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Sun J, Duncan S, Pal S, Kong M. Directed Acyclic Graph Assisted Method For Estimating Average Treatment Effect. J Biopharm Stat 2023:1-20. [PMID: 38151852 DOI: 10.1080/10543406.2023.2296047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/04/2023] [Indexed: 12/29/2023]
Abstract
Observational data, such as electronic clinical records and claims data, can prove invaluable for evaluating the Average Treatment Effect (ATE) and supporting decision-making, provided they are employed correctly. The Inverse Probability of Treatment Weighting (IPTW) method, based on propensity scores, has demonstrated remarkable efficacy in estimating ATE, assuming that the assumptions of exchangeability, consistency, and positivity are met. Directed Acyclic Graphs (DAGs) offer a practical approach to assess the exchangeability assumption, which asserts that treatment assignment and potential outcomes are independent given a set of confounding variables that block all backdoor paths from treatment assignment to potential outcomes. To ensure a consistent ATE estimator, one can adjust for a minimally sufficient adjustment set of confounding variables that block all backdoor paths from treatment assignment to the outcome. To enhance the efficiency of ATE estimators, our proposal involves incorporating both the minimally sufficient adjustment set of confounding variables and predictors into the propensity score model. Extensive simulations were conducted to evaluate the performance of propensity score-based IPTW methods in estimating ATE when different sets of covariates were included in the propensity score models. The simulation results underscored the significance of including the minimally sufficient adjustment set of confounding variables along with predictors in the propensity score models to obtain a consistent and efficient ATE estimator. We applied this proposed method to investigate whether tracheostomy was causally associated with in-hospital infant mortality, utilizing the 2016 Healthcare Cost and Utilization Project Kids' Inpatient Database. The estimated ATE was found to be approximately 2.30%-2.46% with p-value >0.05.
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Affiliation(s)
- Jingchao Sun
- Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky, USA
- Global Statistics and Data Science, Clinical Development and Regulatory, BeiGene, Beijing, China
| | - Scott Duncan
- Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Subhadip Pal
- Department of Analytics in the Digital Era, United Arab Emirates University, Abu Dhabi, United Arab Emirates
| | - Maiying Kong
- Department of Bioinformatics and Biostatistics, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky, USA
- Biostatistics Core, JG Brown Cancer Center, University of Louisville, Louisville, Kentucky, USA
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2
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Liu P, Brooks RL, Bailey CH, Whitney C, Sewell A, Brown AF, Kou YF, Johnson RF, Chorney SR. Survival After Declining Pediatric Tracheostomy Placement. Laryngoscope 2023; 133:3602-3607. [PMID: 37096735 DOI: 10.1002/lary.30712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
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.
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Affiliation(s)
- Palmila Liu
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Rebecca L Brooks
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Candice H Bailey
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Cindy Whitney
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Ashley Sewell
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Ashley F Brown
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology - Head & Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
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3
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Liu P, Teplitzky TB, Kou YF, Johnson RF, Chorney SR. Long-Term Outcomes of Tracheostomy-Dependent Children. Otolaryngol Head Neck Surg 2023; 169:1639-1646. [PMID: 37264977 DOI: 10.1002/ohn.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 03/29/2023] [Accepted: 05/13/2023] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Palmila Liu
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Taylor B Teplitzky
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
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Platt JM, Nettel-Aguirre A, Bjornson CL, Mitchell I, Davis K, Bailey JM. Multidisciplinary coordination of care for children with esophageal atresia and tracheoesophageal fistula. J Child Health Care 2023:13674935231174503. [PMID: 37224564 DOI: 10.1177/13674935231174503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Esophageal Atresia/Tracheoesophageal Atresia (EA/TEF) is a multisystem congenital anomaly. Historically, children with EA/TEF lack coordinated care. A multidisciplinary clinic was established in 2005 to provide coordinated care and improve access to outpatient care. This single-center retrospective cohort study was conducted to describe our cohort of patients with EA/TEF born between March 2005 and March 2011, assess coordination of care, and to compare outcomes of children in the multidisciplinary clinic to the previous cohort without a multi-disciplinary clinic. A chart review identified demographics, hospitalizations, emergency visits, clinic visits, and coordination of outpatient care. Twenty-seven patients were included; 75.9% had a C-type EA/TEF. Clinics provided multidisciplinary care and compliance with the visit schedule was high with a median of 100% (IQR 50). Compared to the earlier cohort, the new cohort (N = 27) had fewer hospital admissions and LOS was reduced significantly in the first 2 years of life. Multidisciplinary care clinics for medically complex children can improve coordination of visits with multiple health care providers and may contribute to reduced use of acute care services.
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Affiliation(s)
- Jody M Platt
- Department of Pediatrics, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alberto Nettel-Aguirre
- Department of Pediatrics, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Candice L Bjornson
- Department of Pediatrics, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Kathryn Davis
- Alberta Children's Hospital, Alberta Health Services, University of Calgary, Calgary, AB, Canada
| | - Ja Michelle Bailey
- Department of Pediatrics, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
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Salik I, Das A, Naftchi AF, Vazquez S, Spirollari E, Dominguez JF, Sukul V, Stewart D, Moscatello A. Effect of tracheostomy timing in pediatric patients with traumatic brain injury. Int J Pediatr Otorhinolaryngol 2023; 164:111414. [PMID: 36527981 DOI: 10.1016/j.ijporl.2022.111414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established. OBJECTIVE This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes. DESIGN/METHODS The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median = 9 days). RESULTS Of the 68,793 patients (mean age = 14, IQR 4-18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age = 16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p < 0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence. CONCLUSIONS Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.
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Affiliation(s)
- Irim Salik
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, 10595, USA.
| | - Ankita Das
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | | | - Sima Vazquez
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Eris Spirollari
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Vishad Sukul
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Dylan Stewart
- Department of Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Augustine Moscatello
- Department of Otolaryngology/Head and Neck Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
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6
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Newton M, Johnson RF, Wynings E, Jaffal H, Chorney SR. Pediatric Tracheostomy-Related Complications: A Cross-sectional Analysis. Otolaryngol Head Neck Surg 2021; 167:359-365. [PMID: 34520273 DOI: 10.1177/01945998211046527] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Micah Newton
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Erin Wynings
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Hussein Jaffal
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, Texas, USA
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7
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Herpes simplex laryngitis: Comparison between pediatric and adult patients. Int J Pediatr Otorhinolaryngol 2021; 142:110596. [PMID: 33434698 DOI: 10.1016/j.ijporl.2020.110596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Infection with herpes simplex virus (HSV) typically causes limited oral and genital symptoms, however HSV can also affect the larynx and result in severe aerodigestive symptoms. Due to the rarity of HSV laryngitis, the symptoms and clinical course of are not well understood. This study aims to more completely characterize HSV laryngitis in order to aid clinicians in understanding and recognition of HSV laryngitis. METHODS Comprehensive literature search of MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews to identify articles relating to HSV laryngitis. Patient demographics, presenting signs and symptoms, treatment and clinical course were extracted from the selected manuscripts. RESULTS There were 31 studies on HSV laryngitis that identified 36 patients (17 pediatric, 19 adult). The average age for pediatric patients was 11 months (9 M, 8F) and 52 years for adults (11 M, 8F). In the pediatric population, stridor was more common at presentation in comparison to the adult population (p < .01). Adults more commonly presented with dysphagia (p = .03) and dysphonia (p < .01) Adult patients were significantly more likely to undergo tracheotomy than pediatric patients (p = .047). The mean length of inpatient hospital stay was 21.2 days in pediatric patients and 15.8 days for adult patients. CONCLUSION HSV laryngitis has a unique presentation in pediatrics and adults, but is nonspecific in both populations leading to delays in diagnosis and treatment. HSV laryngitis is associated with significant morbidity including multi-week hospital stay and risk for needing tracheostomy in both adults and pediatric population which demonstrates need for clinical awareness of this complication of HSV infection.
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8
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Annesi CA, Levin JC, Litt JS, Sheils CA, Hayden LP. Long-term respiratory and developmental outcomes in children with bronchopulmonary dysplasia and history of tracheostomy. J Perinatol 2021; 41:2645-2650. [PMID: 34290373 PMCID: PMC8294252 DOI: 10.1038/s41372-021-01144-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/20/2021] [Accepted: 06/30/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The long-term morbidity among children with severe bronchopulmonary dysplasia who require tracheostomy (tBPD) relative to those without tracheostomy (sBPD) is not well characterized. We compared childhood lung function and neurodevelopmental outcomes in tBPD and sBPD. STUDY DESIGN Retrospective case-control study of N = 49 tBPD and N = 280 sBPD subjects in Boston Children's Hospital Preterm Lung Patient Registry and medical record. We compared NICU course, childhood spirometry, and neurodevelopmental testing. RESULT tBPD subjects were more likely than sBPD to be Black, have pulmonary hypertension, and have subglottic stenosis. tBPD subjects had lower maximal childhood FEV1 % predicted (β = -0.14) and FEV1/FVC (β = -0.08); spirometry curves were more likely to suggest fixed extrathoracic obstruction. tBPD subjects had greater cognitive and motor delays <24 months, and greater cognitive delays >24 months. CONCLUSION Compared to subjects with sBPD who did not require tracheostomy, tBPD subjects suffer from increased long-term impairment in respiratory function and neurodevelopment.
