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Suresh R, Roohani C, Wang CS, Kou YF, Johnson RF, Chorney SR. Subglottic Stenosis After Pediatric Tracheostomy. Laryngoscope 2024. [PMID: 39189344 DOI: 10.1002/lary.31736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 08/12/2024] [Accepted: 08/16/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVES To determine the incidence of subglottic stenosis (SGS) in children after tracheostomy and identify risk factors for development. STUDY DESIGN Retrospective cohort. METHODS All patients (<18 years) undergoing tracheostomy at a tertiary children's hospital between 2015 and 2020 were included. Patients with a direct laryngoscopy (DL) concurrent with tracheostomy and a subsequent DL were included. Medical records, including operative reports, were reviewed to identify subglottic stenosis and associated risk factors. RESULTS A total of 140 patients were included with mean age at tracheostomy of 2.4 years (standard deviation [SD]: 4.3) (median: 0.5 years, interquartile range [IQR]: 0.3-1.5 years) and gestational age of 33.8 weeks (SD: 5.9) (median: 36 weeks, IQR: 28-39 weeks). At initial DL, 24% (N = 34) had subglottic injury and 26% (N = 37) developed SGS. The incidence of SGS after tracheostomy was 11.5 cases per 100 patients per year. At tracheostomy, lower birth weight (1.8 vs. 2.3 kg, p = 0.005), shorter gestational age (31.8 vs. 34.6 weeks, p = 0.01), younger age (0.8 vs. 2.9 years, p = 0.01), lower weight (5.8 vs. 14.7 kg, p = 0.01), and subglottic injury (44% vs. 21%, p = 0.01) were associated with the development of SGS. Multivariable logistic regression analysis associated birth weight (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.31-0.75, p = 0.001) and early subglottic injury (OR: 3.22, 95% CI: 1.31-7.88, p = 0.01) with SGS development. CONCLUSIONS The incidence of SGS after pediatric tracheostomy is estimated at 11.5 cases per 100 patients per year. Low birth weight and subglottic injury at the time of tracheostomy were associated with SGS in this vulnerable population of children. LEVEL OF EVIDENCE 3 Laryngoscope, 2024.
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Affiliation(s)
- Rishi Suresh
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
| | - Cheyenne Roohani
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
| | - Cynthia S Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, 75390, U.S.A
- Department of Pediatric Otolaryngology, Children's Health, Dallas, Texas, 75207, U.S.A
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2
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Zirek F, Çobanoğlu N. Caregiver education before hospital discharge for children on home-invasive mechanical ventilation. Pediatr Pulmonol 2024; 59:2190-2195. [PMID: 38131474 DOI: 10.1002/ppul.26803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/08/2023] [Accepted: 11/11/2023] [Indexed: 12/23/2023]
Abstract
Children on home invasive mechanical ventilation necessitate specialized equipment, continuous monitoring, and multidisciplinary care. Transitioning these children from hospital to home care is complex, demanding careful planning. Guidelines and observational studies emphasize the importance of a standardized, comprehensive, and staged educational approach for caregiver education in discharge planning, yet program variations persist, lacking standardized checklists. This review aims to offer insights into crucial factors for a successful transition from hospital to home care for children using home-invasive mechanical ventilation while also developing comprehensive caregiver checklists to ensure high-quality care, taking into account families' socioeconomic status.
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Affiliation(s)
- Fazılcan Zirek
- Department of Paediatrics, Division of Paediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Nazan Çobanoğlu
- Department of Paediatrics, Division of Paediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
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3
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Tekin MN, Çobanoğlu N. Management of respiratory problems in children on home invasive mechanical ventilation. Pediatr Pulmonol 2024; 59:2216-2223. [PMID: 38251870 DOI: 10.1002/ppul.26875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 12/26/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
The management of respiratory problems in children on home invasive mechanical ventilation (HIMV) is a complex and challenging task. In recent years, with appropriate family education, these patients have been able to be discharged from the hospital and continue their treatment at home. The population of pediatric patients dependent on HIMV has been increasing worldwide, presenting unique and varying care needs. Management of these patients involves addressing ventilator settings, monitoring respiratory status, ensuring airway safety, and providing continuous support and education to patients and their caregivers. Despite the completion of home settings and family education, children on HIMV may encounter various respiratory problems during home follow-up. Prevention and timely management of these complications are crucial to improving patient outcomes. This article summarizes the most significant respiratory problems in children on HIMV and the management strategies for each problem are discussed, emphasizing the importance of appropriate aspiration techniques, regular monitoring, adequate training of caregivers, and a well-prepared emergency plan.
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Affiliation(s)
- Merve Nur Tekin
- Department of Paediatrics, Division of Paediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Nazan Çobanoğlu
- Department of Paediatrics, Division of Paediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
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4
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Henningfeld J, Friedrich AB, Flanagan G, Griffith C, Hughes A, Molkentine L, Steuart R, Wilkinson S, Baker CD. Transitioning children using home invasive mechanical ventilation from hospital to home: Discharge criteria, disparities, and ethical considerations. Pediatr Pulmonol 2024; 59:2113-2130. [PMID: 38441360 DOI: 10.1002/ppul.26948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/15/2024] [Accepted: 02/17/2024] [Indexed: 07/27/2024]
Abstract
Children using home invasive mechanical ventilation (HIMV), a valuable therapeutic option for chronic respiratory failure, constitute a growing population. Transitioning children using HIMV from hospital to home care is a complex process that requires a multidisciplinary approach involving healthcare professionals, caregivers, and community resources. Medical stability, caregiver competence, and home environment suitability are essential factors in determining discharge readiness. Caregiver education and training play a pivotal role in ensuring safe and effective home care. Simulation training and staged education progression are effective strategies for equipping caregivers with necessary skills. Resource limitations, inadequate home nursing support, and disparities in available community resources are common obstacles to successful HIMV discharge. International perspectives shed light on diverse healthcare systems and challenges faced by caregivers worldwide. While standardizing guidelines for HIMV discharge may be complex, collaboration among healthcare providers and the development of evidence-based regional guidelines can improve outcomes for children using HIMV and their caregivers. This review seeks to synthesize literature, provide expert guidance based on experience, and highlight components to safely discharge children using HIMV. It further assesses disparities and divergences within regional and international healthcare systems while addressing relevant ethical considerations.
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Affiliation(s)
- Jennifer Henningfeld
- Department of Pulmonary and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Annie B Friedrich
- Center for Bioethics and Medical Humanities and Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Grace Flanagan
- Department of Respiratory Care Services, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Cynthia Griffith
- Department of Respiratory Care Services, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Anna Hughes
- Paediatric Respiratory Department, Royal Manchester Children's Hospital, Manchester, UK
| | - Lisa Molkentine
- Department of Respiratory Care Services, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Rebecca Steuart
- Section of Special Needs and Complex Care Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stuart Wilkinson
- Paedaitric Respiratory Department, Royal Manchester Childrens Hospital, Manchester University, Manchester, UK
| | - Christopher D Baker
- Department of Pediatrics-Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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5
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Chawla J, Tan HL. Monitoring of physiologic features and treatment aspects of children on home invasive mechanical ventilation. Pediatr Pulmonol 2024; 59:2096-2102. [PMID: 38353355 DOI: 10.1002/ppul.26901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/15/2023] [Accepted: 01/27/2024] [Indexed: 07/27/2024]
Abstract
Pediatric home invasive mechanical ventilation patients are a small but resource-intensive cohort, requiring close monitoring and multidisciplinary care. Patients are often dependent on their ventilator for life support, with any significant complications such as equipment failure, tracheostomy blockage, or accidental decannulation becoming potentially life-threatening if not identified quickly. This review discusses the indications and variations in practice worldwide, in terms of models of care, including home care provision, choice of equipment, and monitoring. With advances in technology, optimal monitoring strategies for home, continue to be debated: In-built ventilator alarms are often inadequately sensitive for pediatric patients, necessitating additional external monitoring devices to minimize risk. Pulse oximetry has been the preferred monitoring modality at home, though in some special circumstances such as congenital central hypoventilation syndrome, home carbon dioxide monitoring may be important to consider. Children should be under regular follow-up at specialist respiratory centers where clinical evaluation, nocturnal oximetry, and capnography monitoring and/or poly(somno)graphy and analysis of ventilator download data can be performed regularly to monitor progress. Recent exciting advances in technology, particularly in telemonitoring, which have potential to hugely benefit this complex group of patients are also discussed.
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Affiliation(s)
- Jasneek Chawla
- Paediatric Respiratory and Sleep Specialist, Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Australia
- Kids Sleep Research Team, Child Health Research Centre, The University of Queensland, Queensland, Australia
| | - Hui-Leng Tan
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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6
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Nayır Büyükşahin H, Yalcın E. The follow-up of children on home invasive mechanical ventilation after hospital discharge. Pediatr Pulmonol 2024; 59:2145-2148. [PMID: 37701948 DOI: 10.1002/ppul.26683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
The number of children on home invasive mechanical ventilation (HIMV) has been increasing because it is a cost-effective strategy, the developments in technological tools, and its psychological and developmental advantages. Therefore, healthcare providers should be familiar with the follow-up of these patients after hospital discharge. This review will highlight the important points to be aware of during home care of children on HIMV, emphasizing the frequency of scheduled hospital visits after hospital discharge, recognizing adverse events related to HIMV, and ensuring the continued care of these children in areas such as vaccination, and performing appropriate tests in the follow-up.
