Early versus late tracheostomy in pediatric intensive care unit: does it matter? A 6-year experience

Indication-based timing of tracheostomy and its effects on outcome in the pediatric intensive care unit

OBJECTIVES

The objective of study was to find an association between the timing of tracheostomy with duration of mechanical ventilation (MV) and length of stay (LOS) in pediatric intensive care unit (PICU) and hospital.

METHODS

The data were collected prospectively from 2000 to 2018 and were analyzed retrospectively. Data included clinical diagnosis, indication, and duration (days) of MV, LOS in PICU and hospital before and after tracheostomy. Patients who did not receive MV or underwent MV for <24 h were excluded. According to the indication of tracheostomy enrolled patients were divided into four groups-airways anomalies (AA), central neurological impairment (CNI), cardiopulmonary insufficiency (CPI), and neuromuscular disorders (NMD). Patients in each group were divided into early (ET) and late tracheostomy (LT) category based on the median (interquartile range interquartile range [IQR]) days of pretracheostomy MV.

RESULTS

Two hundred and fifty six patients were analyzed. The frequency and median [IQR] days of pretracheostomy MV were -AA 54 [7(3,16)], CNI 120 [12(9,16)], CPI 51 [25(16.5,30.5)], and NMD 31[12(8,16.5)]. In AA patients, median (IQR) durations of posttracheostomy MV [2(1,5.2) versus 3.5(2,12); p = 0.032], PICU [7(5,8.2) versus11(7,18); p = 0.004] and hospital [12(9.7,21) versus 21.5(12,28); p = 0.027] stays were lower in ET as compared with LT group. Posttracheostomy MV duration was significantly short in ET patients with CNI and NMD (p < 0.005). The total days of MV, PICU and hospital stay were significantly lower in ET as compared with LT patients in all four groups (p < 0.01).

CONCLUSION

As compared with LT, ET patient had shorter durations of total MV and PICU and hospital stay.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Tracheostomy practices in children on mechanical ventilation: a systematic review and meta-analysis

OBJECTIVE

To evaluate current practices of tracheostomy in children regarding the ideal timing of tracheostomy placement, complications, indications, mortality, and success in decannulation.

SOURCE OF DATA

The authors searched PubMed, Embase, Cochrane Library, Google Scholar, and complemented by manual search. The guidelines of PRISMA and MOOSE were applied. The quality of the included studies was evaluated with the Newcastle-Ottawa Scale. Information extracted included patients' characteristics, outcomes, time to tracheostomy, and associated complications. Odds ratios (ORs) with 95% CIs were computed using the Mantel-Haenszel method.

SYNTHESIS OF DATA

Sixty-six articles were included in the qualitative analysis, and 8 were included in the meta-analysis about timing for tracheostomy placement. The risk ratio for "death in hospital outcome" did not show any benefit from performing a tracheostomy before or after 14 days of mechanical ventilation (p = 0.49). The early tracheostomy before 14 days had a great impact on the days of mechanical ventilation (-26 days in mean difference, p < 0.00001). The authors also found a great reduction in hospital length of stay (-31.4 days, p < 0.008). For the days in PICU, the mean reduction was of 14.7 days (p < 0.007).

CONCLUSIONS

The meta-analysis suggests that tracheostomy performed in the first 14 days of ventilation can reduce the time spent on the ventilator, and the length of stay in the hospital, with no effect on mortality. The decision to perform a tracheostomy early or late may be more dependent on the baseline disease than on the time spent on ventilation .

Optimal Timing of Tracheostomy in Injured Adolescents

OBJECTIVES

To evaluate the optimal timing of tracheostomy for injured adolescents.

DESIGN

Retrospective cohort study.

SETTING

Trauma facilities in the United States.

PATIENTS

Adolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point.

CONCLUSIONS

For injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.

A comparative two-cohort study of pediatric patients with long term stay in ICUs

During the last decades, the number of patients with long stay admissions (LSA) in PICU has increased. The purpose of this study was to identify factors associated with PICU LSA, assessing healthcare resources use and changes in the profile of these patients. A retrospective, observational, single-center study was carried out. Characteristics of LSA were compared between two periods (2006–2010 and 2011–2015). During the earlier period there were 2,118 admissions (3.9% of them LSA), whereas during the second period, there were 1,763 (5.4% of them LSA) (p = 0.025). LSA accounted for 33.7% PICU stay days during the first period and 46.7% during the second (p < 0.001). Higher use of non-invasive ventilation (80.2% vs. 37.8%, p = 0.001) and high-flow oxygen therapy (68.8% vs. 37.8%, p = 0.005) was observed in the 2011–2015 cohort, whereas the use of arterial catheter (77.1% vs. 92.6%, p = 0.005), continuous infusion of adrenaline (55.2% vs. 75.9%, p = 0.004), and hemoderivative transfusion (74% vs. 89.2%, p = 0.010) was less frequent. In the 2006–2010 cohort, hospital-acquired infections were more common (95.2% vs. 68.8%, p < 0.001) and mortality was higher (26.8% vs. 13.8%, p = 0.026). The number of long-stay PICU admissions have increased entailing an intensive use of healthcare resources. These patients have a high risk for complications and mortality.