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Affiliation(s)
- Chandler A. Annesi
- grid.189504.10000 0004 1936 7558Boston University School of Medicine, Boston, MA USA
| | - Jonathan C. Levin
- grid.2515.30000 0004 0378 8438Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Jonathan S. Litt
- grid.2515.30000 0004 0378 8438Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Catherine A. Sheils
- grid.2515.30000 0004 0378 8438Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Lystra P. Hayden
- grid.2515.30000 0004 0378 8438Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Pediatrics, Harvard Medical School, Boston, MA USA ,grid.62560.370000 0004 0378 8294Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, MA USA
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9
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Karkoutli AA, Brumund MR, Evans AK. Bronchopulmonary dysplasia requiring tracheostomy: A review of management and outcomes. Int J Pediatr Otorhinolaryngol 2020; 139:110449. [PMID: 33157458 DOI: 10.1016/j.ijporl.2020.110449] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/10/2020] [Indexed: 12/27/2022]
Abstract
Bronchopulmonary Dysplasia (BPD) is a pulmonary disease affecting newborns, commonly those with prematurity or low birth weight. Its pathogenesis involves underdevelopment of lung tissue with subsequent limitations in ventilation and oxygenation, resulting in impaired postnatal alveolarization. Despite advances in care with improved survival, BPD remains a prevalent comorbidity of prematurity. In severe cases, management may involve mechanical ventilation via tracheostomy. BPD's demand for multidisciplinary care compounds the challenges in management of this condition. Here, we review existing literature: the history of disease, criteria for diagnosis, pathogenesis, and modes of treatment with a focus on the severe subtype: that which is associated with pulmonary hypertension (PAH) for which tracheostomy is often required to facilitate long-term mechanical ventilation. We review the current recommendations for tracheostomy and decannulation.
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Affiliation(s)
- Adam Ahmad Karkoutli
- Louisiana State University Health Sciences Center, School of Medicine, 533 Bolivar Street, New Orleans, LA, 70112, USA
| | - Michael R Brumund
- Pediatric Cardiology, Louisiana State University Health Sciences Center, Department of Pediatrics, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA; Children's Hospital New Orleans, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA
| | - Adele K Evans
- Pediatric Otolaryngology, Louisiana State University Health Sciences Center, Department of Otolaryngology - Head and Neck Surgery, 533 Bolivar Street, Suite 566, New Orleans, LA, 70112, USA; Children's Hospital New Orleans, 200 Henry Clay Avenue, New Orleans, LA, 70118, USA.
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10
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Mai K, Davis RK, Hamilton S, Robertson-James C, Calaman S, Turchi RM. Identifying Caregiver Needs for Children With a Tracheostomy Living at Home. Clin Pediatr (Phila) 2020; 59:1169-1181. [PMID: 32672065 DOI: 10.1177/0009922820941209] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study sought to understand caregiver needs of children with tracheostomies (CWT) living at home and inform development of standardized tracheostomy simulation training curricula. Long-term goals are decreasing hospital readmissions following tracheostomy placement and improving family experiences while implementing a medical home model. We recruited caregivers of CWT and conducted semistructured interviews, subsequently recorded, transcribed, and analyzed for emerging themes using NVivo. Demographic data were collected via quantitative surveys. Twenty-seven caregivers participated. Emerging themes included the following: (1) caregivers felt overwhelmed, sad, frightened when learning need for tracheostomy; (2) training described as adequate, but individualized training desired; (3) families felt prepared to go home, but transition was difficult; (4) home nursing care fraught with difficulty and yet essential for families of CWT. Families of CWT have specific needs related to discharge training, resources, support, and home nursing. Provider understanding of caregiver needs is essential for child well-being, patient-/family-centered care, and may improve health outcomes.
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Affiliation(s)
- Katherine Mai
- Drexel University, Philadelphia, PA, USA.,St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Sue Hamilton
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Sharon Calaman
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Renee M Turchi
- Drexel University, Philadelphia, PA, USA.,St. Christopher's Hospital for Children, Philadelphia, PA, USA
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11
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Windsor AM, Kiell EP, Sobol SE. Predictors of the need for tracheostomy in the neonatal intensive care unit. Int J Pediatr Otorhinolaryngol 2020; 135:110122. [PMID: 32485466 DOI: 10.1016/j.ijporl.2020.110122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Many infants in the neonatal intensive care unit (NICU) require prolonged periods of respiratory support. Microlaryngoscopy and bronchoscopy (MLB) is performed to evaluate for airway pathology and facilitate decision-making regarding further airway interventions or tracheostomy. The objectives of this study are to describe the operative findings of MLB performed on infants in the NICU and determine which pre-operative characteristics or operative findings are predictive of the need for tracheostomy. METHODS The medical records of preterm inpatients in the NICU at a single tertiary care hospital who underwent MLB between January 1, 2013 and January 7, 2016 were reviewed. Baseline and demographic characteristics and intra-operative findings were compared between patients who underwent tracheostomy and those who were successfully weaned from respiratory support. RESULTS Seventy-three preterm patients underwent MLB for respiratory failure, of whom 41 (56.2%) underwent tracheostomy. Patients who underwent tracheostomy had lower mean gestational age (27.4 vs. 30.5 weeks), higher prevalence of bronchopulmonary dysplasia (73.2% vs. 37.5%), lower mean birth weight (1.1 kg vs. 1.6 kg), and a greater number of extubation events (5.2 vs. 3.0) than those who weaned from respiratory support. Abnormal MLB findings were common in both groups, though no single MLB finding differed significantly between groups. CONCLUSIONS Preterm infants in the NICU with gestational age ≤30 weeks, birth weight <1.5 kg, severe pulmonary disease, and who have failed more than 3 extubation attempts are more likely to require tracheostomy.
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Affiliation(s)
- Alanna M Windsor
- Division of Otolaryngology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Eleanor P Kiell
- Department of Otolaryngology, Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Steven E Sobol
- Division of Otolaryngology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA; Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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12
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Abstract
Approximately half of all pediatric tracheostomies are performed in infants younger than 1 year. Most tracheostomies in patients in the NICU are performed in cases of chronic respiratory failure requiring prolonged mechanical ventilation or upper airway obstruction. With improvements in ventilation and management of long-term intubation, indications for tracheostomy and perioperative management in this population continue to evolve. Evidence-based protocols to guide routine postoperative care, prevent and manage tracheostomy emergencies including accidental decannulation and tube obstruction, and attempt elective decannulation are sparse. Clinician awareness of safe tracheostomy practices and larger, prospective studies in infants are needed to improve clinical care of this vulnerable population.
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Affiliation(s)
- Julia Chang
- Department of Otolaryngology, Head and Neck Surgery. Stanford University School of Medicine, Stanford, CA
| | - Douglas R Sidell
- Department of Otolaryngology, Head and Neck Surgery. Stanford University School of Medicine, Stanford, CA
- Stanford Pediatric Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford, CA
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13
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Han SM, Watters KF, Hong CR, Edwards EM, Knell J, Morrow KA, Soll RF, Jaksic T, Horbar JD, Modi BP. Tracheostomy in Very Low Birth Weight Infants: A Prospective Multicenter Study. Pediatrics 2020; 145:peds.2019-2371. [PMID: 32098788 DOI: 10.1542/peds.2019-2371] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In this study, we benchmark outcomes and identify factors associated with tracheostomy placement in infants of very low birth weight (VLBW). METHODS Data were prospectively collected on infants of VLBW (401-1500 g or gestational age of 22-29 weeks) born between 2006 and 2016 and admitted to 796 North American centers. Length of stay (LOS), mortality, associated surgical procedures, and comorbidities were assessed, and infants who received tracheostomy were compared with those who did not. Multivariable logistic regressions were performed to identify risk factors for tracheostomy placement and for mortality in those receiving tracheostomy. RESULTS Of 458 624 infants of VLBW studied, 3442 (0.75%) received tracheostomy. Infants with tracheostomy had a median (interquartile range) LOS of 226 (168-304) days and a mortality rate of 18.8%, compared with 58 (39-86) days and 8.3% for infants without tracheostomy. Independent risk factors associated with tracheostomy placement included male sex, birth weight <1001 g, African American non-Hispanic maternal race, chronic lung disease (CLD), intraventricular hemorrhage, patent ductus arteriosus ligation, and congenital neurologic, cardiac, and chromosomal anomalies. Among infants who received tracheostomy, male sex, birth weight <751 g, CLD, and congenital anomalies were independent predictors of mortality. CONCLUSIONS Infants of VLBW receiving tracheostomy had twice the risk of mortality and nearly 4 times the initial LOS of those without tracheostomy. CLD and congenital anomalies were the strongest predictors of tracheostomy placement and mortality. These benchmark data on tracheostomy in infants of VLBW should guide discussions with patient families and inform future studies and interventions.