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Affiliation(s)
- Halime Nayır Büyükşahin
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Yalcın
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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7
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Raven SA, Montgomery NT, Chen AS, Nourmohammadi Z, Plott J, Shih A, Koppera P, Zopf DA. Effects of saline submersion at body temperature on airway supportive devices including a novel nasopharyngeal device produced using 3D-printing. Am J Otolaryngol 2024; 45:104366. [PMID: 38729016 DOI: 10.1016/j.amjoto.2024.104366] [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: 03/15/2024] [Accepted: 04/27/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE This study investigated dimension changes of various nasopharyngeal airways, including a novel self-supporting device, after saline submersion at body temperature to simulate in-vivo use. Dimension changes over time may reduce efficacy during long-term use and require sizing adjustments or limits on duration of use. MATERIALS AND METHODS Cuffless Covidien endotracheal tubes, pediatric Rusch fixed flange polyvinyl chloride nasal airway tubes, pediatric Rusch Robertazzi style Mediprene nasal airway tubes, and novel silicone elastomer self-supporting nasopharyngeal airways were fully submerged in 0.9 % normal saline solution incubated at 37 degrees Celsius for 15 days. All devices had tube length and wall thickness measured after 0, 1, 2, 3, 4, 5, 10, and 15 days. The 95 % confidence intervals of tube dimensions at each date were compared with the 95 % confidence intervals at day 0. RESULTS The Covidien ET tube, Rusch PVC NPA, and ssNPA tube lengths and wall thicknesses did not change significantly over 15 days. The Rusch Mediprene NPAs had a statistically significant increase in length starting at day 1 and wall thickness at day 2. CONCLUSIONS The novel ssNPA did not expand in the in-vitro environment, supporting its safety for extended use. The PVC NPA and ET tube dimensions also remained stable. However, the Rusch Mediprene NPAs had significant length expansion after 1 day of submersion, indicating a considerable risk of expansion during extended use with potential implications for patient care. Silicone and PVC NPA dimensions remained stable when saturated, indicating these materials may be more appropriate for extended use.
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Affiliation(s)
- Sarah A Raven
- University of Michigan Medical School, Michigan Medicine, University of Michigan, 1301 Catherine Street, Ann Arbor, MI 49109, USA; Department of Otolaryngology - Head and Neck Surgery, Wayne State University, 5E UHC, 4201 St Antoine, Detroit, MI 48201, USA
| | - Nathan T Montgomery
- Department of Mechanical Engineering, College of Engineering, University of Michigan, 2350 Hayward Street, Ann Arbor, MI 48109, USA; Department of Biomedical Engineering, College of Engineering, University of Michigan, 2200 Bonisteel Boulevard, Ann Arbor, MI 48109, USA
| | - Alyssa S Chen
- University of Michigan Medical School, Michigan Medicine, University of Michigan, 1301 Catherine Street, Ann Arbor, MI 49109, USA; Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Mass General Brigham, 243 Charles Street, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Zahra Nourmohammadi
- Department of Biomedical Engineering, College of Engineering, University of Michigan, 2200 Bonisteel Boulevard, Ann Arbor, MI 48109, USA
| | - Jeffrey Plott
- Department of Biomedical Engineering, College of Engineering, University of Michigan, 2200 Bonisteel Boulevard, Ann Arbor, MI 48109, USA
| | - Albert Shih
- Department of Mechanical Engineering, College of Engineering, University of Michigan, 2350 Hayward Street, Ann Arbor, MI 48109, USA; Department of Biomedical Engineering, College of Engineering, University of Michigan, 2200 Bonisteel Boulevard, Ann Arbor, MI 48109, USA
| | - Prabhat Koppera
- Department of Anesthesiology, Michigan Medicine, University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI 48109, USA
| | - David A Zopf
- Department of Biomedical Engineering, College of Engineering, University of Michigan, 2200 Bonisteel Boulevard, Ann Arbor, MI 48109, USA; Department of Otolaryngology - Head and Neck Surgery, Michigan Medicine, University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI 48109, USA.
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8
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Harris JC, Patel RC, Ruiz RL. Pediatric Custom Tracheostomies: A Ten-Year Experience. Laryngoscope 2024; 134:452-458. [PMID: 37194657 DOI: 10.1002/lary.30743] [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: 09/17/2022] [Revised: 03/14/2023] [Accepted: 04/29/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVES To describe the use of customized and custom tracheostomies at our institution, and to identify trends in patient presentation and tracheostomy design. METHODS A retrospective review was conducted for patients at our institution for whom a customized or custom tracheostomy tube was ordered between January 2011 and July 2021. Customized tracheostomy tubes allow for a small selection of alterations to trach design, such as cuff length and flange type. Custom tracheostomies have a unique design created by tracheostomy tube engineers in collaboration with the clinical provider, and are built specifically for a single patient. RESULTS A total of 235 patients were included, of whom 220 (93%) received customized tracheostomies and 15 custom (7%). The most common indications for customized tracheostomy were tracheal or stomal breakdown on a standard tracheostomy (n = 73, 33%) and ventilation difficulties (n = 61, 27%). The most frequent customization was shaft length (n = 126, 57%). The most common indication for custom tracheostomies was a persistent air leak on a standard or customized trach (n = 9) and the most frequent designs were custom cuffs (n = 8), flanges (n = 4), and anteriorly curved shafts (n = 4). Patients treated with a customized tracheostomy had a 5-year overall survival of 75.3%, compared to 51.4% for custom. CONCLUSION These are the first cohorts of pediatric patients with customized and custom tracheostomies to be described. Modifications to tracheostomies, in particular shaft length and cuff design, can address common complications of extended tracheostomy, and may help improve ventilation in the most challenging cases. LEVEL OF EVIDENCE 4 Laryngoscope, 134:452-458, 2024.
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Affiliation(s)
- Jacob C Harris
- Department of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rosemary C Patel
- Department of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ryan L Ruiz
- Department of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Birru F, Gerdung CA, Castro-Codesal M. Microbiology and management of respiratory infections in children with tracheostomy. Paediatr Respir Rev 2023; 48:39-46. [PMID: 37330411 DOI: 10.1016/j.prrv.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/23/2023] [Indexed: 06/19/2023]
Abstract
Tracheostomy-related respiratory infections are common, though the diagnosis and management can be challenging in children. The goal of this review article was to provide an overview of the current knowledge known about recognizing and treating respiratory infections in this population and to emphasize future areas for further research. While several small and retrospective papers attempt to provide information, there remain more questions than answers. We have reviewed ten published articles to understand this topic, bringing to light significant variation in clinical practices across institutions. While identifying the microbiology is important, it is also crucial to recognize when to treat. Differentiating acute infection, chronic infection, and colonization are important features that influence the treatment of lower respiratory tract infection in children with a tracheostomy.
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Affiliation(s)
- F Birru
- Division of Pediatric Respiratory Medicine, University of Alberta, Edmonton, AB, Canada.
| | - C A Gerdung
- Division of Pediatric Respiratory Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Castro-Codesal
- Division of Pediatric Respiratory Medicine, University of Alberta, Edmonton, AB, Canada
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10
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Raynor T, Bedwell J. Pediatric tracheostomy decannulation: what's the evidence? Curr Opin Otolaryngol Head Neck Surg 2023; 31:397-402. [PMID: 37751378 DOI: 10.1097/moo.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW Pediatric decannulation failure can be associated with large morbidity and mortality, yet there are no published evidence-based guidelines for pediatric tracheostomy decannulation. Tracheostomy is frequently performed in medically complex children in whom it can be difficult to predict when and how to safely decannulate. RECENT FINDINGS Published studies regarding pediatric decannulation are limited to reviews and case series from single institutions, with varying populations, indications for tracheostomy, and institutional resources. This article will provide a review of published decannulation protocols over the past 10 years. Endoscopic airway evaluation is required to assess the patency of the airway and address any airway obstruction prior to decannulation. There is considerable variability in tracheostomy tube modification between published protocols, though the majority support a capping trial and downsizing of the tracheostomy tube to facilitate capping. Most protocols include overnight capping in a monitored setting prior to decannulation with observation ranging from 24 to 48 h after decannulation. There is debate regarding which patients should have capped polysomnography (PSG) prior to decannulation, as this exam is resource-intensive and may not be widely available. Persistent tracheocutaneous fistulae are common following decannulation. Excision of the fistula tract with healing by secondary intention has a lower reported operative time, overall complication rate, and postoperative length of stay. SUMMARY Pediatric decannulation should occur in a stepwise process. The ideal decannulation protocol should be safe and expedient, without utilizing excessive healthcare resources. There may be variability in protocols based on patient population or institutional resources, but an explicitly described protocol within each institution is critical to consistent care and quality improvement over time. Further research is needed to identify selection criteria for who would most benefit from PSG prior to decannulation to guide allocation of this limited resource.
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St-Laurent A, Zielinski D, Qazi A, AlAwadi A, Almajed A, Adamko DJ, Alabdoulsalam T, Chiang J, Derynck M, Gerdung C, Kam K, Katz SL, MacLusky I, Mehta K, Mateos D, Nguyen TTD, Praud JP, Proulx F, Seear M, Smith MJ, Wensley D, Amin R. Chronic tracheostomy care of ventilator-dependent and -independent children: Clinical practice patterns of pediatric respirologists in a publicly funded (Canadian) healthcare system. Pediatr Pulmonol 2023; 58:140-151. [PMID: 36178281 DOI: 10.1002/ppul.26171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/06/2022] [Accepted: 09/25/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To describe the current clinical practice patterns of Canadian pediatric respirologists at pediatric tertiary care institutions regarding chronic tracheostomy tube care and management of home invasive ventilation. METHODS A pediatric respirologist/pediatrician with expertise in tracheostomy tube care and home ventilation was identified at each Canadian pediatric tertiary care center to complete a 59-item survey of multiple choice and short answer questions. Domains assessed included tracheostomy tube care, caregiver competency and home monitoring, speaking valves, medical management of tracheostomy complications, decannulation, and long-term follow-up. RESULTS The response rate was 100% (17/17) with all Canadian tertiary care pediatric centers represented and heterogeneity of practice was observed in all domains assessed. For example, though most centers employ Bivona™ (17/17) and Shiley™ (15/17) tracheostomy tubes, variability was observed around tube change, re-use, and cleaning practices. Most centers require two trained caregivers (14/17) and recommend 24/7 eyes on care and oxygen saturation monitoring. Discharge with an emergency tracheostomy kit was universal (17/17). Considerable heterogeneity was observed in the timing and use of speaking valves and speech-language assessment. Inhaled anti-pseudomonal antibiotics are employed by most centers (16/17) though the indication, agent, and protocol varied by center. Though decannulation practices varied considerably, the requirement of upper airway patency was universally required to proceed with decannulation (17/17) independent of ongoing ventilatory support requirements. CONCLUSION Considerable variability in pediatric tracheostomy tube care practice exists across Canada. These results will serve as a starting point to standardize and evaluate tracheostomy tube care nationally.
