A quality study of family-centered care coordination to improve care for children undergoing tracheostomy and the quality of life for their caregivers

IMPORTANCE

Approximately 4000 U.S. children undergo tracheostomy yearly [1], and these surgeries often result in hospital re-admissions that have definite cost and caregiver burdens due to complications that are avoidable with proper training and support.

OBJECTIVE

To assess the impact of a Family-Centered Care Coordination (FCCC) program on the quality of care received by children undergoing tracheostomy and their caregivers.

DESIGN

Caregivers of children undergoing tracheostomies from January 2012 to January 2013 and then a different set of caregivers of children undergoing tracheostomies from January 2015 to January 2016 completed both the Pediatric Tracheostomy Health Status Instrument (PTHSI) 1 month after discharge and the Medical Complications Associated with Pediatric Tracheostomy (MCAT) questionnaire 6 months after initial tracheostomy. To assess complication rates, these same sets of caregivers were asked to complete the MCAT and only those who provided complete medical data for all 6 months were included for comparative analysis.

SETTING

The PTHSI and MCAT were administered at Massachusetts Eye and Ear in a hospital setting.

PARTICIPANTS

Ten caregivers of children undergoing tracheostomies completed the PTHSI before FCCC program implementation and12 caregivers then completed the PTHSI after FCCC implementation. For each of the 2 groups, 5 caregivers provided complete data on the MCAT questionnaires.

EXPOSURES

FCCC is a collection of programs, policies, and tools designed to ensure safe transition home for children undergoing tracheostomies, reduce re-admission rates, and minimize "caregiver burden".

MAIN OUTCOMES AND MEASURES

The PTHSI is a validated caregiver quality of life instrument that was supplemented by the MCAT which records post-discharge medical issues following tracheostomy that relate specifically to the tracheotomy placement.

RESULTS

The time to first follow-up appointment decreased from 6.4 weeks (SD = 1.52) to 6 days (SD = 0.18) with FCCC implementation. The total MCAT scores decreased from 15.2 (SD = 1.1) to 1.3 (SD = 1.3) (Wilcoxon sum rank test: P < 0.016) whereas neither PTHSI scores (P = 0.32) nor the specific caregiver burden domain (P = 0.18) demonstrated a significant change.

CONCLUSIONS

and Relevance: By reducing the time to first follow-up after tracheostomy and by optimizing caregiver tracheostomy tube care and teaching, children's quality of care and caregiver burden can be significantly improved.

Assessment of the feeding Swallowing Impact Survey as a quality of life measure in children with laryngeal cleft before and after repair

OBJECTIVE

To cross-validate the Feeding Swallowing Impact Survey (FSIS), a quality of life instrument, specifically to a subpopulation of children who aspirate due to laryngeal cleft.

INTRODUCTION

The FSIS is a recently validated instrument used to describe caregiver quality of life (QOL) in children with aspiration due to various causes. To cross-validate the FSIS specifically to the subpopulation of children who aspirate due to laryngeal cleft, we tested the hypotheses that caregivers would report significant different scores form baseline if their children improved at the one year mark postintervention due to either successful conservative or surgical measures (discriminant validity) and would not report significant differences in their FSIS reporting if there was no change in their child's aspiration at the one year mark post intervention (convergent validity).

METHODS

The FSIS was administered to the caregivers of 35 children (19 male, 16 female; age range: 5-79 months) who aspirate secondary to known laryngeal cleft (diagnosed by suspension laryngoscopy and inspection). All children had a baseline VFSS demonstrating aspiration and documenting what feeding plan to follow and caregivers completed the FSIS at this point as well. All children regardless of whether they were treated by conservative or surgical intervention underwent a follow-up VFSS at the one year post-intervention mark and the caregivers completed a FSIS at this time point as well.

RESULTS

Among two distinct sub-populations of children who underwent either successful conservative or surgical treatment for their laryngeal cleft and demonstrated improvement at the one year mark (as defined by a VFSS documented decreased need for thickener by at least one consistency or more) and where we hypothesized that FSIS scores would not be significantly different, the caregivers reported no significant differences in FSIS scores cleft repair (mean FSIS scores 2.45 (SD 0.88)/2.1 (SD 0.94); p = 0.28). Moreover, as another test to convergent validity, for children who underwent either unsuccessful conservative treatment (and subsequently went on to need surgery) or who were not successfully surgically treated for their laryngeal cleft and demonstrated no significant improvement at the one year mark (as defined by a VFSS documented decreased need for thickener by at least one consistency or more), the caregivers reported no significant differences in FSIS scores cleft repair (mean FSIS scores 2.8(SD 0.79)/2.5(SD 0.88); p = 0.69). For divergent validity, two distinct sub-populations of children who underwent either successful or not successful surgical treatment for their laryngeal cleft (demonstrated by either improvement or lack of improvement at the one year mark VFSS as defined by a decreased need for thickener by at least one consistency or more) revealed significant differences in caregiver FSIS scores cleft repair (mean FSIS scores 1.38 (SD 0.32); 32.8 (SD 0.79); p=<0.0002).