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Affiliation(s)
- Sam M Han
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | - Karen F Watters
- Department of Otolaryngology and Communication Enhancement, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Charles R Hong
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | - Erika M Edwards
- University of Vermont, Burlington, Vermont; and.,Vermont Oxford Network, Burlington, Vermont
| | - Jamie Knell
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | | | - Roger F Soll
- University of Vermont, Burlington, Vermont; and.,Vermont Oxford Network, Burlington, Vermont
| | - Tom Jaksic
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
| | - Jeffrey D Horbar
- University of Vermont, Burlington, Vermont; and.,Vermont Oxford Network, Burlington, Vermont
| | - Biren P Modi
- Department of Surgery and Center for Advanced Intestinal Rehabilitation, and
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14
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Wang CS, Kou YF, Shah GB, Mitchell RB, Johnson RF. Tracheostomy in Extremely Preterm Neonates in the United States: A Cross-Sectional Analysis. Laryngoscope 2019; 130:2056-2062. [PMID: 31532845 DOI: 10.1002/lary.28304] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 07/30/2019] [Accepted: 08/27/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS Bronchopulmonary dysplasia (BPD) and invasive respiratory support is increasing among extremely preterm neonates. Yet, it is unclear if there is a corresponding increase in tracheostomies. We hypothesize that in extremely preterm neonates with BPD, the incidence of tracheostomy has increased. STUDY DESIGN Retrospective cross-sectional analysis. METHODS We analyzed the 2006 to 2012 Kids' Inpatient Databases (KID) for hospital discharges of nonextremely preterm neonates (gestational age >28 weeks and <37 weeks or birth weight >1,500 g) and extremely preterm neonates (gestational age ≤28 weeks or birth weight ≤1,500 g). We studied tracheostomy placement trends in these two populations to see if they are increasing among extremely preterm neonates, especially those with BPD. RESULTS The study included 1,418,681 preterm neonates (52% male, 50% white, 19% black, 20% Hispanic, 4.2% Asian), of whom 118,676 (8.4%) were extremely preterm. A total of 2,029 tracheostomies were performed, of which 803 (0.68%) were in extremely preterm neonates. The estimated percent change of occurrence of extremely preterm neonates with BPD increased 17% between 2006 and 2012, and tracheostomy placement increased 31%. Amongst all who received tracheostomies, mortality rate was higher in extremely preterm neonates compared to nonextremely preterm neonates (18% vs. 14%, P = .05). However, in extremely preterm neonates, those with tracheostomies had a lower mortality rate compared to those without (18% vs. 24%, P = .002). CONCLUSIONS Extremely preterm neonates, compared to nonextremely preterm neonates, experienced a marked increase in tracheostomies placed from 2006 to 2012 as well as an increased incidence of BPD, confirming our primary study hypothesis. LEVEL OF EVIDENCE 4 Laryngoscope, 130: 2056-2062, 2020.
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Affiliation(s)
- Cynthia S Wang
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gopi B Shah
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatric Otolaryngology, Children's Health, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Ron B Mitchell
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatric Otolaryngology, Children's Health, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatric Otolaryngology, Children's Health, Children's Medical Center Dallas, Dallas, Texas, U.S.A
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15
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Nassel D, Chartrand C, Doré-Bergeron MJ, Lefebvre F, Ballantyne M, Van Overmeire B, Luu TM. Very Preterm Infants with Technological Dependence at Home: Impact on Resource Use and Family. Neonatology 2019; 115:363-370. [PMID: 30909270 DOI: 10.1159/000496494] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 01/02/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine the impact of medical complexity among very preterm infants on health care resource use, family, and neurodevelopmental outcomes at 18 months' corrected age. METHODS This observational cohort study of Canadian infants born < 29 weeks' gestational age in 2009-2011 compared infants with and those without medical complexity defined as discharged home with assistive medical technology. Health care resource use and family outcomes were collected. Children were assessed for cerebral palsy, deafness, blindness, and developmental delay at 18 months. Logistic regression analysis was performed for group comparisons. RESULTS Overall, 466/2,337 infants (20%) needed assistive medical technology at home including oxygen (79%), gavage feeding (21%), gastrostomy or ileostomy (20%), CPAP (5%), and tracheostomy (3%). Children with medical complexity were more likely to be re-hospitalized (OR 3.6, 95% CI 3.0-4.5) and to require ≥2 outpatient services (OR 4.4, 95% CI 3.5-5.6). Employment of both parents at 18 months was also less frequent in those with medical complexity compared to those without medical complexity (52 vs. 60%, p < 0.01). Thirty percent of children with medical complexity had significant neurodevelopmental impairment compared to 13% of those without medical complexity (p < 0.01). Lower gestational age, lower birth weight, bronchopulmonary dysplasia, sepsis, and surgical necrotizing enterocolitis were associated with a risk of medical complexity. CONCLUSION Medical complexity is common following very preterm birth and has a significant impact on health care use as well as family employment and is more often associated with neurodevelopmental disabilities. Efforts should be deployed to facilitate care coordination upon hospital discharge and to support families of preterm children with medical complexity.
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Affiliation(s)
- Delphine Nassel
- Hôpital Erasme, Department of Pediatrics, Université Libre de Bruxelles, Brussels, Belgium, .,Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Québec, Canada,
| | - Caroline Chartrand
- Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Marie-Joëlle Doré-Bergeron
- Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Francine Lefebvre
- Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Marilyn Ballantyne
- Holland Bloorview Kids Rehabilitation Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bart Van Overmeire
- Hôpital Erasme, Department of Pediatrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Thuy Mai Luu
- Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
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16
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Abstract
Neonatal and infant tracheostomies have been valuable in the care and survival of children over the past century. With the implementation of neonatal and pediatric intensive care units, more infants are surviving conditions that were considered fatal. Neonatal tracheostomy plays a vital role in many of these conditions, with significant implications and association with overall mortality, morbidity, and developmental outcomes. Although the technique has not changed much, there have been significant evolutions in indications, survival, complications, and technological advances. Improved outcomes research to decrease the high associated morbidities is needed.
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Affiliation(s)
- Jonathan Walsh
- Department of Otolaryngology Head and Neck Surgery, Johns Hopkins School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA.
| | - Jeffrey Rastatter
- Ann & Robert H. Lurie Children's Hospital of Chicago, Box 25, 225 E Chicago Avenue, Chicago, IL 60611, USA
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17
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Abstract
Bronchopulmonary dysplasia (BPD) is a common complication of prematurity, and despite significant advances in neonatal care over recent decades its incidence has not diminished. Although most affected infants have mild disease requiring a short period of oxygen supplementation or respiratory support, severely affected infants can become dependent on positive pressure support for a prolonged duration. In such cases, investigations should be carried out to ascertain whether there are secondary disease processes exacerbating the child's respiratory status. In case of established severe BPD, respiratory support with non-invasive or invasive positive pressure ventilation is required. In this paper we discuss the indications for, and practicalities of, the various modalities available. Potential cardiorespiratory sequelae of BPD include recurrent respiratory infections, childhood wheezing illnesses, abnormalities of lung structure and function, and pulmonary hypertension.
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Affiliation(s)
- M F A Wright
- Department of Respiratory Paediatrics, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK.
| | - C Wallis
- Department of Respiratory Paediatrics, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK.
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18
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Rawal RB, Farquhar DR, Kilpatrick LA, Drake AF, Zdanski CJ. Considering a Weight Criterion for Neonatal Tracheostomy: An Analysis of the ACS NSQIP-P. Laryngoscope 2018; 129:500-505. [PMID: 30194839 DOI: 10.1002/lary.27272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Neonates weighing < 2.5 kg have known higher rates of surgical mortality and morbidity, but this remains unexamined specifically for tracheostomy. We present outcomes of neonates undergoing tracheostomy stratified by weight. METHODS Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric from 2012 to 2014. Patients undergoing tracheostomy were included. Thirty-day mortality and major/minor complication rates were stratified by weight (group 1: < 2.5 kg; group 2: ≥ 2.5 kg and < 4 kg; group 3: ≥ 4 kg). Patient comorbidities were assessed for independent risk factors of morbidity and mortality. RESULTS Of 183,233 patients, 543 underwent tracheostomy. Forty-four patients were group 1 (mean: 2.2 kg ± 0.25); 170 patients were group 2 (mean: 3.31 kg ± 0.42); and 329 patients were group 3 (mean: 6.4 kg ± 2.7). Between groups 1 and 2, there were no significant differences in mortality (P = 0.47), major complication rates (P = 0.99), or minor complication rates (P = 0.64). In comparing all three groups, there were no significant differences in mortality (P = 0.47), major complication rates (P = 0.80), or minor complication rates (P = 0.77). The overall 30-day mortality for all patients was 4.24%. In a multivariate logistical regression model, weight group did not change the odds of all negative outcomes (group 1: odds ratio [OR] of 0.71; 95% confidence interval [CI], 0.33-1.53 and group 2: OR of 0.78; 95% CI, 0.50-1.22). Bronchopulmonary dysplasia was the only independent significant predictor of major complications (OR, 1.69; 95% CI, 1.02-2.79) (P = 0.04). CONCLUSION Our data indicate that 30-day mortality and morbidity outcomes for neonatal tracheostomy are not affected by weight. Overall 30-day mortality should be discussed with caregivers preoperatively. LEVEL OF EVIDENCE 4 Laryngoscope, 129:500-505, 2019.