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Affiliation(s)
- Aaron St-Laurent
- Department of Paediatrics, Division of Respiratory Medicine, Children's Hospital-London Health Sciences Centre, London, Ontario, Canada
| | - David Zielinski
- Division of Pediatric Respirology, Department of Pediatrics, Montreal Children's Hospital/McGill University, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Adam Qazi
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
| | - Aceel AlAwadi
- Mubarak Al-Kabeer Hospital, Ministry of Health of Kuwait, Jabriya, Kuwait
| | - Athari Almajed
- Mubarak Al-Kabeer Hospital, Ministry of Health of Kuwait, Jabriya, Kuwait
| | - Darryl J Adamko
- Department of Pediatrics, Division of Respiratory Medicine, Jim Pattison's Children's Hospital, Saskatoon, Saskatchewan, Canada
| | - Tareq Alabdoulsalam
- Section of Pediatric Respirology, Department of Pediatrics and Child Health, HSC Winnipeg Children's Hospital/University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jackie Chiang
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
| | - Michael Derynck
- Department of Pediatrics, Kingston Health Sciences Centre/Queen's University, Kingston, Ontario, Canada
| | - Chris Gerdung
- Stollery Children's Hospital, Department of Pediatrics, The Division of Respiratory Medicine, University of Alberta, Edmonton Alberta, Canada
| | - Karen Kam
- Department of Pediatrics, Section of Respiratory Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sherri L Katz
- Department of Pediatrics, Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Ian MacLusky
- Department of Pediatrics, Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada
| | - Kevan Mehta
- Department of Pediatrics, Division of Respirology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Dimas Mateos
- Department of Pediatrics, Pediatric Respirology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - The Thanh D Nguyen
- Department of Pediatrics, Division of Respirology, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Jean-Paul Praud
- Division of Respiratory Medicine, Department of Pediatrics, University of Sherbrooke, Quebec, Canada
| | - Frederic Proulx
- Department of Pediatrics, Division of Respirology, CHUL et Centre Mère-Enfant Soleil, Quebec, Quebec, Canada
| | - Michael Seear
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Mary Jane Smith
- Department of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| | - David Wensley
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Reshma Amin
- Department of Pediatrics, The Division of Respiratory Medicine, Toronto, The Hospital for Sick Children, Ontario, Canada
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Noritz G, Davidson L, Steingass K. Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy. Pediatrics 2022; 150:e2022060055. [PMID: 36404756 DOI: 10.1542/peds.2022-060055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.
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Affiliation(s)
- Garey Noritz
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
| | - Lynn Davidson
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Katherine Steingass
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
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Gipsman A, Prero M, Toltzis P, Craven D. Tracheobronchitis in children with tracheostomy tubes: Overview of a challenging problem. Pediatr Pulmonol 2022; 57:814-821. [PMID: 34981895 DOI: 10.1002/ppul.25814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 12/21/2022]
Abstract
Tracheobronchitis is common in children with tracheostomy tubes. These children are predisposed to respiratory infections due to the bypassing of normal upper airway defense mechanisms by the tracheostomy, bacterial colonization of the tracheostomy tube itself, and underlying medical conditions. Diagnosis of bacterial tracheobronchitis is challenging due to the difficulty in differentiating between bacterial colonization and infection, as well as between viral and bacterial etiologies. Difficulty in diagnosis complicates management decisions, and there are currently no consensus guidelines to assist clinicians in the treatment of these patients. Frequent administration of systemic antibiotics causes adverse effects and leads to the emergence of resistant organisms. Topical administration of antibiotics via nebulization or direct instillation may lead to a significantly higher concentration of drug in the upper and lower airways without causing systemic side effects, although therapeutic trials in children with tracheostomy tubes are lacking. Several preventative measures such as regular airway clearance and the use of a speaking valve may mitigate the risk of developing respiratory infections.
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Affiliation(s)
- Alexander Gipsman
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Moshe Prero
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Philip Toltzis
- Department of Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel Craven
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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14
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Phuaksaman C, Niyomkarn W, Somboon P, Boonjindasup W, Hantragool S, Sritippayawan S. Long-term Outcomes of Pediatric Tracheostomy Home Care in a Limited Resource Setting of Professional Home Nurse. HOME HEALTH CARE MANAGEMENT AND PRACTICE 2022. [DOI: 10.1177/10848223221082661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Long-term outcomes of pediatric patients with a tracheostomy in developing countries where professional home nurse is not accessible has rarely been reported. We, therefore, investigated the prevalence and associating factors of long-term outcomes in these children. Retrospective chart review was conducted in 85 tracheostomized children who were discharged to home during January 2012 to December 2020. Tracheostomy home care was provided by caregivers who completed the tracheostomy home care program. Prevalence of unplanned readmission with acute respiratory problems within 30 days after the first hospital discharge was 17.6%. Lower respiratory tract infection (LRTI) after hospital discharge was found in 72.9% (median frequency of 1.0 episode/case/year). Among 80 children who had surveillance airway endoscopy, 46.3% demonstrated late tracheostomy-related airway complications. Independent factor associated with late tracheostomy-related airway complications was a follow-up period longer than 1 year. Decannulation success was found in 21.2%. Most of them had tracheostomy for their upper airway anomalies. The mortality rate was 7%. Most of them died from their underlying diseases. In conclusion, pediatric tracheostomy home care undertaken by caregivers is feasible in developing countries where home nurse is not available. The prevalence of unplanned readmission with acute respiratory problems within 30 days after hospital discharge and late tracheostomy-related airway complications were comparable with those reported in developed countries. However, we still had a high prevalence of post-tracheostomy LRTI which was a challenging problem that needed to be investigated and resolved.
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15
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Yilmaz Yegit C, Kilinc AA, Can Oksay S, Unal F, Yazan H, Köstereli E, Gulieva A, Arslan H, Uzuner S, Onay ZR, Kilic Baskan A, Collak A, Atag E, Ergenekon AP, Bas Ikizoğlu N, Ay P, Oktem S, Gokdemir Y, Girit S, Cakir E, Uyan ZS, Cokugras H, Karadag B, Karakoc F, Erdem Eralp E. The ISPAT project: Implementation of a standardized training program for caregivers of children with tracheostomy. Pediatr Pulmonol 2022; 57:176-184. [PMID: 34562057 DOI: 10.1002/ppul.25704] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/15/2021] [Accepted: 09/15/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Tracheostomy-related morbidity and mortality mainly occur due to decannulation, misplacement, or obstruction of the tube. A standardized training can improve the skills and confidence of the caregivers in tracheostomy care (TC). OBJECTIVE Our primary aim was to evaluate the efficiency of standardized training program on the knowledge and skills (changing-suctioning the tracheostomy tube) of the participants regarding TC. MATERIALS AND METHODS Sixty-five caregivers of children with tracheostomy were included. First, participants were evaluated with written test about TC and participated in the practical tests. Then, they were asked to participate in a standardized training session, including theoretical and practical parts. Baseline and postintervention assessments were compared through written and practical tests conducted on the same day. RESULTS A significant improvement was observed in the written test score after the training. The median number of correct answers of the written test including 23 questions increased 26%, from 12 to 18 (p < .001). The median number of correct steps in tracheostomy tube change (from 9 to 16 correct steps out of 16 steps, 44% increase) and suctioning the tracheostomy tube (from 9 to 17 correct steps out of 18 steps, 44% increase) also improved significantly after the training (p < .001, for both). CONCLUSION Theoretical courses and practical hands-on-training (HOT) courses are highly effective in improving the practices in TC. A standardized training program including HOT should be implemented before discharge from the hospital. Still there is a need to assess the impact of the program on tracheostomy-related complications, morbidity, and mortality in the long term.
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Affiliation(s)
- Cansu Yilmaz Yegit
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Ayse Ayzit Kilinc
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Sinem Can Oksay
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Fusun Unal
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Hakan Yazan
- Division of Pediatric Pulmonology, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Ebru Köstereli
- Division of Pediatric Pulmonology, Koc University, School of Medicine, Istanbul, Turkey
| | - Aynur Gulieva
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Hüseyin Arslan
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Selçuk Uzuner
- Division of Pediatrics, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Zeynep Reyhan Onay
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Azer Kilic Baskan
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Abdulhamit Collak
- Division of Pediatrics, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Emine Atag
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Almala Pinar Ergenekon
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Nilay Bas Ikizoğlu
- Division of Pediatric Pulmonology, Sureyyapasa Chest Diseases and Thoracic Surgery Training Hospital
| | - Pinar Ay
- Division of Public Health, Marmara University, School of Medicine, Istanbul, Turkey
| | - Sedat Oktem
- Division of Pediatric Pulmonology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Yasemin Gokdemir
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Saniye Girit
- Division of Pediatric Pulmonology, Istanbul Medeniyet University, Faculty of Health Sciences, Istanbul, Turkey
| | - Erkan Cakir
- Division of Pediatric Pulmonology, Istanbul Bezmialem University, School of Medicine, Istanbul, Turkey
| | - Zeynep Seda Uyan
- Division of Pediatric Pulmonology, Koc University, School of Medicine, Istanbul, Turkey
| | - Haluk Cokugras
- Division of Pediatric Pulmonology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Bulent Karadag
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Fazilet Karakoc
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Ela Erdem Eralp
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
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16
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Baker CD. Chronic respiratory failure in bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3490-3498. [PMID: 33666365 DOI: 10.1002/ppul.25360] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 11/09/2022]
Abstract
Although survival has improved dramatically for extremely preterm infants, those with the most severe forms of bronchopulmonary dysplasia (BPD) fail to improve in the neonatal period and go on to develop chronic respiratory failure. When careful weaning of respiratory support is not tolerated, the difficult decision of whether or not to pursue chronic ventilation via tracheostomy must be made. This requires shared decision-making with an interdisciplinary medical team and the child's family. Although they suffer from increased morbidity and mortality, the majority of these children will survive to tolerate ventilator liberation and tracheostomy decannulation. Care coordination for the technology-dependent preterm infant is complex, but there is a growing consensus that chronic ventilation can best support neurodevelopmental progress and improve long-term outcomes.
