The assessment of quality of life in children with tracheostomies and their families in a low to middle income country (LMIC)

Children with a tracheostomy: Global speech-language therapists' practice

PURPOSE

Speech-language Therapists (SLTs) are specialists in communication, feeding and swallowing as core members of the paediatric tracheostomy multidisciplinary team (MDT). Inconsistent tracheostomy care leads to staff and family frustration and delayed intervention. Little is known about international SLT tracheostomy practices.

METHODS

This global survey explored training, clinical practices, perceived knowledge, skills and roles, and barriers for SLTs working with paediatric tracheostomy. Survey questions consisted of Likert scale and open-ended questions. 92 SLTs completed the survey representing 6 continents and 19 countries.

RESULTS

Overall SLTs were confident in their knowledge of communication, and feeding but less confident in weaning, tracheostomy care skills (such as suctioning and cuff deflation) and specialist tracheostomy tube use (such as tracheostomy tubes with a subglottic suction port). Formal competency training was infrequent but most had access to supervision. Understanding of the SLT role by the MDT was perceived as good. Many felt managing one-way speaking valves was part of their role. The majority reported staffing, lack of guidelines and access to resources (one-way speaking valves and flexible endoscopic evaluation of swallowing) as barriers.

CONCLUSIONS

This expert opinion paper summarises the current evidence-base and international paediatric tracheostomy practice. SLTs were experienced and confident in tracheostomy. The SLT role varies internationally with a lack of formal written policy to guide practice and a variability in access to education.

Impact of pediatric tracheostomy on family caregivers' burden and quality of life: a systematic review and meta-analysis

Introduction

The incidence of pediatric tracheostomy is on the rise. More children are undergoing tracheostomy at a younger age and living longer and cared for at home. Caring for children with tracheostomy affects the caregivers' Quality of Life (QOL) and caregiver burden. We undertook a systematic review and meta-analysis to determine the impact of pediatric tracheostomy on caregivers' QOL and caregiver burden.

Methods

We performed a search for quantitative studies measuring QOL, caregiver burden and related factors such as psychological distress, coping, stress, and financial strain using validated instruments, reported by caregivers of children with tracheostomy. We searched PubMed, Embase, Cochrane Central Register of Clinical Trials, CINAHL, and PsycINFO with the following search terms: "pediatrics," "tracheostomy," "quality of life," "caregivers," "care burden" from the inception of respective databases to 23rd May 2024. Meta-analysis was conducted using R (version 4.3.1).

Results

Twenty-three studies (1,299 caregivers) were included in systematic review. Seven studies (469 caregivers) using Pediatric Quality of Life Family Integrated Module underwent meta-analysis. The pooled mean total family impact score, parental health-related QOL, family functioning score were 70.29 [95% CI, 61.20-79.37], 69.27 [95% CI, 60.88-77.67], and 72.96 [95% CI, 65.92-80.00] respectively. Other key instruments were the Pediatric Tracheostomy Health Status Instrument and Zarit Burden Interview. Qualitative synthesis identified several risk factors for lower QOL and higher caregiver burden: comorbidities in children, younger age at tracheostomy, need for additional medical equipment, presence of older siblings, higher financial strain, being the sole caregiver or being unmarried, and maternal depression. Caregivers' QOL correlated positively with coping and negatively with stress which is, in turn, associated with medical complications in the first year and the duration of tracheostomy. About 40% of mothers experienced moderate to severe caregiver burden while caring for their children with tracheostomy and this was significantly correlated with depression. Encouragingly, parents also reported positive experience including closeness of the family, feeling stronger, and having a strong sense of mastery.

Discussion

Caregivers of children with tracheostomy experience low QOL and high caregiver burden, which were exacerbated by various medical and psychosocial factors. QOL should be assessed during clinical encounters to identify caregivers who require additional support which includes learning coping and stress reduction strategies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=334457, identifier CRD42022334457.

Fighting to Breathe and Fighting for Health-Related Quality of Life: Measuring the Impact of Being Dependent on Technology for Breathing on the Child and Their Caregiver

BACKGROUND AND OBJECTIVE

Medical advancement has enabled children to survive congenital airway anomalies, rare diseases and critical illnesses with medical technology including tracheostomies and long-term ventilation to support breathing. This study aimed to assess (1) the validity of the EQ-TIPS and EQ-5D-Y-3L in children dependent on technology and (2) the impact of caring for these children on the EQ-5D-5L and CarerQoL.

METHODS

Caregivers of children aged 1 month to 18 years completed the EQ-TIPS or EQ-5D-Y-3L, Pediatric Quality of Life Inventory (PedsQL) and Paediatric Tracheostomy Health Status Instrument (PTHSI) to reflect the child's health. In addition, caregivers self-completed the EQ-5D-5L and CarerQoL. Reports of problems on EQ dimensions were compared across age groups with the Fisher's exact test. Spearman and Pearson's correlation coefficients and Kruskal-Wallis H-test were used to explore the association between caregiver and child scores, concurrent validity, and known-group validity of the EQ-TIPS and EQ-5D-Y-3L.