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Affiliation(s)
- Rounak B Rawal
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Douglas R Farquhar
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Lauren A Kilpatrick
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Amelia F Drake
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
| | - Carlton J Zdanski
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, U.S.A
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19
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Rocha G, Soares P, Gonçalves A, Silva AI, Almeida D, Figueiredo S, Pissarra S, Costa S, Soares H, Flôr-de-Lima F, Guimarães H. Respiratory Care for the Ventilated Neonate. Can Respir J 2018; 2018:7472964. [PMID: 30186538 PMCID: PMC6110042 DOI: 10.1155/2018/7472964] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/12/2018] [Indexed: 11/19/2022] Open
Abstract
Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborn's lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.
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Affiliation(s)
- Gustavo Rocha
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Paulo Soares
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Américo Gonçalves
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Ana Isabel Silva
- Department of Physical and Rehabilitation Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Diana Almeida
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Sara Figueiredo
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
| | - Susana Pissarra
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sandra Costa
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Henrique Soares
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Filipa Flôr-de-Lima
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Hercília Guimarães
- Department of Neonatology, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
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20
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Adly A, Youssef TA, El-Begermy MM, Younis HM. Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review. Eur Arch Otorhinolaryngol 2017; 275:679-690. [PMID: 29255970 DOI: 10.1007/s00405-017-4838-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/01/2017] [Indexed: 02/07/2023]
Abstract
The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.
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Affiliation(s)
- Ahmed Adly
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
| | - Tamer Ali Youssef
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt.
| | - Marwa M El-Begermy
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
| | - Hussein M Younis
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
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21
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Yu H, Mamey MR, Russell CJ. Factors associated with 30-day all-cause hospital readmission after tracheotomy in pediatric patients. Int J Pediatr Otorhinolaryngol 2017; 103:137-141. [PMID: 29224755 PMCID: PMC5728177 DOI: 10.1016/j.ijporl.2017.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine factors associated with post-tracheotomy hospital readmission within 30 days of discharge. METHODS Children 18 years and younger who underwent tracheotomy at Children's Hospital Los Angeles (CHLA) between 1/1/2005 and 12/31/2013 with at least 30 days of follow-up at CHLA were identified through ICD-9 procedure codes. Patient characteristics and covariates were obtained by linking manual chart review and administrative data. We used multivariate logistic regression to identify the independent association between risk factors and the primary outcome of 30-day all-cause same-hospital readmission. RESULTS Of the 273 patients included, the median age at admission was 6 months [interquartile range (IQR): 1-51 months]. Among this primarily male (60.8%) and Hispanic (66.3%) cohort with a high proportion of discharge on positive pressure ventilation (47.1%), the 30-day readmission rate was 22% (n = 60). Of the readmissions, 92% (n = 55) were unplanned and 64% (n = 35) were associated with acute respiratory illnesses. Multivariate regression analysis demonstrated that, among patients ≤12 months, discharge on positive pressure ventilation [adjusted odds ratio (aOR) = 2.88, 95% confidence interval (CI) = 1.19-6.97] was associated with increased odds of readmission, while gastrostomy tube placement during the tracheotomy hospitalization (aOR = 0.42, 95% CI = 0.19-0.96) and prematurity (aOR = 0.35, 95% CI = 0.15-0.83) were associated with decreased odds of readmission. In patients >1 year of age, increased length of hospitalization (aOR = 1.01 per hospital day, 95% CI = 1-1.02) and presence of comorbid malignancy (aOR = 6.03, 95% CI = 1.25-29.16) were associated with increased odds of readmission. CONCLUSIONS Over one-fifth of children undergoing tracheotomy had an unplanned hospital readmission within 30 days after discharge. Because the majority of readmissions were unplanned and due to acute respiratory illnesses, future research should investigate how discharge procedures and improved care coordination may lower readmission rates in high-risk patients (e.g., patients discharged on positive pressure ventilation).
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Affiliation(s)
- Helena Yu
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mary Rose Mamey
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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22
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Levit OL, Shabanova V, Bazzy-Asaad A, Bizzarro MJ, Bhandari V. Risk factors for tracheostomy requirement in extremely low birth weight infants. J Matern Fetal Neonatal Med 2017; 31:447-452. [PMID: 28139937 DOI: 10.1080/14767058.2017.1287895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM To identify variables that affect the risk of tracheostomy in a population of extremely low birth weight (ELBW) infants. METHODS A retrospective matched case-control study was conducted. ELBW infants with a tracheostomy were compared with controls without tracheostomy. Data collection included demographics, detailed information about each intubation and extubation attempt, the use of steroids and the presence of comorbidities. Statistical analyses include conditional logistic regression and Poisson regression for clustered observations. RESULTS Twenty-eight ELBW infants with a tracheostomy were identified. Mean gestational age for both cases and controls was 25 weeks (22-29) and 67.9% were males. Tracheostomy was performed on average on day of life 118 (95%CI: 107-128) and weight at tracheostomy was 2877 g (95%CI: 2657-3098). In the final model, cumulative days with an endotracheal tube (ETT) and total number of intubation episodes were associated with a tracheostomy. For each additional day of intubation, odds of tracheostomy increased by 11% (OR = 1.11, 95%CI: 1.01, 1.23) and with each new intubation episode/failed extubation episode, odds of tracheostomy increased by 150% from the previous episode (OR = 2.5, 95%CI: 1.2, 5.2). CONCLUSIONS Greater cumulative exposure to ETT ventilation and number of intubations is associated with having a tracheostomy.
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Affiliation(s)
- Orly L Levit
- a Department of Pediatrics , Yale University School of Medicine , New Haven , CT , USA
| | | | - Alia Bazzy-Asaad
- a Department of Pediatrics , Yale University School of Medicine , New Haven , CT , USA
| | - Matthew J Bizzarro
- a Department of Pediatrics , Yale University School of Medicine , New Haven , CT , USA
| | - Vineet Bhandari
- c Department of Pediatrics , Drexel University College of Medicine , Philadelphia , PA , USA
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Starplasty tracheostomy: case series and literature review. Eur Arch Otorhinolaryngol 2017; 274:2261-2266. [PMID: 28175990 DOI: 10.1007/s00405-017-4464-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/12/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The starplasty tracheostomy (SPT) technique has been suggested to reduce the short-term complications of tracheostomy, including accidental decannulation and pneumothorax. The aim of the present study was to conduct a review of key parameters prior to and following treatment of neonates and children with the SPT technique, including indications, complications, perioperative department stay, and overall length of stay in one University-Affiliated Medical Center. METHODS A retrospective chart review of all children under the age of 18 underwent SPT in a single center between February 2006 and January 2012. RESULTS Among the 39 patients reviewed, the median age at the time of surgery was 14.5 months, ranging from 3 days to 8.8 years. The most common indication for SPT was respiratory insufficiency resulting from central nervous system disorders (15, 38.4%) followed by neuromuscular disorders (14, 35.9%). Ten (25.6%) operations were performed on neonatal intensive care unit (NICU) patients and 29 (74.4%) on pediatric intensive care unit (PICU) patients. The median postoperative hospital stay was 19.5 days (range of 3-207 days); however, the median postoperative stay in the PICU was 13.5 days. There were no decannulations or any other short-term complications after SPT, and no SPT-related deaths occurred. CONCLUSIONS In our series, pediatric SPT was not associated with any major complications. Therefore, we conclude that SPT should be considered as a safe and advantageous alternative for traditional tracheotomy, especially in patients with low probability of future decannulation, and, therefore, at low risk of a persistent tracheocutaneous fistula.
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Tolomeo CT, Major NE, Szondy MV, Bazzy-Asaad A. Standardizing Care and Parental Training to Improve Training Duration, Referral Frequency, and Length of Stay: Our Quality Improvement Project Experience. J Pediatr Nurs 2017; 32:72-79. [PMID: 28341025 DOI: 10.1016/j.pedn.2016.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 10/12/2016] [Accepted: 10/21/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES At our institution, there is a six bed Pediatric Respiratory Care Unit for technology dependent infants and children with a tracheostomy tube. A lack of consistency in patient care and parent/guardian education prompted our group to critically evaluate the services we provided by revisiting our teaching protocol and instituting a new model of care in the Unit. The aims of this quality improvement (QI) project were to standardize care and skills proficiency training to parents of infants with a tracheostomy tube in preparation for discharge to home. METHODS After conducting a current state survey of key unit stakeholders, we initiated a multidisciplinary, QI project to answer the question: 'could a standardized approach to care and training lead to a decrease in parental/guardian training time, a decrease in length of stay, and/or an increase in developmental interventions for infants with tracheostomy tubes'? A convenience sample of infants with a tracheostomy tube admitted to the Pediatric Respiratory Care Unit were included in the study. Descriptive statistics were used to analyze the results. RESULTS Through this QI approach, we were able to decrease the time required by parents to achieve proficiency in the care of a technology dependent infant, the length of stay for these infants, and increase referral of the infants for developmental assessment. CONCLUSIONS These outcomes have implications for how to approach deficiencies in patient care and make changes that lead to sustained improvements.