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Affiliation(s)
- Christopher D Baker
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Alsunaid S, Holden VK, Kohli A, Diaz J, O'Meara LB. Wound care management: tracheostomy and gastrostomy. J Thorac Dis 2021; 13:5297-5313. [PMID: 34527367 PMCID: PMC8411156 DOI: 10.21037/jtd-2019-ipicu-13] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/27/2020] [Indexed: 01/12/2023]
Abstract
Percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) tube placements are routine procedures performed in the intensive care units (ICUs). They are performed to facilitate care and promote healing. They also help prevent complications from prolonged endotracheal intubation and malnutrition. In most cases, both are performed simultaneously. Physicians performing them require knowledge of local anatomy, tissue and vascular relationships, along with advance bronchoscopy and endoscopy skills. Although PDTs and PEGs are considered relatively low-risk procedures, operators need to have the knowledge and skill to recognize and prevent adverse outcomes. Current published literature on post-procedural care and stoma wound management was reviewed. Available recommendations for the routine care of tracheostomy and PEG tubes are included in this review. Signs and symptoms of early PDT- and PEG-related complications and their management are discussed in detail. These include hemorrhage, infection, accidental decannulation, tube obstruction, clogging, and dislodgement. Rare, life-threatening complications are also discussed. Multidisciplinary teams are needed for improved patient care, and members should be aware of all pertinent care aspects and potential complications related to PDT and PEG placement. Each institute is strongly encouraged to have detailed protocols to standardize care. This review provides a state-of-the-art guidance on the care of patients with tracheostomies and gastrostomies specifically in the ICU setting.
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Affiliation(s)
- Sammar Alsunaid
- Division of Pulmonary & Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Van K Holden
- Division of Pulmonary & Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akshay Kohli
- Department of Internal Medicine, Medstar Washington Hospital Center, Georgetown University, Washington, DC, USA
| | - Jose Diaz
- Division of Acute Care Emergency Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Lindsay B O'Meara
- Division of Acute Care Emergency Surgery, University of Maryland Medical Center, Baltimore, MD, USA
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18
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Discharge Practices for Children with Home Mechanical Ventilation across the United States. Key-Informant Perspectives. Ann Am Thorac Soc 2021; 17:1424-1430. [PMID: 32780599 DOI: 10.1513/annalsats.201912-875oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: In 2016, the American Thoracic Society released clinical practice guidelines for pediatric chronic home invasive ventilation pertaining to discharge practices and subsequent management for patients with invasive ventilation using a tracheostomy. It is not known to what extent current U.S. practices adhere to these recommendations.Objectives: Hospital discharge practices and home health services are not standardized for children with invasive home mechanical ventilation (HMV). We assessed discharge practices for U.S. children with HMV.Methods: A survey of key-informant U.S. clinical providers of children with HMV, identified with purposeful and snowball sampling, was conducted. Topics included medical stability, family caregiver training, and discharge guidelines. Close-ended responses were analyzed using descriptive statistics. Responses to open-ended questions were analyzed using open coding with iterative modification for major theme agreement.Results: Eighty-eight responses were received from 157 invitations. Eligible survey responses from 59 providers, representing 44 U.S. states, included 49.2% physicians, 37.3% nurses, 10.2% respiratory therapists, and 3.4% case managers. A minority, 22 (39%) reported that their institution had a standard definition of medical stability; the dominant theme was no ventilator changes 1-2 weeks before discharge. Nearly all respondents' institutions (94%) required that caregivers demonstrate independent care; the majority (78.4%) required two trained HMV caregivers. Three-fourths described codified discharge guidelines, including the use of a discharge checklist, assurance of home care, and caregiver training. Respondents described variable difficulty with obtaining durable medical equipment, either because of insurance or durable-medical-equipment company barriers.Conclusions: This national U.S. survey of providers for HMV highlights heterogeneity in practice realities of discharging pediatric patients with HMV. Although no consensus exists, defining medical stability as no ventilator changes 1-2 weeks before discharge was common, as was having an institutional requirement for training two caregivers. Identification of factors driving heterogeneity, data to inform standards, and barriers to implementation are needed to improve outcomes.
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19
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Chawla J, Edwards EA, Griffiths AL, Nixon GM, Suresh S, Twiss J, Vandeleur M, Waters KA, Wilson AC, Wilson S, Tai A. Ventilatory support at home for children: A joint position paper from the Thoracic Society of Australia and New Zealand/Australasian Sleep Association. Respirology 2021; 26:920-937. [PMID: 34387937 PMCID: PMC9291882 DOI: 10.1111/resp.14121] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/04/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022]
Abstract
The goal of this position paper on ventilatory support at home for children is to provide expert consensus from Australia and New Zealand on optimal care for children requiring ventilatory support at home, both non-invasive and invasive. It was compiled by members of the Thoracic Society of Australia and New Zealand (TSANZ) and the Australasian Sleep Association (ASA). This document provides recommendations to support the development of improved services for Australian and New Zealand children who require long-term ventilatory support. Issues relevant to providers of equipment and areas of research need are highlighted.
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Affiliation(s)
- Jasneek Chawla
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Elizabeth A Edwards
- New Zealand Respiratory & Sleep Institute, Starship Children's Hospital, Auckland, New Zealand
| | - Amanda L Griffiths
- Respiratory & Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Gillian M Nixon
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Sadasivam Suresh
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jacob Twiss
- New Zealand Respiratory & Sleep Institute, Starship Children's Hospital, Auckland, New Zealand
| | - Moya Vandeleur
- Respiratory & Sleep Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Karen A Waters
- Sleep Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Andrew C Wilson
- Respiratory & Sleep Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Susan Wilson
- Child Youth Mental Health Services, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Andrew Tai
- Respiratory & Sleep Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
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20
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Verma R, Mocanu C, Shi J, Miller MR, Chiang J, Wolter NE, Propst EJ, St-Laurent A, Amin R. Decannulation following tracheostomy in children: A systematic review of decannulation protocols. Pediatr Pulmonol 2021; 56:2426-2443. [PMID: 34231976 DOI: 10.1002/ppul.25503] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/18/2021] [Accepted: 04/30/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To provide a systematic review of the existing pediatric decannulation protocols, including the role of polysomnography, and their clinical outcomes. METHODS Five online databases were searched from database inception to May 29, 2020. Study inclusion was limited to publications that evaluated tracheostomy decannulation in children 18 years of age and younger. Data extracted included patient demographics and primary indication for tracheostomy. Methods used to assess readiness for decannulation were noted including the use of bronchoscopy, tracheostomy tube modifications, and gas exchange measurements. After decannulation, details regarding mode of ventilation, location, and length of observation period, and clinical outcomes were also collected. Descriptive statistical analyses were performed. RESULTS A total of 24 studies including 1395 children were reviewed. Tracheostomy indications included upper airway obstruction at a well-defined anatomic site (35%), upper airway obstruction not at a well-defined site (12%) and need for long-term ventilation and pulmonary care (53%). Bronchoscopy was routinely used in 23 of 24 (96%) protocols. Tracheostomy tube modifications in the protocols included capping (n = 20, 83%), downsizing (n = 14, 58%), and fenestrations (n = 2, 8%). Measurements of gas exchange included polysomnography (n = 13/18, 72%), oximetry (n = 10/18, 56%), blood gases (n = 3,17%), and capnography (n = 3, 17%). After decannulation, children in 92% of protocols were transitioned to room air. Observation period of 48 h or less was used in 76% of children. CONCLUSIONS There exists large variability in pediatric decannulation protocols. Polysomnography plays an integral role in assessing most children for tracheostomy removal. Evidence-based guidelines to standardize pediatric tracheostomy care remain an urgent priority.
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Affiliation(s)
- Rahul Verma
- Department of Pediatrics, Children's Hospital, Western University, London, Ontario, Canada
| | - Cora Mocanu
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Jenny Shi
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michael R Miller
- Department of Pediatrics, Children's Hospital, Western University, London, Ontario, Canada
- Children's Health Research Institute, London, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Aaron St-Laurent
- Division of Respiratory Medicine, Children's Hospital, Western University, London, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences (CHES) SickKids Research Institute, Toronto, Ontario, Canada
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21
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Keane A, Saadi RA, Slonimsky E, Wilson M, May J. Comparison of tracheoscopy and portable chest X-Ray in the evaluation of infant tracheostomy tube position. Int J Pediatr Otorhinolaryngol 2021; 141:110566. [PMID: 33348124 DOI: 10.1016/j.ijporl.2020.110566] [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: 08/22/2020] [Revised: 12/13/2020] [Accepted: 12/13/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare tracheoscopy and chest radiograph measurements of tracheostomy tube position in infants. STUDY DESIGN Retrospective chart review. SETTING Otolaryngology Department at Penn State Milton S. Hershey Medical Center. SUBJECTS AND METHODS All cases of pediatric patients who underwent tracheotomy at less than 1 year of age from 2014 to 2019 were reviewed. Patients were included if they had both intraoperative measurement of tracheostomy tube position relative to the carina by tracheoscopy and postoperative chest radiograph. Documented intraoperative findings were compared to measurements made on chest radiograph by an attending radiologist blinded to the intraoperative measurements. RESULTS The study included 66 patients; 30 patients (14:16, M:F) had available data. The mean distance from the distal tracheostomy tube to the carina measured by tracheoscopy was 8.88 mm (range, 3.5-20 mm) and measured radiographically was 11.71 mm (range, 2.4-23.3 mm). The mean difference between the measurements was 2.82 mm (p-value = 0.016). Ninety percent (n = 27) of patients had measurements that differed by greater than 2 mm; 53% (n = 16) had measurements that differed by 5 mm and 1% (n = 3) had measurements differing by greater than 10 mm. CONCLUSION In the infant population, significant discrepancy was found between direct tracheoscopy and chest radiograph measurements of the tracheostomy tube position. Measurements obtained by chest radiographs tend to overestimate the relative distance of the distal tracheostomy tube to the carina as compared to that of tracheoscopy. Clinical decisions regarding changes to tracheostomy tube sizes should mostly rely on tracheoscopy performed with the patient supine.