DISCUSSION

This results of this study provide convergent and divergent validity supporting the cross-validation of the FSIS instrument to be utilized as a validated QOL instrument to evaluate children with aspiration specifically due laryngeal cleft as another tool with which to evaluate the outcomes of medical or surgical interventions for this disorder.

PD-L1 expression and CD8+ infiltration shows heterogeneity in juvenile recurrent respiratory papillomatosis

INTRODUCTION

Tumor immunotherapy have broadened therapeutic options for tumor treatment. The role of immune function in juvenile recurrent respiratory papillomatosis (JRRP) has not been investigated. Applying immunoblockade inhibitors as a novel disease treatment is unclear. Our study, for the first time, evaluates immune infiltration and immuno-suppressive molecule expression in JRRP. Our study provides insights in possibly treating this disease with tumor immunotherapies. We aimed to determine expression of programmed death-ligand 1 (PD-L1), a cancer escape protein, and presence of CD8+ T cell infiltration in tumor microenvironment.

MATERIAL AND METHODS

Seven patients with JRRP (mean age: 7.43; age range 3-17) in this study routinely have their tumors surgical debulked at Massachusetts Eye and Ear Infirmary. Following surgery, samples were de-identified and sent to pathology where they were stained and analyzed.

RESULTS

Six out of seven patients expressed PD-L1 on tumor cells to various extents. Three patients showed concurrent PD-L1 expression on tumor cells and abundant CD8+ tumor infiltrating lymphocytes as well as PD-L1+ stromal lymphocytes, while PD-L1 expression on tumor cells were not associated with CD8+ tumor infiltrating T cells nor PD-L1+ stromal lymphocytes in the other three patients. HPV 6/11 and p16 was detected in all the patients. There appeared to be no correlation between either PD-L1 expression and CD8+ infiltration and clinical severity as measured by both the number of surgeries per year or Derkay score.

CONCLUSIONS

Despite a small cohort, the expression of p16 and HPV 6/11 in all of the patients confirms the tissues were HPV tumor cells. PD-L1 expression was detected in the vast majority of tumor samples, while inflammatory cell compartments showed a higher degree of variation. Expression of PD-L1 on tumor cells but not inflammatory cells raises the possibility of a tumor cell intrinsic manner of PD-L1 expression. In contrast, a group of patients showed PD-L1 positivity in both tumor and inflammatory cells along with abundant CD8+ tumor infiltrating lymphocytes, suggesting adoptive immune resistance in these tumors and potential benefits from tumor immunotherapy.

Radiation exposure from videofluoroscopic swallow studies in children with a type 1 laryngeal cleft and pharyngeal dysphagia: A retrospective review

INTRODUCTION

Radiation exposure is recognized as having long term consequences, resulting in increased risks over the lifetime. Children, in particular, have a projected lifetime risk of cancer, which should be reduced if within our capacity. The objective of this study is to quantify the amount of ionizing radiation in care for children being treated for aspiration secondary to a type 1 laryngeal cleft. With this baseline data, strategies can be developed to create best practice pathways to maintain quality of care while minimizing radiation exposure.

METHODS

Retrospective review of 78 children seen in a tertiary pediatric aerodigestive center over a 5 year period from 2008 to 2013 for management of a type 1 laryngeal cleft. The number of videofluoroscopic swallow studies (VFSS) per child was quantified, as was the mean effective dose of radiation exposure. The 78 children reviewed were of mean age 19.9 mo (range 4 mo-12 years). All children were evaluated at the aerodigestive center with clinical symptomatology and subsequent diagnosis of a type 1 laryngeal cleft. Aspiration was assessed via VFSS and exposure data collected. Imaging exams where dose parameters were not available were excluded.