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Affiliation(s)
- Concettina Tina Tolomeo
- Yale University School of Medicine, Department of Pediatrics, Section of Respiratory Medicine, 333 Cedar Street, LMP 3094, New Haven, CT 06520-8064, United States.
| | - Nili E Major
- Yale University School of Medicine, Department of Pediatrics, Developmental & Behavioral Pediatrics, 1 Long Wharf Drive, 5(th) Floor, New Haven, CT 06511, United States
| | - Mary V Szondy
- Yale New Haven Children's Hospital, Department of Care Coordination, 1 Park Street, New Haven, CT 06510, United States
| | - Alia Bazzy-Asaad
- Yale University School of Medicine, Department of Pediatrics, Section of Respiratory Medicine, 333 Cedar Street, LMP 3094, New Haven, CT 06520-8064, United States
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Lee JH, Koo CH, Lee SY, Kim EH, Song IK, Kim HS, Kim CS, Kim JT. Effect of early vs. late tracheostomy on clinical outcomes in critically ill pediatric patients. Acta Anaesthesiol Scand 2016; 60:1281-8. [PMID: 27377041 DOI: 10.1111/aas.12760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/29/2016] [Accepted: 05/31/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Few studies investigated the optimal timing for tracheostomy and its influence on the clinical outcomes in critically ill pediatric patients. This study evaluated the differences in clinical outcomes between early and late tracheostomy in pediatric intensive care unit (ICU) patients. METHODS We assessed 111 pediatric patients. Patients who underwent a tracheostomy within 14 days of mechanical ventilation (MV) were assigned to the early tracheostomy group, whereas those who underwent tracheostomy after 14 days of MV were included in the late tracheostomy group. Clinical outcomes, including mortality, duration of MV, length of ICU and hospital stays, and incidence of ventilator-associated pneumonia (VAP) were compared between the groups. RESULTS Of the 111 pediatric patients, 61 and 50 were included in the early and late tracheostomy groups, respectively. Total MV duration and the length of ICU and hospital stay were significantly longer in the late tracheostomy group than in the early tracheostomy group (all P < 0.01). The VAP rate per 1000 ventilator days before tracheostomy was 2.6 and 3.8 in the early and late tracheostomy groups, respectively. There were no significant differences in mortality rate between the groups. No severe complications were associated with tracheostomy itself. CONCLUSIONS Tracheostomy performed within 14 days after the initiation of MV was associated with reduced duration of MV and length of ICU and hospital stay. Although there was no effect on mortality rate, children may benefit from early tracheostomy without severe complications.
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Affiliation(s)
- J.-H. Lee
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - C.-H. Koo
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - S.-Y. Lee
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - E.-H. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - I.-K. Song
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - H.-S. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - C.-S. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
| | - J.-T. Kim
- Department of Anesthesiology and Pain Medicine; Seoul National University Hospital; Seoul Korea
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Abstract
Neonates and infants may need a tracheostomy for many different reasons, ranging from airway obstruction to a requirement for long term mechanical ventilator support. Here, we present the pathophysiology of the many congenital and acquired conditions that might be managed with a tracheostomy. Decisions about tracheostomy demand consideration of not only the benefits, but also the potential side-effects, which may differ in the short and long term and may be attributable to underlying conditions as well as the tracheostomy. Evaluation of potential advantages of tracheostomy will influence decisions about optimal timing. In many cases, an infant may 'graduate' from dependence on a tracheostomy and resume a natural airway, although some will require reconstructive airway surgery.
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Affiliation(s)
- Sara B DeMauro
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Julie L Wei
- Nemours Children's Hospital, Orlando, FL, USA; University of Central Florida College of Medicine, Orlando, FL, USA
| | - Richard J Lin
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Abstract
The etiologies of pediatric lung injury requiring surgical intervention can be infectious, traumatic, congenital, or iatrogenic. Childhood pneumonia is a significant global health problem affecting 150 million children worldwide. Sequelae of pulmonary infections potentially requiring surgery include bronchiectasis, lung abscess, pneumatocele, and empyema. Trauma, congenital conditions such as cystic fibrosis and iatrogenic injuries can result in pneumothoraces, chylothoraces, or bronchopleural fistulae. Recurrence rates for spontaneous pneumothorax treated non-operatively in pediatric patients approach 50-60%. Chylothoraces in newborns may occur spontaneously or due to birth trauma, whereas in older children the etiology is almost always iatrogenic. This article examines the surgical management for the complications of lung injury in pediatric patients. In addition, we review the available pediatric evidence for early tracheostomy as well as treatment strategies for the negative ramifications of tracheostomy.
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Affiliation(s)
| | - Chad Hamner
- Cook Children׳s Medical Center, Fort Worth, Texas.
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Unal S, Bilgin LK, Gonulal D, Akcan FA. Optimal Time of Tracheotomy in Infants: Still a Dilemma. Glob Pediatr Health 2015; 2:2333794X15569300. [PMID: 27335940 PMCID: PMC4784622 DOI: 10.1177/2333794x15569300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective. Infants with respiratory failure may require prolonged intubation. There is no consensus on the time of tracheotomy in neonates. Methods. We evaluated infants applied tracheotomy, time of procedure, and early complications in our neonatal intensive care unit (NICU) retrospectively from January 2012 to December 2013. Results. We identified 9 infants applied tracheotomy with gestational ages 34 to 41 weeks. Their diagnoses were hypotonic infant, subglottic stenosis, laryngeal cleft, neck mass, and chronic lung disease. Age on tracheotomy ranged from 4 to 10 weeks. Early complication ratio was 33.3% with minimal bleeding (1), air leak (1), and canal revision requirement (1). We discharged 7 infants, and 2 infants died in the NICU. Conclusion. Tracheotomy makes infant nursing easy for staff and families even at home. If carried out by a trained team, the procedure is safe and has low complication. When to apply tracheotomy should be individualized, and airway damage due to prolonged intubation versus risks of tracheotomy should be taken into consideration.
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Affiliation(s)
- Sevim Unal
- Ankara Children's Hematology Oncology Research Hospital, Ankara, Turkey
| | | | - Deniz Gonulal
- Ankara Children's Hematology Oncology Research Hospital, Ankara, Turkey
| | - Fatih Alper Akcan
- Ankara Children's Hematology Oncology Research Hospital, Ankara, Turkey
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Ogilvie LN, Kozak JK, Chiu S, Adderley RJ, Kozak FK. Changes in pediatric tracheostomy 1982-2011: a Canadian tertiary children's hospital review. J Pediatr Surg 2014; 49:1549-53. [PMID: 25475792 DOI: 10.1016/j.jpedsurg.2014.04.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/28/2014] [Accepted: 04/28/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric tracheostomy has undergone notable changes in frequency and indication over the past 30 years. This study investigates pediatric tracheostomy at British Columbia Children's Hospital (BCCH) over a 30-year period. METHODS A retrospective chart review of tracheostomy cases at BCCH from 1982 to 2011 was conducted. Charts were reviewed for demographics, date of tracheostomy, indication, complications, mortality and date of decannulation. Data from three 10-year time periods were compared using Fisher's Exact test to examine changes over time. RESULTS 251 procedures (154 males) performed on 231 patients were reviewed. Mean age at tracheostomy was 3.74 years with 48% of procedures undertaken before the age of one year. Frequency of procedure by year has generally declined into the early 2000's. Upper airway obstruction was the most common indication accounting for 33% of procedures. The rate of complication across the entire cohort was 22% with 63% of patients being decannulated. Tracheostomy related mortality occurred in 2.0% of cases reviewed. CONCLUSIONS Changes occurred in primary indications with infections indicating less procedures and neurological impairments indicating more procedures over time. Complications increased and the decannulation rate decreased over this 30-year review. Pediatric tracheostomy is considered a safe and effective procedure at BCCH.
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Affiliation(s)
- Lauren N Ogilvie
- Division of Pediatric Otolaryngology, BC Children's Hospital, Division of Otolaryngology, 4480 Oak Street, Vancouver, BC, V6H 3V4
| | - Jessica K Kozak
- Division of Pediatric Otolaryngology, BC Children's Hospital, Division of Otolaryngology, 4480 Oak Street, Vancouver, BC, V6H 3V4
| | - Simon Chiu
- Division of Pediatric Otolaryngology, BC Children's Hospital, Division of Otolaryngology, 4480 Oak Street, Vancouver, BC, V6H 3V4
| | - Robert J Adderley
- Home Tracheostomy Care and Home Ventilation Program, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, V6H 3V4
| | - Frederick K Kozak
- Division of Pediatric Otolaryngology, BC Children's Hospital, Division of Otolaryngology, 4480 Oak Street, Vancouver, BC, V6H 3V4.