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Affiliation(s)
- Allison Keane
- Department of Otolaryngology - Head and Neck Surgery, Penn State Health, Milton S. Hershey Medical Center, 500 University Drive, P.O Box 850, MC H091, Hershey, 17033, PA, USA
| | - Robert A Saadi
- Department of Otolaryngology - Head and Neck Surgery, Penn State Health, Milton S. Hershey Medical Center, 500 University Drive, P.O Box 850, MC H091, Hershey, 17033, PA, USA
| | - Einat Slonimsky
- Department of Radiology, Penn State Health, Milton S. Hershey Medical Center, 500 University Drive, P.O Box 850, Hershey, 17033, PA, USA
| | - Meghan Wilson
- Department of Otolaryngology - Head and Neck Surgery, Penn State Health, Milton S. Hershey Medical Center, 500 University Drive, P.O Box 850, MC H091, Hershey, 17033, PA, USA
| | - Jason May
- Department of Otolaryngology - Head and Neck Surgery, Penn State Health, Milton S. Hershey Medical Center, 500 University Drive, P.O Box 850, MC H091, Hershey, 17033, PA, USA.
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22
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Palliative Care for Children with Lung Diseases. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Al Bahri K, Liu CC. Surveillance endoscopy in pediatric tracheostomy: A systematic review. Int J Pediatr Otorhinolaryngol 2021; 140:110533. [PMID: 33296833 DOI: 10.1016/j.ijporl.2020.110533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To systematically review the literature on the yield of surveillance airway endoscopy in pediatric patients with tracheostomies. METHODS A systematic search was performed according to PRISMA guidelines of the MEDLINE/Pubmed and Embase databases. Data were collected on the following outcomes of interest: abnormal airway findings in surveillance endoscopy performed in pediatric tracheostomy patients, frequency and nature of interventions performed during endoscopy, and predictive factors associated with abnormal airway findings. RESULTS Seven studies were included in the review. The timing of endoscopy post-tracheostomy placement was variable and ranged from 1 to 24 months. All studies reported abnormal airway findings on initial endoscopic examination, with rates varying from 20 to 87%. Airway granulomas/granulation tissue was the most common finding, followed by airway stenosis and suprastomal collapse. Interventions performed to improve airway safety occurred in 18%-64% of patients undergoing surveillance endoscopy. The most commonly reported interventions were debridement of granulation tissue and dilation of subglottic stenosis. No endoscopy-related complications were reported across the studies. The presence of tracheostomy-related symptoms was the most consistently reported predictor of abnormal airway findings and airway interventions. CONCLUSION Pediatric tracheostomy patients undergoing surveillance airway endoscopy have a high rate of abnormal airway findings and interventions. However, additional studies are needed before routine endoscopy can be recommended in asymptomatic patients.
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Affiliation(s)
- Khaloud Al Bahri
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Canada
| | - C Carrie Liu
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Canada; Division of Pediatric Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Canada.
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24
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Hebbar KB, Kasi AS, Vielkind M, McCracken CE, Ivie CC, Prickett KK, Simon DM. Mortality and Outcomes of Pediatric Tracheostomy Dependent Patients. Front Pediatr 2021; 9:661512. [PMID: 34017809 PMCID: PMC8129024 DOI: 10.3389/fped.2021.661512] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/06/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: To describe clinical factors associated with mortality and causes of death in tracheostomy-dependent (TD) children. Methods: A retrospective study of patients with a new or established tracheostomy requiring hospitalization at a large tertiary children's hospital between 2009 and 2015 was conducted. Patient groups were developed based on indication for tracheostomy: pulmonary, anatomic/airway obstruction, and neurologic causes. The outcome measures were overall mortality rate, mortality risk factors, and causes of death. Results: A total of 187 patients were identified as TD with complete data available for 164 patients. Primary indications for tracheostomy included pulmonary (40%), anatomic/airway obstruction (36%), and neurologic (24%). The median age at tracheostomy and duration of follow up were 6.6 months (IQR 3.5-19.5 months) and 23.8 months (IQR 9.9-46.7 months), respectively. Overall, 45 (27%) patients died during the study period and the median time to death following tracheostomy was 9.8 months (IQR 6.1-29.7 months). Overall survival at 1- and 5-years following tracheostomy was 83% (95% CI: 76-88%) and 68% (95% CI: 57-76%), respectively. There was no significant difference in mortality based on indication for tracheostomy (p = 0.35), however pulmonary indication for tracheostomy was associated with a shorter time to death (HR: 1.9; 95% CI: 1.04-3.4; p = 0.04). Among the co-morbid medical conditions, children with seizure disorder had higher mortality (p = 0.04). Conclusion: In this study, TD children had a high mortality rate with no significant difference in mortality based on indication for tracheostomy. Pulmonary indication for tracheostomy was associated with a shorter time to death and neurologic indication was associated with lower decannulation rates.
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Affiliation(s)
- Kiran B Hebbar
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Ajay S Kasi
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Monica Vielkind
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Courtney E McCracken
- Pediatric Biostatistics Core, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Caroline C Ivie
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Kara K Prickett
- Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Dawn M Simon
- Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
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26
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Trang H, Samuels M, Ceccherini I, Frerick M, Garcia-Teresa MA, Peters J, Schoeber J, Migdal M, Markstrom A, Ottonello G, Piumelli R, Estevao MH, Senecic-Cala I, Gnidovec-Strazisar B, Pfleger A, Porto-Abal R, Katz-Salamon M. Guidelines for diagnosis and management of congenital central hypoventilation syndrome. Orphanet J Rare Dis 2020; 15:252. [PMID: 32958024 PMCID: PMC7503443 DOI: 10.1186/s13023-020-01460-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Congenital Central Hypoventilation Syndrome (CCHS) is a rare condition characterized by an alveolar hypoventilation due to a deficient autonomic central control of ventilation and a global autonomic dysfunction. Paired-like homeobox 2B (PHOX2B) mutations are found in most of the patients with CCHS. In recent years, the condition has evolved from a life-threatening neonatal onset disorder to include broader and milder clinical presentations, affecting children, adults and families. Genes other than PHOX2B have been found responsible for CCHS in rare cases and there are as yet other unknown genes that may account for the disease. At present, management relies on lifelong ventilatory support and close follow up of dysautonomic progression. BODY: This paper provides a state-of-the-art comprehensive description of CCHS and of the components of diagnostic evaluation and multi-disciplinary management, as well as considerations for future research. CONCLUSION Awareness and knowledge of the diagnosis and management of this rare disease should be brought to a large health community including adult physicians and health carers.
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Affiliation(s)
- Ha Trang
- Hôpital Universitaire Robert Debré, Centre de référence des maladies respiratoires rares, and Université de Paris, Paris, France
| | - Martin Samuels
- Staffordshire Children’s Hospital, Stoke-on-Trent, Staffs and Great Ormond Street Hospital, London, UK
| | - Isabella Ceccherini
- Istituto Giannina Gaslini, UOSD Laboratory of Genetics and Genomics of Rare Diseases, Genoa, Italy
| | - Matthias Frerick
- Department of Pediatrics, Klinikum Dritter Orden, Munich, Germany
| | | | - Jochen Peters
- Department of Pediatrics, Klinikum Dritter Orden, Munich, Germany
| | | | - Marek Migdal
- Department of Anaesthesiology and Intensive care, Children’s Memorial Health Institute, Warsaw, Poland
| | | | | | - Raffaele Piumelli
- Sleep Disordered Breathing and SIDS Center, Meyer Children’s Hospital, Florence, Italy
| | | | - Irena Senecic-Cala
- University Hospital Centre, Department of Pediatrics, Zagreb and School of Medicine, Zagreb, Croatia
| | - Barbara Gnidovec-Strazisar
- University Children’s Hospital, Department of child, adolescent & developmental neurology, University Clinical Centre Ljubljana, Ljubljana, Slovenia
| | - Andreas Pfleger
- Medical University of Graz, Paediatric Pulmonology and Allergology, Graz, Austria
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Nam IC, Shin YS, Jeong WJ, Park MW, Park SY, Song CM, Lee YC, Jeon JH, Lee J, Kang CH, Park IS, Kim K, Sun DI. Guidelines for Tracheostomy From the Korean Bronchoesophagological Society. Clin Exp Otorhinolaryngol 2020; 13:361-375. [PMID: 32717774 PMCID: PMC7669309 DOI: 10.21053/ceo.2020.00353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/19/2020] [Indexed: 12/17/2022] Open
Abstract
The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.