RESULTS

The mean number of VFSS each child received during the total course of treatment was 3.24 studies (range 1-10). The average effective radiation dose per pediatric VFSS was 0.16 mSv (range: 0.03 mSv-0.59 mSv) per study. Clinical significance was determined by comparison to a pediatric CXR. At our facility a CXR yields an effective radiation dose of 0.017 mSv. Therefore, a patient receives an equivalent total of 30.6 CXR over the course of management.

CONCLUSIONS

Radiation exposure has known detrimental effects particularly in pediatric patients. The total ionizing radiation from VFSS exams over the course of management of aspiration has heretofore not been reported in peer reviewed literature. With this study's data in mind, future developments are indicated to create innovative clinical pathways and limit radiation exposure.

Quality improvement utilizing in-situ simulation for a dual-hospital pediatric code response team

OBJECTIVE

Given the rarity of in-hospital pediatric emergency events, identification of gaps and inefficiencies in the code response can be difficult. In-situ, simulation-based medical education programs can identify unrecognized systems-based challenges. We hypothesized that developing an in-situ, simulation-based pediatric emergency response program would identify latent inefficiencies in a complex, dual-hospital pediatric code response system and allow rapid intervention testing to improve performance before implementation at an institutional level.

METHODS

Pediatric leadership from two hospitals with a shared pediatric code response team employed the Institute for Healthcare Improvement's (IHI) Breakthrough Model for Collaborative Improvement to design a program consisting of Plan-Do-Study-Act cycles occurring in a simulated environment. The objectives of the program were to 1) identify inefficiencies in our pediatric code response; 2) correlate to current workflow; 3) employ an iterative process to test quality improvement interventions in a safe environment; and 4) measure performance before actual implementation at the institutional level.

RESULTS

Twelve dual-hospital, in-situ, simulated, pediatric emergencies occurred over one year. The initial simulated event allowed identification of inefficiencies including delayed provider response, delayed initiation of cardiopulmonary resuscitation (CPR), and delayed vascular access. These gaps were linked to process issues including unreliable code pager activation, slow elevator response, and lack of responder familiarity with layout and contents of code cart. From first to last simulation with multiple simulated process improvements, code response time for secondary providers coming from the second hospital decreased from 29 to 7 min, time to CPR initiation decreased from 90 to 15 s, and vascular access obtainment decreased from 15 to 3 min. Some of these simulated process improvements were adopted into the institutional response while others continue to be trended over time for evidence that observed changes represent a true new state of control.

CONCLUSIONS

Utilizing the IHI's Breakthrough Model, we developed a simulation-based program to 1) successfully identify gaps and inefficiencies in a complex, dual-hospital, pediatric code response system and 2) provide an environment in which to safely test quality improvement interventions before institutional dissemination.

International Pediatric Otolaryngology Group (IPOG) consensus recommendations: Routine peri-operative pediatric tracheotomy care

OBJECTIVES

To develop consensus recommendations for peri-operative tracheotomy care in pediatric patients.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group.

RESULTS

Consensus recommendations including pre-operative, intra-operative, and post-operative considerations, as well as sedation and nutrition management are described. These recommendations are based on the collective opinion of the IPOG members and are targeted to (i) otolaryngologists who perform tracheotomies on pediatric patients, (ii) intensivists who are involved in the shared-care of these patients, and (iii) allied health professionals.

CONCLUSION

Pediatric peri-operative tracheotomy care consensus recommendations are aimed at improving patient-centered care in this patient population.

International Pediatric ORL Group (IPOG) laryngomalacia consensus recommendations

OBJECTIVE

To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia.

METHODS

Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG).

RESULTS

Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy.

CONCLUSION

Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.

Identification of distinct layers within the stratified squamous epithelium of the adult human true vocal fold

OBJECTIVES/HYPOTHESIS

A precise molecular schema for classifying the different cell types of the normal human vocal fold epithelium is lacking. We hypothesize that the true vocal fold epithelium has a cellular architecture and organization similar to that of other stratified squamous epithelia including the skin, cornea, oral mucosa, and esophagus. In analogy to disorders of the skin and gastrointestinal tract, a molecular definition of the normal cell types within the human vocal fold epithelium and a description of their geometric relationships should serve as a foundation for characterizing cellular changes associated with metaplasia, dysplasia, and cancer.

STUDY DESIGN

Qualitative study with adult human larynges.

METHODS

Histologic sections of normal human laryngeal tissue were analyzed for morphology (hematoxylin and eosin) and immunohistochemical protein expression profile, including cytokeratins (CK13 and CK14), cornified envelope proteins (involucrin), basal cells (NGFR/p75), and proliferation markers (Ki67).