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Marom T, Joseph RA, Grindle CR, Shah UK. Tracheotomy after laryngotracheoplasty: risk factors over 10 years. [Corrected]. J Pediatr Surg 2014; 49:1206-9. [PMID: 25092077 DOI: 10.1016/j.jpedsurg.2013.11.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/21/2013] [Accepted: 11/22/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Subglottic stenosis (SGS) is the most common congenital and/or acquired laryngotracheal anomaly requiring tracheotomy in infants. We sought to determine factors associated with a greater likelihood of tracheotomy in symptomatic infants with SGS who underwent laryngotracheoplasty (LTP). METHODS Retrospective case series with chart review of patients undergoing single-stage LTP for SGS over a 10-year period (2001-2010) in a tertiary-care pediatric hospital. RESULTS Twenty-two children (15 boys, 7 girls), with a mean gestational age of 32.5weeks, underwent LTP with and without interpositional grafting, at a median age of 89days. Ten patients (43%) required postoperative tracheotomy. Of patients weighing <2.5kg, 7 of 8 eventually required tracheotomy, while none weighing >5kg needed tracheotomy (p=0.003). The average length of stay for patients with a tracheotomy was 125days, while those without tracheotomy required only 58days (p=0.011). The grade of SGS (p=0.809), gender (p=0.968), age at surgery (p=0.178), and gestational age (p=0.117) were not significantly associated with the need for tracheotomy. Weight at surgery was significantly correlated with the likelihood of needing tracheotomy (p=0.003). CONCLUSIONS Patients who weighed less than 2.5kg at the time of LTP procedures were more likely to require a postoperative tracheotomy. Children who required tracheotomy had longer lengths of hospital stay.
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Affiliation(s)
- Tal Marom
- Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, USA.
| | - Rachel A Joseph
- Christiana Care Health System, Newark, DE, USA; Duquesne University, Pittsburgh, PA, USA
| | - Christopher R Grindle
- Clinical Otolaryngology, University of Connecticut Health Center, Farmington, CT, USA; Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Udayan K Shah
- Division of Pediatric Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Departments of Otolaryngology-Head & Neck Surgery and Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA
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Developmental outcomes of very preterm infants with tracheostomies. J Pediatr 2014; 164:1303-10.e2. [PMID: 24472229 PMCID: PMC4035374 DOI: 10.1016/j.jpeds.2013.12.014] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 10/07/2013] [Accepted: 12/11/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the neurodevelopmental outcomes of very preterm (<30 weeks) infants who underwent tracheostomy. STUDY DESIGN Retrospective cohort study from 16 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network over 10 years (2001-2011). Infants who survived to at least 36 weeks (N = 8683), including 304 infants with tracheostomies, were studied. Primary outcome was death or neurodevelopmental impairment (NDI; a composite of ≥1 of developmental delay, neurologic impairment, profound hearing loss, severe visual impairment) at a corrected age of 18-22 months. Outcomes were compared using multiple logistic regression. We assessed the impact of timing by comparing outcomes of infants who underwent tracheostomy before and after 120 days of life. RESULTS Tracheostomies were associated with all neonatal morbidities examined and with most adverse neurodevelopmental outcomes. Death or NDI occurred in 83% of infants with tracheostomies and 40% of those without (OR adjusted for center 7.0, 95% CI 5.2-9.5). After adjustment for potential confounders, odds of death or NDI remained higher (OR 3.3, 95% CI 2.4-4.6), but odds of death alone were lower (OR 0.4, 95% CI 0.3-0.7) among infants with tracheostomies. Death or NDI was lower in infants who received their tracheostomies before, rather than after, 120 days of life (aOR 0.5, 95% CI 0.3-0.9). CONCLUSIONS Tracheostomy in preterm infants is associated with adverse developmental outcomes and cannot mitigate the significant risk associated with many complications of prematurity. These data may inform counseling about tracheostomy in this vulnerable population.
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Rane S, Bathula S, Thomas RL, Natarajan G. Outcomes of tracheostomy in the neonatal intensive care unit: is there an optimal time? J Matern Fetal Neonatal Med 2014; 27:1257-61. [PMID: 24215607 DOI: 10.3109/14767058.2013.860438] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare short-term outcomes of infants who underwent early versus late tracheostomy during their initial hospitalization after birth and determine the association, if any, between tracheostomy timing and outcomes. STUDY DESIGN Retrospective chart review of infants who underwent a tracheostomy during their initial hospitalization at a single site. RESULTS The median (range) gestational age of our cohort (n = 127) was 28 (23-42) weeks and birth weight was 988 (390-4030) g. Tracheostomy indications included airway lesions (47%), bronchopulmonary dysplasia (25%), both (22%) and others (6%). Median postmenstrual age (PMA) at tracheostomy was 45 (35-75) weeks. Death occurred in 27 (21%) infants and 65 (51%) infants were mechanically ventilated. G-tube was present at discharge in 42 (33%) infants. Infants who underwent early tracheostomy (<45 weeks PMA) (n = 66) had significantly lower gestational ages, weights and respiratory support than the late (≥45 weeks PMA) (n = 61) group. Death (29.5% versus 14%), home ventilation (41% versus 21%) and G tube (44% versus 14%) were significantly more frequent in the late tracheostomy group. On bivariate regression, outcomes were not independently associated with tracheostomy timing, after adjustment for gestational age and respiratory support. CONCLUSIONS Of infants who underwent tracheostomy during the initial hospitalization after birth, 21% died. On adjusted analysis, tracheostomy timing was not independently associated with outcomes.
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Affiliation(s)
- Sharayu Rane
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine
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Kim HR, Choi JY, Kim SY, Lee BK, Jung YH, Heo JS, Shin SH, Kim EK, Kim HS, Choi JH. Timing of Liberation from Ventilation Assistance and Decannulation in Preterm Infants with Bronchopulmonary Dysplasia after Tracheostomy. NEONATAL MEDICINE 2014. [DOI: 10.5385/nm.2014.21.4.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Hye-Rim Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Yoon Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sae Yun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Byoung Kook Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ju sun Heo
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jung-Hwan Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Rane S, Shankaran S, Natarajan G. Parental perception of functional status following tracheostomy in infancy: a single center study. J Pediatr 2013; 163:860-6. [PMID: 23660377 DOI: 10.1016/j.jpeds.2013.03.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 02/06/2013] [Accepted: 03/27/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the functional outcomes of children who underwent a tracheostomy in the initial hospitalization after birth and to determine their correlates. STUDY DESIGN We administered the validated 43-item Functional Status-II (FS-II) questionnaire by Stein and Jessop over the telephone to caregivers of surviving children. The FS-II items generated a total score, age-specific: (1) total; (2) general health (GH); and (3) responsiveness, activity, or interpersonal functioning (IPF) scores in specific age group categories. RESULTS FS-II was administered to 51/62 (82.2%) survivors at a median (range) age of 5 (1-10) years; 27% children were on the ventilator and 43% required devices. About 40% of children had a median of 1 (1-4) hospitalization in the previous 6 months. Scores were >2 SD below means in 55%, 24%, and 55% cases for age-specific T, GH, and R/A/IPF scores respectively. The T and R/A/IPF scales were significantly higher in those with private, rather than public, maternal insurance, as were T and R/A/IPF scores for children ≥ 4 years, compared with younger children. On regression analysis, FS-II T, GH, and R/A/IPF scores were independently associated with maternal private insurance (P = .02). R/A/IPF scores were also significantly associated with corrected age at FS-II administration. CONCLUSIONS One-third of surviving children who underwent tracheostomy during their initial hospitalization remained technology-dependent. The parental FS-II questionnaires revealed low R/A/IPF scores, especially at younger ages and in those with maternal public insurance. Further research on family-level interventions to improve functional outcomes in this population is warranted.
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Affiliation(s)
- Sharayu Rane
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI 48201, USA
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Osborn AJ, de Alarcón A, Hart CK, Cotton RT, Rutter MJ. Tracheocutaneous fistula closure in the pediatric population: should secondary closure be the standard of care? Otolaryngol Head Neck Surg 2013; 149:766-71. [PMID: 23963612 DOI: 10.1177/0194599813500761] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Tracheocutaneous fistula (TCF) closure is achieved by excision followed either by primary closure or healing by secondary intention. Although primary closure provides immediate resolution of the fistula, it is associated with more severe potential complications. Healing by secondary intention minimizes these potential complications; however, it is inconvenient for the patient and may be more likely to require revision surgery. We have had 2 life-threatening complications after primary closure, and as a result, we largely changed our practice pattern. We compared complication and success rates of the 2 methods since this change to determine its ramifications. STUDY DESIGN Historical cohort study. SETTING Academic tertiary care pediatric otolaryngology practice. Subjects and Methods Two hundred sixteen patients who underwent TCF closure between January 2004 and August 2012. RESULTS Forty-six (21.3%) fistulae were addressed by primary closure, and 170 (78.7%) were addressed by secondary intention. The complication and revision rates were not significantly different between the 2 methods (8.7% vs 10% and 8.7% vs 14.7%, respectively). CONCLUSION In our study, we did not see any statistical differences between the 2 methods studied but could not exclude clinically important differences that may have favored one method over the other. Although our comparative results were inconclusive, we have adopted secondary closure as standard practice for management of pediatric TCF. Individual surgeons and patients may use the data presented to help guide decisions concerning which procedure is most appropriate.