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Affiliation(s)
| | - Inn-Chul Nam
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Seob Shin
- Department of Otolaryngology-Head and Neck Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Woo Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Myeon Song
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Young Chan Lee
- Department of Otolaryngology-Head and Neck Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Hyun Jeon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Il Sun
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Gulla KM, Sahoo T, Sachdev A. Technology-dependent children. Int J Pediatr Adolesc Med 2020; 7:64-69. [PMID: 32642538 PMCID: PMC7335821 DOI: 10.1016/j.ijpam.2019.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
Abstract
In recent past, revolution in medical technology resulted in improved survival rates and outcomes of critically ill children. Unfortunately, its impact relating to morbidity is not well documented. Although survival rates of these critically ill children who are medically fragile and technology-dependent have improved, we as health professionals are still in the learning curve to improve the quality of life of these children at home. Factors such as support from society, infrastructure, and funding play an important role in technology-dependent child care at home. In this review, commonly prescribed home-based medical technologies such as home ventilation, enteral nutrition, renal replacement therapy, and peripherally inserted central catheter, which are useful for quick revision, are described.
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Affiliation(s)
- Krishna Mohan Gulla
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Tanushree Sahoo
- Division of Neonatology, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Sachdev
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
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Kumarasinghe D, Wong EH, Duvnjak M, Smith MC, Palme CE, Riffat F. Colonization rates of tracheostomy tubes associated with the frequency of tube changes. ANZ J Surg 2020; 90:2310-2314. [PMID: 32419324 DOI: 10.1111/ans.15970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tracheostomy-tube change protocols are implemented primarily due to concern regarding infections. Currently changes vary from within 4 weeks post-insertion to 3 monthly thereafter. However, currently no evidence-based guidelines exist to justify these protocols. This study aims to assess the colonization of tracheostomy-tubes associated with the frequency of changes. METHODS A prospective cohort study over 18-months of adult tracheostomy patients at a single institution (inpatient/outpatients). Patients were grouped based on whether tubes were changed at ≤4 weeks or >4 weeks and microbiology swabs sent for microscopy, culture and sensitivities. RESULTS A total of 65 patients were enrolled. No statistically significant difference in colonization in patients undergoing tube changes more than every 4 weeks to those less than every 4 weeks was found (56.2% versus 57.1%, χ2 = 0.004, P = 0.95). CONCLUSION The timing of tracheostomy-tube changes may not affect colonization and infection rates. Routine changes for the purpose of reducing infection risk may not be needed unless clinically indicated.
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Affiliation(s)
- Dulitha Kumarasinghe
- Department of Otolaryngology-Head and Neck Surgery, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Eugene H Wong
- Department of Otolaryngology-Head and Neck Surgery, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Marin Duvnjak
- Department of Otolaryngology-Head and Neck Surgery, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Mark C Smith
- Department of Otolaryngology-Head and Neck Surgery, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Department of Otolaryngology-Head and Neck Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Carsten E Palme
- Department of Otolaryngology-Head and Neck Surgery, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Department of Otolaryngology-Head and Neck Surgery, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Faruque Riffat
- Department of Otolaryngology-Head and Neck Surgery, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Department of Otolaryngology-Head and Neck Surgery, Macquarie University Hospital, Sydney, New South Wales, Australia
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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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Lawrence PR, Chambers R, Faulkner MS, Spratling R. Evidence-Based Care of Children With Tracheostomies: Hospitalization to Home Care. Rehabil Nurs 2020; 46:83-86. [PMID: 32108728 DOI: 10.1097/rnj.0000000000000254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Routine tracheostomy care in children maintains airway patency, minimizes infection, and ensures skin integrity around the tracheostomy stoma to prevent complications. Using evidence-based recommendations for care of the mature tracheostomy limits variation in practice and leads to better patient outcomes in all care settings. Incorporating evidence-based care into practice is especially important because children with tracheostomies are at high risk for morbidity and mortality. The purpose of this review is to summarize the most current, evidence-based literature for pediatric tracheostomy care, including stoma care and tracheostomy suctioning. Rehabilitation nurses can then include these best practices when caring for children with tracheostomies and when educating caregivers who provide tracheostomy care to children at home.
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Affiliation(s)
- Patricia R Lawrence
- Byrdine F. Lewis College of Nursing and Health Professions, Georgia State University, Atlanta, GA, USA
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Paglietti MG, Porcaro F, Sovtic A, Cherchi C, Verrillo E, Pavone M, Bottero S, Cutrera R. Decannulation in children affected by congenital central hypoventilation syndrome: A proposal of an algorithm from two European centers. Pediatr Pulmonol 2019; 54:1663-1669. [PMID: 31313536 DOI: 10.1002/ppul.24448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/16/2019] [Indexed: 11/08/2022]
Abstract
RATIONALE Long-life ventilatory assistance is necessary for survival in pediatric patients with congenital central hypoventilation syndrome (CCHS). Invasive mechanical ventilation (IMV) through tracheostomy is the most used method, especially in the first years of life when the central nervous system is maturing. Nevertheless, IMV via tracheostomy is not ideal because tracheostomy in children is associated with impaired speech and language development, also frequent infections of the lower airway tract occur. OBJECTIVE Only few reports describe the transition from IMV to the noninvasive method, ending with decannulation in CCHS affected patients. We aim to provide our experience regarding decannulation program in CCHS affected children and to describe a proposal of an algorithm concerning transition from invasive to noninvasive ventilation (NIV) in CCHS patients. METHODS The study has been conducted retrospectively. Four children from two European centers underwent tracheostomy removal and decannulation, upon request of patients and their families. RESULTS All children were trained to carry out tracheostomy capping before decannulation and underwent endoscopic assessment of upper and lower airway. Subsequently they started training to NIV at mean age of 106.25 months (±40.7 SD). Decannulation occurred 12 months after and no patients needed the reintroduction of tracheal cannula in either short or long term follow up. CONCLUSIONS our study shows that effective liberation from IMV, the transition to NIV and decannulation are possible in CCHS affected children and offers a proposal of an algorithm which can be applied in selected centers.
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Affiliation(s)
- Maria Giovanna Paglietti
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Aleksandar Sovtic
- Department of Pulmonology, Mother and Child Health Institute and School of Medicine University of Belgrade, Serbia
| | - Claudio Cherchi
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisabetta Verrillo
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Martino Pavone
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sergio Bottero
- Airway Surgery Unit, Department Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
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Liu CC, Soares JJ, Elder L, Hill L, Abts M, Bonilla-Velez J, Dahl JP, Johnson KE, Ong T, Striegl AM, Whitlock K, Parikh SR. Surveillance endoscopy after tracheostomy placement in children: Findings and interventions. Laryngoscope 2019; 130:1327-1332. [PMID: 31670383 DOI: 10.1002/lary.28247] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/26/2019] [Accepted: 08/05/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES/HYPOTHESIS The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions. STUDY DESIGN Retrospective case series. METHODS This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ2 tests and logistic regression were used to identify risk factors for the development of abnormal changes. RESULTS There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%). CONCLUSIONS The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation. LEVEL OF EVIDENCE 4 Laryngoscope, 130:1327-1332, 2020.
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Affiliation(s)
- C Carrie Liu
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Jennifer J Soares
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Leslie Elder
- Seattle Children's Hospital, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Leslee Hill
- Seattle Children's Hospital, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Matthew Abts
- Department of Pulmonary and Sleep Medicine, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Juliana Bonilla-Velez
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - John P Dahl
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Kaalan E Johnson
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Thida Ong
- Department of Pulmonary and Sleep Medicine, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Amanda M Striegl
- Department of Pulmonary and Sleep Medicine, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Kathryn Whitlock
- Center for Clinical and Translational Research, Virginia Mason Medical Center, Seattle, Washington, U.S.A
| | - Sanjay R Parikh
- Department of Pediatric Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, Seattle, Washington, U.S.A
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Abstract
PURPOSE OF REVIEW Modern medical advances have resulted in an increased survival after extremely preterm birth. However, some infants will develop severe bronchopulmonary dysplasia (BPD) and fail to wean from invasive or noninvasive positive pressure support. It remains unclear which infants will benefit from tracheostomy placement for chronic ventilation. Once the decision to pursue chronic ventilation has been made, questions remain with respect to the timing of tracheotomy surgery, optimal strategies for mechanical ventilation, and multidisciplinary care in both the inpatient and outpatient settings. The appropriate time for weaning mechanical ventilation and tracheostomy decannulation has similarly not been determined. RECENT FINDINGS Although there remains a paucity of randomized controlled trials involving infants with severe BPD, a growing body of evidence suggests that chronic ventilation via tracheostomy is beneficial to support the growth and development of severely affected preterm children. However, delivering such care is not without risk. Chronic ventilation via tracheostomy requires complex care coordination and significant resource utilization. SUMMARY When chronic respiratory insufficiency limits a preterm infant's ability to grow and develop, chronic invasive ventilation may facilitate neurodevelopmental progress and may lead to an improved long-term outcome.
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Sharif-Askary B, Cheng TZ, Brown CS, Campbell JC, Yong Ji KS, Raynor EM. Airway findings in children with tracheostomies: When is diagnostic bronchoscopy and laryngoscopy indicated? Int J Pediatr Otorhinolaryngol 2019; 117:73-77. [PMID: 30579093 PMCID: PMC6333488 DOI: 10.1016/j.ijporl.2018.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/15/2018] [Accepted: 11/15/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To determine the utility of diagnostic laryngoscopy and bronchoscopy in children with tracheostomies and to describe the incidence of airway findings. METHODS Retrospective cohort study examining children with tracheostomies who underwent direct laryngoscopy and bronchoscopy (DLB) at Duke University Hospital between 2008 and 2016. RESULTS A total of 81 patients who underwent 114 bronchoscopies met inclusion criteria. The median time between tracheostomy and first DLB was 13 months (IQR 4.25-14.75). Sixty-six patients were diagnosed with findings on DLB (81.5%). Suprastomal granulation tissue was the most common complication (59.0%), followed by increased tracheal secretions (23%), stomal and peristomal granulation (13.2%), tracheal ulcer (3.3%), and suprastomal collapse (1.6%). The proportion of patients with airway findings who underwent endoscopy >6 months post-tracheostomy was higher than those <6 months post-tracheostomy, although this did not reach statistical significance (90.6% vs. 75.5%, p = 0.087). However, when examining tracheostomy-related findings, the proportion of patients with airway findings who underwent DLB >6 months post-tracheostomy (61%) compared to <6 months post-tracheostomy (36%) was significantly different (p = 0.026). Patients who were symptomatic before bronchoscopy were more likely to have positive findings (91.9% vs. 72.7%, p = 0.027) and patients were more likely to be symptomatic if they had DLB >6 months after tracheostomy versus <6 months after tracheostomy (68.8% vs. 30.6%; p < 0.001). CONCLUSION The high incidence of airway findings, especially tracheostomy-related findings, noted on DLB supports the continued use of airway endoscopies in children post-tracheostomy. Timing of DLB may play a role in determining utility with evaluation and symptomatic patients should be more closely monitored as they demonstrate higher rates of airway findings.