RESULTS

We demonstrated that three distinct cell strata with unique marker profiles are present within the stratified squamous epithelium of the true vocal fold. We used these definitions to establish that cell proliferation is restricted to certain cell types and layers within the epithelium. These distinct cell types are reproducible across five normal adult larynges.

CONCLUSION

We have established that three layers of cells are present within the normal adult stratified squamous epithelium of the true vocal fold. Furthermore, replicating cell populations are largely restricted to the parabasal strata within the epithelium. This delineation of distinct cell populations will facilitate future studies of vocal fold regeneration and cancer.

LEVEL OF EVIDENCE

N/A.

Quantitative distinction of unique vocal fold subepithelial architectures using optical coherence tomography

OBJECTIVES

The primary objective of this study was to quantitatively analyze ex vivo porcine, fetal human, and adult human vocal folds by use of optical coherence tomography (OCT). A secondary objective was to quantitatively discriminate among 1-, 2-, and 3-layer lamina propria structures.

METHODS

We performed an analysis of the vocal folds of 10 adult pig, 3 adult human, and 2 fetal human vocal fold specimens using OCT and histologic techniques. We present a quantitative comparison of the OCT results and histologic findings.

RESULTS

We found that OCT allowed for the visualization of the subepithelial vocal fold architecture of all imaged tissue, and that it revealed distinct characteristic signal intensities for each type of specimen.

CONCLUSIONS

Optical coherence tomography was developed for in vivo imaging of biological microstructures. This study demonstrates the ability of OCT to differentiate between the vocal fold architectures of 3 histologically distinct types of vocal folds. Future studies aim to develop a quantitative optical imaging algorithm that can be used to facilitate an in vivo longitudinal clinical investigation of the changes that occur in this layered structure over time and maturation.

Clinical consensus statement: tracheostomy care

OBJECTIVE

This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications.

METHODS

A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed.

RESULTS

The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs.

CONCLUSION

The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy.

Severe glottic stenosis in a parturient with ectodermal dysplasia

Airway stenosis in pregnancy is challenging and the literature does not offer consensus regarding its evaluation and anesthetic management. A 21-year-old nulliparous woman with ectodermal dysplasia and severe glottic stenosis was referred to the obstetric anesthesia team for evaluation and peripartum management recommendations. She had a history of a congenital complete glottic web that required a tracheostomy at birth. After decannulation at age four, she was lost to follow-up. On examination in early pregnancy, she was found to have a dangerously narrow airway with fixed vocal cords and a glottic aperture of 2-3mm. At nine weeks of gestation an elective tracheostomy was performed under local anesthesia. She later underwent an uneventful cesarean delivery under spinal anesthesia. Ultimately, early interdisciplinary planning for an elective tracheostomy helped assure patient safety during advancing pregnancy and delivery.

Pediatric paradoxical vocal-fold motion: presentation and natural history

OBJECTIVES

To describe (1) a cohort of children with paradoxical vocal-fold motion (PVFM) who were referred to a multidisciplinary airway center and (2) the outcomes of various treatment modalities including speech therapy, gastroesophageal reflux disease treatment, and psychiatric treatment.

PATIENTS AND METHODS

This was a case series with chart review of children younger than 18 years with PVFM evaluated at a tertiary care pediatric airway center over a 36-month period.

RESULTS

Fifty-nine children with PVFM were evaluated. The cohort had a mean age of 13.64 years (range: 8-18 years) and a female-to-male ratio of 3:1. Speech therapy as an initial treatment resulted in a 63% (24 of 38) success rate after an average of 3.7 treatment sessions. Speech therapy was a more successful treatment than antireflux therapy (P = .001). Ten percent (6 of 59) of the children presented with a known psychiatric diagnosis, and 30% (18 of 59) of children in the cohort were ultimately diagnosed with a psychiatric condition. Children with inspiratory stridor at rest had a lower initial success rate with speech therapy (56%), a higher rate of underlying psychiatric disorders (75%), and a high rate of success after psychiatric treatment (100%) that required, on average, 3 sessions over a 2-month period.

CONCLUSIONS

To our knowledge, this is the largest study to date on pediatric PVFM. The majority of children with PVFM improve with speech therapy. Children with PVFM at rest may be better treated with psychiatric therapy than speech therapy. Furthermore, children who present with symptoms at rest may have a higher likelihood of underlying psychiatric disease.