RESULTS

Responses from 144 caregivers were collected, 66 for children aged 1 month to 4 years completing EQ-TIPS and 78 for children aged 5-18 years completing EQ-5D-Y-3L. The EQ-TIPS showed a higher report of no problems for social interaction for children aged 1-12 months (p = 0.040) than the older age groups, there were however no differences in the level sum score (LSS) or EQ Visual Analogue Scale scores between the age groups. The EQ-5D-Y-3L showed a significantly less report of problems for mobility (p = 0.013) and usual activities (p = 0.006) for children aged 5-7 years compared with children aged 8-12 and children aged 13-18 years. Similarly, the 5-7 years of age group had a significantly lower EQ-5D-Y-3L LSS compared with the older groups (H = 12.08, p = 0.002). The EQ-TIPS and EQ-5D-Y-3L showed moderate-to-strong associations with the PedsQL. EQ-TIPS median LSS was able to differentiate between groups on the clinical prognosis with a better health-related quality of life (HRQoL) in those where weaning from technology is possible compared with those where weaning is not possible (H = 18.98, p = 0.011). The EQ-5D-Y-3L can discriminate between breathing technology, where those with only a tracheostomy reported better HRQoL (H = 8.92, p = 0.012), and between mild and moderate clinical severity (H = 19.42, p < 0.001). Neither the PedsQL nor the PTHSI was able to discriminate between these groups across the age range. Caregiver and child HRQoL scores showed moderate-to-strong associations.

CONCLUSIONS

The EQ-TIPS and EQ-5D-Y-3L showed good validity in children dependent on the technology for breathing. The EQ-TIPS and EQ-5D-Y-3L LSS were all able to differentiate between children with known clinical variables and outperformed both the PedsQL and PTHSI, making them preferable for intervention research. The caregiver scores are associated with the child HRQoL scores and thus a spill-over should be accounted for in any interventions targeting this cohort. It is recommended that future studies investigate the reliability and responsiveness of these measures in children dependent on technology for breathing.

Tracheostomy, the Not So Definitive Airway?: Tracheostomy Morbidity in Pediatric Craniofacial Patients

BACKGROUND

Tracheostomy is the definitive treatment for airway management in severe cases of craniofacial-associated upper airway obstruction, like the Pierre-Robin sequence, but is associated with significant morbidity. The purpose of this study was to examine tracheostomy-associated morbidities and mortalities in craniofacial patients to identify opportunities to improve clinical care and patient prognosis.

METHODS

The study was a retrospective review of pediatric craniofacial patients who were tracheostomized between 2016 and 2022. Data regarding their demographics, craniofacial diagnoses, endoscopic airway anomalies, intubation grade of view classification, tracheostomy-related complications, and causes of mortality were analyzed.

RESULTS

Sixteen of the 17 tracheostomized pediatric patients had the Pierre-Robin sequence, with 5 of those patients having an additional syndromic craniofacial diagnosis. Additional airway anomalies were found in 82.4% of the patients. The mean length of hospital stay after tracheostomy was 4.08 months. Infection was the most common complication, observed in 94.1% of patients, followed by stomal granulation in 76.5% of patients. Two mortalities were observed: one following the compassionate removal of ventilator support and the other following the accidental dislodgment of the tracheostomy tube.

CONCLUSIONS

Tracheostomy-related complications were observed in all craniofacial patients in this group. Compared with the general pediatric population, tracheostomized craniofacial patients may endure longer hospital stays and greater stomal granulation rates. Mandibular distraction osteogenesis may allow for tracheostomy avoidance in these patients, and future research should focus on comparing the long-term complication rates and outcomes between tracheostomy mandibular distraction osteogenesis in this challenging patient population.

Factors influencing quality of life in children with tracheostomy with emphasis on home care visits: a multi-centre investigation

OBJECTIVE

Only a few studies have assessed the quality of life in children with tracheostomies. This study aimed to evaluate the quality of life and the factors influencing it in these children.

METHOD

This cross-sectional, two-centre study was conducted on paediatric patients living in the community with a tracheostomy by using the Pediatric Quality of Life Inventory. Clinical and demographic information of patients, as well as parents' socioeconomic factors, were obtained.

RESULTS

A total of 53 patients met our inclusion criteria, and their parents agreed to participate. The mean age of patients was 6.85 years, and 21 patients were ventilator-dependent. The total paediatric health-related quality of life score was 59.28, and the family impact score was 68.49. In non-ventilator-dependent patients, multivariate analyses indicated that social functioning and health-related quality of life were negatively affected by the duration of tracheostomy. The Quality of Life of ventilator-dependent patients was influenced by care visits and the presence of pulmonary co-morbidities.

CONCLUSION

Children with tracheostomies have a lower quality of life than healthy children do. Routine care visits by a respiratory therapist and nurses yielded significantly improved quality of life in ventilator-dependent children.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Flowchart for selecting an appropriate surgical airway in neurologically impaired pediatric intubated patients: a case series

OBJECTIVE

Medical advances have resulted in increased survival rates of neurologically impaired children who may require mechanical ventilation and subsequent tracheostomy as a surgical airway. However, at present, there is no definite consensus regarding the timing and methods for placement of a surgical airway in a neurologically impaired intubated child who needs to be cared for over a long-term period. We therefore created a flowchart for the selection of a surgical airway for Neurologically Impaired Pediatric Patients (NIPPs).