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Affiliation(s)
| | - Tracy Z Cheng
- Duke University School of Medicine, DUMC 3710, Durham, NC, 27710, USA
| | - Clifford S Brown
- Division of Head and Neck Surgery & Communication Sciences, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27707, USA
| | - James C Campbell
- Duke University School of Medicine, DUMC 3710, Durham, NC, 27710, USA
| | | | - Eileen M Raynor
- Division of Head and Neck Surgery & Communication Sciences, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, 27707, USA.
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Doherty C, Neal R, English C, Cooke J, Atkinson D, Bates L, Moore J, Monks S, Bowler M, Bruce IA, Bateman N, Wyatt M, Russell J, Perkins R, McGrath BA. Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia 2018; 73:1400-1417. [PMID: 30062783 DOI: 10.1111/anae.14307] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 01/09/2023]
Abstract
Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.
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Affiliation(s)
- C Doherty
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Neal
- Paediatric Intensive Care Medicine, Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - C English
- Department of Paediatric ENT, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Cooke
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - D Atkinson
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - L Bates
- Department of Anaesthesia and Intensive Care Medicine, Royal Bolton Hospital, Bolton, UK
| | - J Moore
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Monks
- Department of Anaesthesia, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - M Bowler
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - I A Bruce
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Bateman
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
| | - M Wyatt
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - J Russell
- Department of Paediatric ENT, Our Lady's Children's Hospital, Dublin, Ireland
| | - R Perkins
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Herbst LA, Desai S, Benscoter D, Jerardi K, Meier KA, Statile AM, White CM. Going back to the ward-transitioning care back to the ward team. Transl Pediatr 2018; 7:314-325. [PMID: 30460184 PMCID: PMC6212378 DOI: 10.21037/tp.2018.08.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Transition of care from the intensive care unit (ICU) to the ward is usually an indication of the patient's improving clinical status, but is also a time when patients are particularly vulnerable. The transition between care teams poses a higher risk of medical error, which can be mitigated by safe and complete patient handoff and medication reconciliation. ICU readmissions are associated with increased mortality as well as ICU and hospital length of stay (LOS); however tools to accurately predict ICU readmission risk are limited. While there are many mechanisms in place to carefully identify patients appropriate for transfer to the ward, the optimal timing of transfer can be affected by ICU strain, limited resources such as ICU beds, and overall hospital capacity and flow leading to suboptimal transfer times or delays in transfer. The patient and family perspectives should also be considered when planning for transfer from the ICU to the ward. During times of transition, families will meet a new care team, experience uncertainty of future care plans, and adjust to a different daily routine which can lead to increased stress and anxiety. Additionally, a subset of patients, such as those with new technology, require additional multidisciplinary support, education and care coordination which can contribute to longer hospital LOS if not addressed proactively early in the hospitalization while the patient remains in the ICU. In this review article, we describe key components of the transfer from ICU to the ward, discuss current strategies to optimize timing of patient transfers, explore strategies to partner with patients and families during the transfer process, highlight patient populations where additional considerations are needed, and identify future areas of exploration which could improve the care transition from the ICU to the ward.
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Affiliation(s)
- Lori A Herbst
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA.,Geriatrics & Palliative Care Division, Department of Family & Community Medicine, UC College of Medicine, Cincinnati, OH, USA
| | - Sanyukta Desai
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Dan Benscoter
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Karen Jerardi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Katie A Meier
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
| | - Christine M White
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, UC College of Medicine, Cincinnati, OH, USA
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Querney J, Ethier JL. Tracheostomy reversal years after patient lost to follow-up. J Otolaryngol Head Neck Surg 2018; 47:46. [PMID: 30001737 PMCID: PMC6044025 DOI: 10.1186/s40463-018-0291-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 07/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Pediatric tracheostomies occur for various reasons, including prologned intubation, and require a multidisciplinary approach with routine follow-up. Case presentation This report reviews the history and clinical outcome of a 29 year old female patient who was lost to follow-up for nearly two decades after a pediatric tracheostomy. When she presented to the Otolaryngology service as an adult the original indication for tracheostomy had resolved and decannulation was initiated, but a profound psychological dependence had developed. Conclusion This case outlines the importance of regular follow-up for tracheostomy patients, as well as health care barriers faced in remote rural communities.
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Affiliation(s)
- Jill Querney
- University of Alberta, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada.
| | - Jean-Luc Ethier
- Timmins and District Hospital, Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON, P3E 2C6, Canada
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Amin R, Zabih W, Syed F, Polyviou J, Tran T, Propst EJ, Holler T. What families have in the emergency tracheostomy kits: Identifying gaps to improve patient safety. Pediatr Pulmonol 2017; 52:1605-1609. [PMID: 28556570 DOI: 10.1002/ppul.23740] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 04/30/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the contents of parent-created emergency tracheostomy kits and identify deficiencies. METHODS This was an observational study. Data on emergency tracheostomy kits were abstracted for 30 consecutive children who had a tracheostomy tube in situ during an outpatient clinic visit with the Division of Respiratory Medicine and/or the Department of Otolaryngology-Head and Neck Surgery at the Hospital for Sick Children between February 1 and October 30, 2016. A checklist of 12 essential items based on expert consensus was used to evaluate each tracheostomy kit. RESULTS Emergency tracheostomy kits from all children were missing at least one item from the 12-item checklist. Nineteen (63%) kits had three or more critical items missing. All kits had the same size tracheotomy tube. Twenty-two (73%) kits did not have a half size smaller tracheostomy tube. Fifteen (50%) were missing a manual resuscitation bag and four (13.3%) were missing a suction machine. Children who had tracheostomy tube in situ for ≥4 years were more likely to have ≥3 missing items in their kit (43.4%) compared to those who had tracheostomy tube for <4 years (20%), (χ2 (1) = 9.85, P = 0.0017). CONCLUSION Maintenance of a fully stocked emergency tracheostomy kit can save a child's life. It is incumbent upon healthcare providers to ensure ongoing reassessment of knowledge and skills required to care for a child with a tracheostomy tube and to regularly review the components of a child's emergency tracheostomy kit.
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Affiliation(s)
- Reshma Amin
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Weeda Zabih
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Faiza Syed
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joanna Polyviou
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tuyen Tran
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Evan J Propst
- University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Theresa Holler
- University of Toronto, Toronto, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
OBJECTIVES This study was aimed to evaluate the utility and benefits of flexible fiberoptic bronchoscopy (FFB) prior to tracheostomy decannulation. METHODS Besides demographic data, initial cause of tracheostomy, primary diagnosis, pre-tracheostomy and pre-decannulation bronchoscopic findings and duration of tracheostomy were collected from medical charts. The type of active intervention following bronchoscopy and outcome after decannulation were recorded. Departmental decannulation policy and procedure were used in all patients. RESULTS Forty-nine tracheostomized patients who underwent decannulation attempt were included. The median age of the children at the time of decannulation was 3 years (range 4 months-16 years). The median duration of tracheostomy was 8 months (range 1-86 months). Prolonged mechanical ventilation was the commonest indication for tracheostomy. There were 45 abnormal findings on FFB in 36 patients. Airway granulation was the commonest abnormality (23/45, 51%). Successful decannulation without any intervention was possible in 23 (46.9%) cases. 12 of these had normal bronchoscopy. Fifteen (30.6%) patients required surgical interventions before attempting decannulation. In five patients decannulation failed, while in six children decannulation was not attempted after FFB. CONCLUSION Pre-decannulation flexible fiberoptic bronchoscopy in children with tracheostomy helps in identifying the possible causes of decannulation failure and helps in deciding the appropriate intervention.