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Affiliation(s)
- Alexander J Osborn
- Division of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Overman AE, Liu M, Kurachek SC, Shreve MR, Maynard RC, Mammel MC, Moore BM. Tracheostomy for infants requiring prolonged mechanical ventilation: 10 years' experience. Pediatrics 2013; 131:e1491-6. [PMID: 23569088 DOI: 10.1542/peds.2012-1943] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite advances in care of critically ill neonates, extended mechanical ventilation and tracheostomy are sometimes required. Few studies focus on complications and clinical outcomes. Our aim was to provide long-term outcomes for a cohort of infants who required tracheostomy. METHODS This study is a retrospective review of 165 infants born between January 1, 2000 and December 31, 2010 who required tracheostomy and ventilator support. Children with complex congenital heart disease were excluded. RESULTS Median gestational age was 27 weeks (range 22-43), and birth weight was 820 g (range 360-4860). The number of male (53.9%) and female (46.1%) infants was similar (P = .312). Infants were divided into 2 groups based on birth weight ≤1000 g (A) and >1000 g (B). Group A: 87 (57.6%) infants; group B 64 (42.4%). Overall tracheostomy rate was 6.9% (87/1345) for group A versus 0.9% (64/6818) for B (P <.001). Group A had a longer time from intubation to positive pressure ventilation independence, 505 days (range 62-1287) vs 372 days (range 15-1270; P = .011). Infants who had >1 reason for tracheostomy comprised 78.8% of the sample; 69.1% of infants were discharged on ventilators. Birth weight did not affect time from tracheostomy to decannulation (P = .323). More group A infants were decannulated (P = .023). laryngotracheal reconstruction rate was 35.8%. Five-year survival was 89%. Group B had higher mortality (P = .033). 64.2% of infants had developmental delays; 74.2% had ≥2 comorbidities. CONCLUSIONS Tracheostomy rates were higher for extremely low birth weight infants than previously reported rates for all infants. Decannulation rates and laryngotracheal reconstruction rates were consistent with previous studies. Survival rates were high, but developmental delay and comorbidities were frequent.
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Affiliation(s)
- Alison E Overman
- Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota, USA
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Mandy G, Malkar M, Welty SE, Brown R, Shepherd E, Gardner W, Moise A, Gest A. Tracheostomy placement in infants with bronchopulmonary dysplasia: safety and outcomes. Pediatr Pulmonol 2013; 48:245-9. [PMID: 22570313 DOI: 10.1002/ppul.22572] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 03/26/2012] [Indexed: 11/08/2022]
Abstract
Optimizing the timing and safety for the placement of a tracheostomy in infants with bronchopulmonary dysplasia (BPD) has not been determined. The purpose of the present study was to describe the data from a single institution about the efficacy and safety of tracheostomy placement in infants with BPD needing long-term respiratory support. We established a service line for the comprehensive care of infants with BPD and we collected retrospective clinical data from this service line. We identified patients that had a trachostomy placed using the local Vermont-Oxford database, and obtained clinical data from chart reviews. We identified infants who had a tracheostomy placed for the indication of severe BPD only. Safety and respiratory efficacy was assessed by overall survival to discharge and the change in respiratory supportive care from just before placement to 1-month post-placement. Twenty-two patients (750 ± 236 g, 25.4 ± 2.1 weeks gestation) had a tracheostomy placed on day of life 177 ± 74 which coincided with a post-conceptual age of 51 ± 10 weeks. At placement these infants were on high settings to support their lung disease. The mean airway pressure (MAP) was 14.3 ± 3.3 cmH(2) O, the peak inspiratory pressure was 43.7 ± 8.0 cmH(2) O, and the FiO(2) was 0.51 ± 0.13. The mean respiratory severity score (MAP × FiO(2) ) 1 month after tracheostomy was significantly (P = 0.03) lower than prior to tracheostomy. Survival to hospital discharge was 77%. All patients with tracheostomies that survived were discharged home on mist collar supplemental oxygen. In conclusion, the high survival rate in these patients with severe BPD and the decreased respiratory support after placement of a tracheostomy suggests that high ventilatory pressures should not be a deterrent for placement of a tracheostomy. Future research should be aimed at determining optimal patient selection and timing for tracheostomy placement in infants with severe BPD.
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Affiliation(s)
- George Mandy
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030.
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Viswanathan S, Mathew A, Worth A, Mhanna MJ. Risk factors associated with the need for a tracheostomy in extremely low birth weight infants. Pediatr Pulmonol 2013; 48:146-50. [PMID: 22644794 DOI: 10.1002/ppul.22599] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/10/2012] [Indexed: 11/10/2022]
Abstract
In an attempt to determine the risk factors associated with the need for a tracheostomy in extremely low birth weight (ELBW) infants, a retrospective, case control study was conducted (each infant with a tracheostomy [case] was matched to two controls). Medical records were reviewed for patients' characteristics, risk factors for tracheostomy and outcome. During the study period (June 1996 to Dec 2010), 934 ELBW infants were admitted to our institution and nine infants had a tracheostomy and were matched to 18 controls. There were no differences in birth weight (BW) and gestation age (GA) between cases and controls (828.1 ± 136.2 g vs. 822.0 ± 140.9 g [P = 0.91] and 26.6 ± 1.8 weeks vs. 26.5 ± 1.6 weeks [P = 0.88], respectively). In comparison to their controls, infants with a tracheostomy had a higher rate of intubation (median 13 [11-15] vs. 3 [2-5], P ≤ 0.001), a higher rate of total intubation attempts (median 18 [13-21] vs. 5.5 [3-7], P = 0.001), and more days of mechanical ventilation prior to their tracheostomy (mean 100.7 ± 27.7 vs. 29.2 ± 19.8 days [P < 0.001]). Also infants with a tracheostomy had a higher rate of non-congenital upper airway obstruction (55% [5/9] vs. 0% [0/18]; P = 0.001), a higher rate of chronic lung disease (100% [9/9] vs. 5% [1/18]; P < 0.001) and a higher mortality (44% [4/9] vs. 0% [0/18]; P = 0.007) than their controls. In conclusion, chronic lung disease, multiple intubations and intubation attempts, duration of mechanical ventilation, and non-congenital upper airway obstruction are risk factors associated with tracheostomies in ELBW infants.
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Affiliation(s)
- Sreekanth Viswanathan
- Division of Neonatology, Department of Pediatrics at MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Papoff P, Cerasaro C, Caresta E, Barbàra CS, Midulla F, Moretti C. Current strategies for treating infants with severe bronchopulmonary dysplasia. J Matern Fetal Neonatal Med 2012; 25 Suppl 3:15-20. [DOI: 10.3109/14767058.2012.712352] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The influence of peak airway pressure and oxygen requirement on infant tracheostomy. Int J Pediatr Otorhinolaryngol 2012; 76:869-72. [PMID: 22445797 DOI: 10.1016/j.ijporl.2012.02.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 02/25/2012] [Accepted: 02/28/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine if and how the preoperative peak airway pressure and oxygen requirement of an infant (less than 6 months of age) who requires mechanical ventilation influences the physician's decision to perform a tracheostomy on that infant. STUDY DESIGN Nationwide survey. SUBJECTS Pediatric Otolaryngologists. METHODS A web-based survey was developed and sent to all members of the American Society of Pediatric Otolaryngology. RESULTS 150 of the 348 surveys were returned (43%). The majority of respondents do not consider the patient's requirement for elevated peak airway pressure (PAP) or the patient's requirement for a high percentage of oxygen as a contraindication to performing a tracheostomy in that patient (54.7 and 72.1% respectively). The presence of preoperative high PAP influenced 68.2% of respondents to consider using a cuffed tracheostomy tube. In the immediate postoperative period, the most common complication resulting in significant morbidity or mortality was mucous plugging, and the majority of respondents attributed postoperative morbidity and mortality to preoperative pulmonary comorbidity. CONCLUSIONS Preoperative PAP and the patient's oxygen requirement do not influence the surveyed otolaryngologists' decision whether or not to perform a tracheostomy in the infant population. However, PAP do influence whether or not a cuffed tracheostomy tube is used.
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Seki K, Iwasaki S, An H, Horiguchi H, Mori M, Nishimaki S, Yokota S. Early discharge from a neonatal intensive care unit and rates of readmission. Pediatr Int 2011; 53:7-12. [PMID: 20534023 DOI: 10.1111/j.1442-200x.2010.03179.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Increasing admissions to neonatal intensive care units (NICUs) demand early discharge from the units. Our hospital aims to early discharge patients who meet the following requirements: they are able to regulate body temperature; neither apnea nor bradycardia is observed; and bodyweight increases with lactation. We studied the real state of this strategy. METHODS We looked at postmenstrual age, bodyweight, complication at the time of discharge and the readmission rate in 609 patients with gestational age of less than 34 weeks, who were discharged from our NICU between January 2000 and March 2008. RESULTS The postmenstrual age and bodyweight at discharge decreased with the increase of gestational age. This tendency was stronger in cases with gestational age of less than 26 weeks. A comparison was made between two patient groups with a gestational age of less than 26 weeks and with the age of 26 weeks or longer. Many patients with a gestational age of less than 26 weeks suffered frequently from complications and were on home oxygen therapy. The readmission rates within 3 months and 1 year of NICU discharge were 10.4% and 26.9% in patients with gestational age between 22 and 25 weeks, respectively, while those rates were 2.8% and 7.4% in patients with gestational weeks of 26 to 34, respectively. CONCLUSION The postmenstrual age and bodyweight at NICU discharge decreased in inverse proportion to gestational age, especially less than 26 weeks. Our requirements for early discharge were verified by the readmission rate in this investigation.