METHODS

The flowchart includes information on the patients' backgrounds, such as intubation period, prognosis related to reversibility, and history of aspiration pneumonia. To evaluate the importance of the flowchart, first we conducted a survey of pediatricians regarding selection of a surgical airway, and we also evaluated the appropriateness of the flowchart among pediatricians and caregivers through questionnaire surveys which include satisfaction with the decision-making process, and postoperative course after discharge.

RESULTS

A total of 21 NIPPs with intubation underwent surgery and a total of 24 participants (14 pediatricians and 10 caregivers) completed the survey. The answers regarding the importance of the flowchart showed that eleven pediatricians had experience selecting of surgical airways, nine of whom had had experiences in which they had to make a difficult decision. The answers regarding the appropriateness of the flowchart revealed that all pediatricians and caregivers were satisfied with the decision-making process and postoperative course after discharge using the flowchart.

CONCLUSIONS

The present study demonstrated the effectiveness of our flowchart for selecting an appropriate surgical airway in NIPP. By referring to our flowchart, pediatricians and caregivers are likely to be able to select an appropriate surgical airway, leading to increased satisfaction with the decision-making process and postoperative course.

LEVEL OF EVIDENCE: 4

COVID-19 y enfermedad pulmonar pediátrica: Experiencia en un centro de atención terciaria en Sudáfrica

La pandemia de COVID-19 resultó en una rápida diseminación global, con profundos impactos en los sistemas de salud. Aunque los datos pediátricos muestran de manera consistente un cuadro clínico más leve, se ha identificado que la enfermedad pulmonar crónica es un factor de riesgo para la hospitalización y para desarrollar una enfermedad grave. En África, continente formado predominantemente por países con ingresos bajos o medios (LMIC), la elevada prevalencia de VIH, tuberculosis, desnutrición y hacinamiento aumenta aún más los riesgos a la salud. En este trabajo se revisa la literatura sobre COVID-19 y enfermedad pulmonar crónica en niños, y relata nuestra experiencia en un centro de atención pulmonar pediátrico en Ciudad del Cabo, Sudáfrica. Los datos epidemiológicos en Sudáfrica confirman una baja prevalencia de la enfermedad grave, donde los pacientes < 18 años comprenden 8% de todos los casos diagnosticados de COVID-19 y 3% de todas las admisiones por esa causa. Se encontró una reducción en la admisión hospitalaria por otras infecciones del tracto respiratorio inferior. Aunque el servicio de pulmonología atiende niños con una amplia variedad de condiciones respiratorias crónicas, incluyendo bronquiectasias, fibrosis quística, asma, enfermedad pulmonar intersticial y pacientes con traqueostomías, no se observó un incremento significativo en las admisiones por COVID-19, y en quienes desarrollaron COVID-19, el curso de la enfermedad no fue grave. La evidencia actual sugiere que la preexistencia de una enfermedad respiratoria en niños no parece ser un factor de riesgo significativo para el COVID-19 grave. Aún se requieren datos longitudinales para evaluar el riesgo en niños con inmunosupresión y enfermedades pulmonares intersticiales. Los impactos indirectos de la respuesta a la pandemia en la salud respiratoria de los niños son notables, y es muy probable que aún deban comprenderse y cuantificarse. Garantizar el acceso de los niños a servicios preventivos y de cuidado completos durante este tiempo es prioritario.

COVID-19 and Pediatric Lung Disease: A South African Tertiary Center Experience

The COVID-19 pandemic led to rapid global spread with far-reaching impacts on health-care systems. Whilst pediatric data consistently shown a milder disease course, chronic lung disease has been identified as a risk factor for hospitalization and severe disease. In Africa, comprised predominantly of low middle-income countries (LMIC), the additional burden of HIV, tuberculosis, malnutrition and overcrowding is high and further impacts health risk. This paper reviewed the literature on COVID-19 and chronic lung disease in children and provides our experience from an African pediatric pulmonary center in Cape Town, South Africa. South African epidemiological data confirms a low burden of severe disease with children <18 years comprising 8% of all diagnosed cases and 3% of all COVID-19 admissions. A decrease in hospital admission for other viral lower respiratory tract infections was found. While the pulmonology service manages children with a wide range of chronic respiratory conditions including bronchiectasis, cystic fibrosis, asthma, interstitial lung disease and children with tracheostomies, no significant increase in COVID-19 admissions were noted and in those who developed COVID-19, the disease course was not severe. Current evidence suggests that pre-existing respiratory disease in children does not appear to be a significant risk factor for severe COVID-19. Longitudinal data are still needed to assess risk in children with immunosuppression and interstitial lung diseases. The indirect impacts of the pandemic response on child respiratory health are notable and still likely to be fully realized and quantified. Ensuring children have access to full preventive and care services during this time is priority.