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McPherson ML, Shekerdemian L, Goldsworthy M, Minard CG, Nelson CS, Stein F, Graf JM. A decade of pediatric tracheostomies: Indications, outcomes, and long-term prognosis. Pediatr Pulmonol 2017; 52:946-953. [PMID: 28263440 DOI: 10.1002/ppul.23657] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 11/03/2016] [Accepted: 11/27/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To define the mortality and long-term outcomes of children undergoing tracheostomy. DESIGN Retrospective chart and Texas Department of Health Bureau of Vital Statistics review of patients admitted to a Pediatric Intensive Care Unit who underwent a tracheostomy between 2001 and 2011. Mortality and decannulation rates were compared based on tracheostomy indication and age. SUBJECTS A total of 426 patients admitted to a Pediatric Intensive Care Unit in a large tertiary children's hospital. RESULTS The median patient age was 1.5 years (3 days-24 years). Primary indications for tracheostomy included (a) airway obstruction, (b) congenital neurologic disease, (c) acquired neurologic disease, (d) congenital respiratory disease, and (e) acquired respiratory disease. Overall, 98 patients (23%) died during the study period, and 75th percentile survival time was 5.9 years (95%CI: 3-8). Patients undergoing a tracheostomy for airway obstruction were the least likely to die; while patients with acquired neurologic disease were most likely to die. A total of 163 patients (38%) were decannulated, and 50% were decannulated at 1.2 years (95%CI: 0.9-1.5). Patients with congenital neurologic disease were the least likely to undergo decannulation. Over half of the patients were discharged from the hospital requiring some form of mechanical respiratory support in addition to their tracheostomy. CONCLUSIONS In this largest cohort of long-term follow-up to date, we have shown the overall risk of mortality varied according to the indication for the tracheostomy. We were unable to determine exact causes of death. The likelihood of being decannulated also correlates with the underlying indication for the tracheostomy. Pediatr Pulmonol. 2017; 52:946-953. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mona L McPherson
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Lara Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Michelle Goldsworthy
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Charles G Minard
- Baylor College of Medicine, Dan L. Duncan Institute for Clinical and Translation Research, Houston, Texas
| | - Cynthia S Nelson
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Fernando Stein
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
| | - Jeanine M Graf
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Section of Critical Care Medicine, Fannin 6621, WT 6-006, Houston 77030, Texas
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Clinical Evaluation of Invasive Home Mechanical Ventilation Dependent Pediatric Patients. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.9531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chiang J, Amin R. Respiratory Care Considerations for Children with Medical Complexity. CHILDREN-BASEL 2017; 4:children4050041. [PMID: 28534851 PMCID: PMC5447999 DOI: 10.3390/children4050041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/08/2017] [Accepted: 05/16/2017] [Indexed: 12/13/2022]
Abstract
Children with medical complexity (CMC) are a growing population of diagnostically heterogeneous children characterized by chronic conditions affecting multiple organ systems, the use of medical technology at home as well as intensive healthcare service utilization. Many of these children will experience either a respiratory-related complication and/or they will become established on respiratory technology at home during their care trajectory. Therefore, healthcare providers need to be familiar with the respiratory related complications commonly experienced by CMC as well as the indications, technical and safety considerations and potential complications that may arise when caring for CMC using respiratory technology at home. This review will outline the most common respiratory disease manifestations experienced by CMC, and discuss various respiratory-related treatment options that can be considered, including tracheostomy, invasive and non-invasive ventilation, as well as airway clearance techniques. The caregiver requirements associated with caring for CMC using respiratory technology at home will also be reviewed.
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Affiliation(s)
- Jackie Chiang
- Holland Bloorview Kids Rehabilitation Hospital, The University of Toronto, Toronto, ON M4G 1R8, Canada.
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, ON M5G 1X8, Canada.
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Berlinski A, Ari A, Davies P, Fink J, Majaesic C, Reychler G, Tatla T, Amirav I. Workshop Report: Aerosol Delivery to Spontaneously Breathing Tracheostomized Patients. J Aerosol Med Pulm Drug Deliv 2017; 30:207-222. [PMID: 28075193 DOI: 10.1089/jamp.2016.1348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The number of pediatric and adult patients requiring tracheostomy has increased. Many of them require aerosol therapy as part of their treatment. Practitioners have little guidance on how to optimize drug delivery in this population. The following is a report of a workshop dedicated to review the current status of aerosol delivery to spontaneously breathing tracheostomized patients and to provide practice recommendations.
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Affiliation(s)
- Ariel Berlinski
- 1 Department of Pediatrics, University of Arkansas for Medical Sciences , and Pediatric Aerosol Research Laboratory at Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Arzu Ari
- 2 Department of Respiratory Therapy, Georgia State University , Atlanta, Georgia
| | - Phil Davies
- 3 Department of Respiratory Paediatrics, Royal Hospital for Children , Glasgow, United Kingdom
| | - Jim Fink
- 4 Aerogen Pharma Corp. , San Mateo, California
| | - Carina Majaesic
- 5 Department of Pediatrics, University of Alberta , Edmonton, Alberta, Canada
| | - Gregory Reychler
- 6 Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Pneumologie, ORL & Dermatologie, Université Catholique de Louvain , Brussels, Belgium
| | - Taran Tatla
- 7 Department of ENT-Head & Neck Surgery, London North West Healthcare NHS Trust , London, United Kingdom
| | - Israel Amirav
- 5 Department of Pediatrics, University of Alberta , Edmonton, Alberta, Canada
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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 ST, Kim MG, Jeon JH, Jeong JH, Min SK, Park JY, Choi SW. Analysis of morbidity, mortality, and risk factors of tracheostomy-related complications in patients with oral and maxillofacial cancer. Maxillofac Plast Reconstr Surg 2016; 38:32. [PMID: 27617258 PMCID: PMC4996875 DOI: 10.1186/s40902-016-0078-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/11/2016] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to analyze and describe the morbidity and mortality associated with tracheostomy in patients with oral cancer and to identify the risk factors associated with tracheostomy complications. Methods We performed a retrospective chart review of patients who underwent tracheostomy during a major oral cancer resection between March 2001 and January 2016 at the National Cancer Center, Korea. Overall, we included 51 patients who underwent tracheostomy after oral cancer surgery. We assessed the morbidity and mortality of tracheostomy and determined the risks associated with tracheostomy complications. Results Twenty-two tracheostomy-related complications occurred in 51 patients. The morbidity and mortality rates were 35.2 % (n = 18) and 0 % (n = 0), respectively. Tracheostomy-related complications were tracheitis (n = 4), obstructed tracheostomy (n = 9), displaced tracheostomy (n = 5), air leakage (n = 1), stomal dehiscence (n = 1), and decannulation failure (n = 2). Most complications (19/22) occurred during the early postoperative period. Considering the risk factors for tracheostomy complications, the type of tube used was associated with the occurrence of tracheitis (p < 0.05). Additionally, body mass index and smoking status were associated with tube displacement (p < 0.05). However, no risk factors were significantly associated with obstructed tracheostomy. Conclusions Patients with risk factors for tracheostomy complications should be carefully observed during the early postoperative period by well-trained medical staff.
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Affiliation(s)
- Seung Tae Lee
- Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408 Republic of Korea
| | - Min Gyun Kim
- Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408 Republic of Korea
| | - Jae Ho Jeon
- Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408 Republic of Korea
| | - Joo Hee Jeong
- Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408 Republic of Korea
| | - Seung Ki Min
- Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408 Republic of Korea
| | - Joo Yong Park
- Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408 Republic of Korea
| | - Sung Weon Choi
- Oral Oncology Clinic, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 10408 Republic of Korea
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Cristea AI, Baker CD. Ventilator weaning and tracheostomy decannulation in children: More than one way. Pediatr Pulmonol 2016; 51:773-4. [PMID: 27061157 PMCID: PMC5081685 DOI: 10.1002/ppul.23418] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/13/2016] [Accepted: 03/23/2016] [Indexed: 11/06/2022]
Affiliation(s)
- A Ioana Cristea
- Indiana University School of Medicine, Indianapolis, Indiana
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Liptzin DR, Connell EA, Marable J, Marks J, Thrasher J, Baker CD. Weaning nocturnal ventilation and decannulation in a pediatric ventilator care program. Pediatr Pulmonol 2016; 51:825-9. [PMID: 27111393 PMCID: PMC5070936 DOI: 10.1002/ppul.23436] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 01/05/2016] [Accepted: 02/23/2016] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Children with chronic respiratory failure and upper airway disorders may require tracheostomy placement and long-term mechanical ventilation, yet many improve to permit ventilator weaning and decannulation. METHODS As a quality improvement project, we conducted a chart review of patients followed by our Ventilator Care Program who underwent evaluation for weaning nocturnal ventilation (NV) and/or decannulation from 2007-2014. We collected patient demographics and characterized location, monitoring techniques, and outcomes for patients undergoing weaning NV or decannulation. We attempted to implement end tidal carbon dioxide (ETCO2 ) monitoring and used linear regression to compare ETCO2 with morning pCO2 . RESULTS Weaning NV was successful in 20/21 patients. Decannulation was successful in 18/21 attempts. Once implemented, ETCO2 was piloted and successfully performed in 12 attempts (29%). Blood testing was performed in 24/42 trials (57%). When measured, the final ETCO2 result partially correlated with morning pCO2 (R(2) = 0.53, P < 0.02). Neither blood testing nor ETCO2 was performed for the four patients with unsuccessful attempts. CONCLUSIONS Inpatient observation for weaning NV and decannulation is safe and, in most cases, successful. With close observation, weaning NV at home may also be safe. Blood testing and ETCO2 monitoring were frequently utilized, but rarely affected decision-making since signs of respiratory distress were observed clinically prior to testing. ETCO2 monitoring may provide reassurance without venipuncture. With our experience, we propose an algorithm for weaning NV and decannulation. Pediatr Pulmonol. 2016;51:825-829. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Deborah R Liptzin
- Department of Pediatrics, Section of Pediatric Pulmonary Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Breathing Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Elisabeth A Connell
- Department of Pediatrics, Section of Pediatric Pulmonary Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Breathing Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Jennifer Marable
- Department of Pediatrics, Section of Pediatric Pulmonary Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Breathing Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Jill Marks
- Department of Pediatrics, Section of Pediatric Pulmonary Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Breathing Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Jodi Thrasher
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Christopher D Baker
- Department of Pediatrics, Section of Pediatric Pulmonary Medicine, University of Colorado School of Medicine, Aurora, Colorado.,Breathing Institute, Children's Hospital Colorado, Aurora, Colorado
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Abstract
Tracheotomy refers to a surgical incision made into a trachea. Tracheostomy, on the other hand, refers to a surgical procedure whereby the tracheal lumen is positioned in close proximity to the skin surface. Tracheostomy is an uncommon procedure in the pediatric population. When required tracheostomy is typically performed as an open surgical procedure under general anesthesia with the patient intubated. However, it may need to be performed under local anesthesia or over a rigid bronchoscope in the patient with a precarious airway. Over the past half century, the primary indication for pediatric tracheostomy has shifted from acute infectious airway compromise to the need for prolonged ventilatory support in neurologically compromised children. The surgical technique, choice of tracheostomy tube, and post-operative care requires a nuanced approach in infants and young children. This article will review these topics in a comprehensive fashion.
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Affiliation(s)
- Paolo Campisi
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, Ontario, Canada M5G 1×8.
| | - Vito Forte
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, Ontario, Canada M5G 1×8
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