Pediatric laryngeal diadochokinetic rates: establishing a normative database

OBJECTIVE

Laryngeal diadochokinetic (L-DDK) rate is a measure of laryngeal neural integrity. The objectives for this study included the following: (1) establish the first comprehensive pediatric normative database for L-DDK rates (DDK) using the Voice Evaluation Suite, a computerized voice analysis program; and (2) analyze normal L-DDK rates for age and gender differences.

STUDY DESIGN

Cross-sectional study with planned data collection.

SETTING

Outpatient pediatric otolaryngology clinic.

SUBJECTS AND METHODS

Three hundred seven children aged 4 to 18 with normal voices. L-DDK rates were collected during a 6-month period. Main outcome measures included age, gender, and L-DDK rates.

RESULTS

Three hundred seven children (151 girls and 156 boys) were evaluated. There was no statistically significant difference between the overall mean L-DDK rate of boys (2.69 syllables/s) compared to girls (2.55 syllables/s; P > .05). Further analysis of all individual age groups did not reveal any statistical significance between boys and girls. There was a statistically significant difference among children aged 4 to 11 compared to those 12 to 18 years old. Among boys aged 4 to 11, the mean rate was 2.49 syllables per second, whereas among 12- to 18-year-olds, the rate was 2.95 syllables per second (P < .01). The mean rate was 2.40 syllables per second among girls aged 4 to 11 and 2.74 syllables per second for those aged 12 to 18 (P < .01).

CONCLUSION

This is the largest normative pediatric L-DDK analysis in the English literature. The findings suggest that neurolaryngeal development approaches adult maturation at the beginning of the teenage years. These data have the potential application for objective measurement of neurolaryngeal coordination in children with neurologic impairment and also in children who have undergone nerve reinnervation procedures.

MRI with synchronized audio to evaluate velopharyngeal insufficiency

OBJECTIVE

To demonstrate the feasibility of simultaneous-acquired magnetic resonance imaging (MRI) and high-quality synchronized audio recording for evaluating velopharyngeal closure.

DESIGN

Institutional Review Board-approved case series.

SETTING

Tertiary care hospital.

PATIENTS

Three healthy adult volunteers with a normal speech pattern.

INTERVENTIONS

MRI with simultaneous recorded audio files evaluating velopharyngeal closure.

MAIN OUTCOME MEASURE

Precise imaging and audio coordination of specific phonatory tasks.

RESULTS

Synchronization of MRI and audio in all three adults.

CONCLUSION

Our novel imaging and audio protocol provides simultaneous acquired MRI with synchronized high quality audio for evaluating velopharyngeal closure. This technique may provide the opportunity to improve diagnosis and surgical planning in patients with velopharyngeal insufficiency.

Prevalence of noise-induced hearing-threshold shifts and hearing loss among US youths

OBJECTIVE

We investigated trends in noise-induced threshold shifts (NITSs), high-frequency hearing loss (HFHL), and low-frequency hearing loss (LFHL).

METHODS

A total of 4310 adolescents 12 to 19 years of age completed audiometric testing during National Health and Nutrition Examination Surveys in 1988-1994 and 2005-2006. NITS criteria were audiometric patterns of decreased 3- to 6-kHz thresholds but preserved 0.5- to 1-kHz and 8-kHz thresholds; HFHL and LFHL criteria were high and low pure-tone averages, respectively, of >15 dB HL.

RESULTS

There were no significant increases in NITSs (odds ratio [OR]: 0.81 [95% confidence interval [CI]: 0.53-1.22]; P = .29), HFHL (OR: 1.21 [95% CI: 0.87-1.69]; P = .25), or LFHL (OR: 1.37 [95% CI: 0.77-2.45]; P = .28) between survey periods. However, a significant increase in the prevalence of NITSs occurred among female youths (11.6% [95% CI: 9.0%-14.1%] vs 16.7% [95% CI: 13.2%-20.3%]; P < .0001). The overall prevalence of exposure to loud noise or listening to music through headphones in the previous 24 hours increased from 19.8% (95% CI: 17.6%-22.1%) to 34.8% (95% CI: 31.0%-38.5%; P < .0001). In 2005-2006, female youths had a similar prevalence of exposure to recreational noise (23.6% [95% CI: 19.6%-27.6%] vs 27.7% [95% CI: 23.6%-31.8%]; P < .0001) and a lower prevalence of hearing-protection use (3.4% [95% CI: 1.6%-5.3%] vs 10.3% [95% CI: 7.3%-13.2%]; P < .0001) compared with male youths.

CONCLUSIONS

Increased exposure to recreational noise and minimal use of hearing protection might have lead to an increase in NITS prevalence among female youths.