germs were found: Pseudomona aeruginosa in six patients (60%), Staphylococcus aureus in three patients (30%), and Enterobacter cloacae in three patients (30%). Furthermore, four patients were successfully decannulated (28.5%), five patients died (35.7%) but only in one (7.14%), death could be attributed to tracheostomy.

CONCLUSION

The need for prolonged mechanical ventilation in patients with neurologic disorders was the main indication for tracheostomy in our pediatric population; most of these children were younger than one year. The procedure had little impact in overall mortality in this group of patients.