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Affiliation(s)
- Kazuo Seki
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Japan.
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Tolomeo C'T', Bazzy-Asaad A. Utilization of a second caregiver in the care of a child with a tracheostomy in the homecare setting. Pediatr Pulmonol 2010; 45:656-60. [PMID: 20578067 DOI: 10.1002/ppul.21233] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To safely discharge a child with a tracheostomy tube to home, we require two legal guardians/parents to complete a special training program. However, there are times when two parents/guardians are unavailable or unwilling to be trained. Therefore, the purpose of this study was to evaluate the role of the second caregiver of a child with a tracheostomy tube in the home setting. METHODS A retrospective, descriptive, qualitative, pilot study of a convenience sample of parents of 16 children who were discharged from the hospital with a tracheostomy tube between September 2004 and December 2008 was conducted. Data were obtained from the unit's discharge database and from the primary and/or secondary caregivers. Univariate analyses were used to determine the frequency of primary and secondary caregiver participation at home. Themes were generated from caregiver responses regarding utilization of a second caregiver in the home. RESULTS A majority (93.8%, n = 15) reported primary caregivers participating very often in the care of the infant at home; less than half (31.3%, n = 5) reported comparable secondary caregiver participation. Fifty percent (n = 8) said they would not be able to care for the infant at home without another trained caregiver. Analysis of the caregiver responses revealed three major themes: confidence, safety, and respite/support. CONCLUSION Findings support the importance of training two caregivers in the care of a child being discharged with a tracheostomy tube. Training should include the medical/nursing care of the child as well as anticipatory guidance regarding what to expect and the need for respite services.
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Brinsmead TL, Davies MW. Securing endotracheal tubes: does NeoBar availability improve tube position? J Paediatr Child Health 2010; 46:243-8. [PMID: 20337879 DOI: 10.1111/j.1440-1754.2009.01678.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess if neonatal endotracheal tube (ETT) position improved with introduction of the NeoBar. METHODS This retrospective study compared two cohorts of intubated neonates and their x-rays. During the first 2-month study period, ETTs were secured with tape only--the 'Tape-only' period; during the second study period, they were secured with a NeoBar (or tape if the NeoBar was unsuitable)--the 'NeoBar' period. ETT tip position was assessed subjectively as very high, high, OK, low, or very low; and objectively by vertebral body position and the ETT-tip-to-T1 distance. RESULTS During the Tape-only period, 59 babies had 275 x-rays with an ETT visible. During the NeoBar period, 67 babies had 331 x-rays with an ETT visible. There were 160 (58.2%) and 193 (58.3%) assessed as OK during the Tape-only and NeoBar periods, respectively (Fisher's Exact Test, P= 1.0). There were more very high tubes during the NeoBar period, and more low and very low tubes during the Tape-only period (Chi-squared test, P= 0.011). A similar trend was observed with the distribution of the ETT-tip-to-T1 distance (difference not statistically significant, Mann-Whitney test, P= 0.079). CONCLUSION During both time periods, less than two-thirds of ETTs were located in an acceptable position. For ETTs in unacceptable positions, there were more tubes in the higher positions during the NeoBar period, and more tubes in the lower positions during the Tape-only period. Further investigation is necessary to clarify if the differences in ETT position on x-ray correlate with relevant clinical outcomes.
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Affiliation(s)
- Tammy Lee Brinsmead
- Grantley Stable Neonatal Unit, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia.
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Effect of a Syndromic Diagnosis on Mandibular Size and Sagittal Position in Robin Sequence. J Oral Maxillofac Surg 2009; 67:2323-31. [DOI: 10.1016/j.joms.2009.06.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Accepted: 06/23/2009] [Indexed: 11/30/2022]
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Sousa A, Nunes T, Roque Farinha R, Bandeira T. Traqueostomia: Indicações e complicações em doentes pediátricos. REVISTA PORTUGUESA DE PNEUMOLOGIA 2009. [DOI: 10.1016/s0873-2159(15)30129-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Pereira KD, Smith SL, Henry M. Failed extubation in the neonatal intensive care unit. Int J Pediatr Otorhinolaryngol 2007; 71:1763-6. [PMID: 17850890 DOI: 10.1016/j.ijporl.2007.07.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2007] [Revised: 07/30/2007] [Accepted: 07/31/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the causes of failed extubation in the Neonatal Intensive Care Unit (NICU) and the need for airway intervention. STUDY DESIGN Retrospective chart review. SETTING Tertiary care children's hospital. PATIENTS We identified all premature infants (gestational age <37 weeks) admitted to the NICU of a tertiary care children's hospital from January 1998 until December 2006 who underwent direct laryngoscopy and bronchoscopy (DLB) in the operating room (OR) for failed extubation. Data was collected on weight, gestational age, co-morbid conditions, number of failed extubations, findings at DLB and whether or not a tracheostomy was performed. RESULTS DLBs were performed on 63 patients to evaluate the cause of failed extubation. Group A comprised of 50 patients who underwent tracheostomy. They had an average gestational age of 30.0 weeks, birth weight of 1457g and number of failed extubations 2.68. Group B consisted of 13 patients who did not undergo tracheostomy. They had an average gestational age of 34.5 weeks, birth weight of 2309g and number of failed extubations 1.33. 56.0% of the tracheostomy group and 38.5% of the non-tracheostomy group had chronic lung disease (CLD). At endoscopy, 44% of Group A and 23.1% of Group B had some degree of subglottic stenosis. CONCLUSION Abnormal laryngotracheal findings are common in neonates who fail extubation. When compared to their counterparts with similar co-morbidities, neonates with CLD, gestational age of 30 weeks or below and low birth weight are twice as likely to have subglottic edema and fail extubation. They are also likely to be candidates for a tracheostomy.
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Affiliation(s)
- Kevin D Pereira
- Department of Otolaryngology-Head and Neck Surgery, The University of Texas, Medical School at Houston, Houston, TX, United States.
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Pereira KD, Weinstock YE. Bronchoscopy assisted neonatal tracheostomy (BANT): a new technique. Int J Pediatr Otorhinolaryngol 2007; 71:211-5. [PMID: 17098295 DOI: 10.1016/j.ijporl.2006.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Revised: 10/05/2006] [Accepted: 10/05/2006] [Indexed: 11/25/2022]
Abstract
Neonatal tracheostomy is a complex procedure associated with significant morbidity due to the small size and medical condition of the patient. Standard techniques have been well described and depend on palpation and visual identification of the trachea in the wound. This can at times be exceedingly difficult depending on the anatomical configuration of the neck. The potential for damage to adjacent neurovascular structures increases as dissection strays away from the midline. We describe a new technique that restricts dissection strictly to the midline and ensures accurate placement of the tracheostomy below the first tracheal ring. We feel that this technique will significantly shorten the operative time for the procedure and also reduce the morbidity associated with it.
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Affiliation(s)
- Kevin D Pereira
- The Department of Otolaryngology, University of Texas Medical School at Houston, Houston, TX 77030, USA.
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Sisk EA, Kim TB, Schumacher R, Dechert R, Driver L, Ramsey AM, Lesperance MM. Tracheotomy in very low birth weight neonates: indications and outcomes. Laryngoscope 2006; 116:928-33. [PMID: 16735883 DOI: 10.1097/01.mlg.0000214897.08822.14] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE/HYPOTHESIS To review incidence of, indications for, and outcomes of tracheotomy in very low birth weight (VLBW) infants. STUDY DESIGN Retrospective review in tertiary care hospital. METHODS Eighteen VLBW (<1,500 g) infants with bronchopulmonary dysplasia undergoing tracheotomy in the neonatal intensive care unit between October 1997 and June 2002 were studied. Controls consisted of 36 VLBW infants undergoing intubation without tracheotomy, two per study infant, matched by gestational age and weight. Outcome measures included duration and number of intubation events, time to decannulation, complications, comorbidities, length of stay, and speech, language, and swallowing measures. RESULTS Infants undergoing tracheotomy had an average duration of intubation of 128.8 days with a median number of 11.5 intubation events, both significantly greater than those of controls. Percentage of those with laryngotracheal stenosis was 44% of study infants had laryngotracheal stenosis compared to 1.6% in all intubated VLBW infants. The tracheotomy group had a significantly higher incidence of gastroesophageal reflux, pulmonary hypertension, and gastrostomy tube placement. The overall tracheotomy-related complication rate was 38.9%. Three were lost to follow-up, and five deaths occurred, two possibly tracheotomy-related. Six of ten were decannulated by an average time of 3.8 years, two of six after laryngotracheal reconstruction. Four of ten remained cannulated for a variety of reasons. Disorders of speech, language, and swallowing were common. CONCLUSIONS When considering tracheotomy in VLBW infants, the total number of intubation events should be monitored as well as the total duration of intubation. The relatively high incidence of laryngotracheal stenosis argues for earlier endoscopy and possibly earlier tracheotomy in infants with developing stenoses.
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Affiliation(s)
- Elizabeth A Sisk
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan 48109-0241, USA
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