Elective Tracheostomy in Critically Ill Children: A 10-Year Single-Center Experience From a Lower-Middle Income Country

Objective

Tracheostomy is a commonly performed procedure amongst critically ill patients, especially in cases of prolonged mechanical ventilation (PMV). This study aimed to describe the indications, clinical characteristics, and outcomes of elective pediatric tracheostomies in critically ill children at our center.

Methods

A retrospective review of medical records of children who underwent elective tracheostomies in our pediatric intensive care unit (PICU) was conducted from January 2009 to June 2018. Data were extracted based on demographics, indications of tracheostomy, and patient outcomes. Results were reported as mean with standard deviation and as frequencies with percentage.

Results

Of the 3,200 patients admitted to the PICU during the study period, 1,130 were intubated. A total of 48 (4.2% of 1,130) children underwent an elective tracheostomy. 30/48 (62.5%) children had an early tracheostomy. 34/48 (71%) patients were males. Approximately 25% of our patients undergoing a tracheostomy had an underlying neurological condition as the primary diagnosis, followed by respiratory conditions (23%). The most common indications for elective tracheostomy were PMV (>7 days) (n=24, 50%) and extubation failure (n=9, 18.7%). Early tracheostomy (<14 days) had better patient outcomes in terms of ventilator-free days (8.57±4.64 in early tracheostomy vs. 6.38±6.17 days in late tracheostomy, P=0.04). The sedation-free days and ICU-free days were also significantly increased in the early tracheostomy group than in the late tracheostomy group. The successful weaning and ICU discharge rate were significantly higher in the early tracheostomy group than in the late tracheostomy group (78.1% vs. 59.7%, P<0.05; and 69.2% vs. 49.5%, P<0.05, respectively). Ventilator-associated pneumonia was more common in the late tracheostomy group (n= 14, 77%), compared to early tracheostomy group (n=12, 40%) (P=0.03). Two patients expired from tracheostomy-related complications.

Conclusion

PMV was the most common indication for an elective tracheostomy. Early tracheostomy is associated with improved patient outcomes; therefore, a standardized approach toward mechanically ventilated children is recommended.

Timing of tracheostomy placement among children with severe traumatic brain injury: A propensity-matched analysis

BACKGROUND

Early tracheostomy has been associated with shorter hospital stay and fewer complications in adult trauma patients. Guidelines for tracheostomy have not been established for children with severe traumatic brain injury (TBI). The purpose of this study was to (1) define nationwide trends in time to extubation and time to tracheostomy and (2) determine if early tracheostomy is associated with decreased length of stay and fewer complications in children with severe TBI.

METHODS

Records of children (<15 years) with severe TBI (head Abbreviated Injury Severity [AIS] score ≥3) who were mechanically ventilated (>48 hours) were obtained from the National Trauma Data Bank (2007-2015). Outcomes after early (≤14 days) and late (≥15 days) tracheostomy placement were compared using 1:1 propensity score matching to control for potential confounding by indication. Propensity scores were calculated based on age, race, pulse, blood pressure, Glasgow Coma Scale motor score, injury mechanism, associated injury Abbreviated Injury Severity scores, TBI subtype, craniotomy, and intracranial pressure monitor placement.

RESULTS

Among 6,101 children with severe TBI, 5,740 (94%) were extubated or died without tracheostomy, 95% of the time within 18 days. Tracheostomy was performed in 361 children (6%) at a median [interquartile range] of 15 [10, 22] days. Using propensity score matching, we compared 121 matched pairs with early or late tracheostomy. Early tracheostomy was associated with fewer ventilator days (14 [9, 19] vs. 25 [19, 35]), intensive care unit days (19 [14, 25] vs. 31 [24, 43]), and hospital days (26 [19, 41] vs. 39 [31, 54], all p < 0.05). Pneumonia (24% vs. 41%), venous thromboembolism (3% vs. 13%), and decubitus ulcer (4% vs. 13%) occurred less frequently with early tracheostomy (p < 0.05).

CONCLUSIONS

Early tracheostomy is associated with shorter hospital stay and fewer complications among children with severe TBI. Extubation without tracheostomy is rare beyond 18 days after injury.

LEVEL OF EVIDENCE

Prognostic and epidemiological, retrospective comparative study, level III.

Pediatric tracheostomy first tube change: When is it safe?

OBJECTIVES

The first tracheostomy tube change is typically performed on days 5-7 post-operatively, however recent international consensus guidelines suggested that, with maturation sutures, days 3-5 is appropriate. We evaluate whether a first tube change on day 2 post-operatively is safe and effective.

METHODS

We carried out a retrospective review of all patients undergoing tracheostomy between 2009 and 2018. Exclusion criteria were patients on whom the senior authors did not operate, operations done elsewhere, cases where maturation sutures were not used or a patient died prior to first tube change. We noted patient details, indication for tracheostomy, the need for long-term ventilation, timing of the first tube change, decannulation and need for surgical closure of persistent tracheocutaneous fistula.

RESULTS

93 patients were identified, of which 83 were included. The age range was 0-16 years, with the youngest day one of life and an overall mean age of 1.91 years. 59% of patients required long-term ventilation due to various co-morbidities. 26 patients (31%) underwent a first tube change on day 2 post-operatively. All these were uneventful and were irrespective of the patient's need for ventilation. Of the 42 patients who have subsequently been decannulated, 33 (79%) were noted to have a persistent tracheocutaneous fistula requiring surgical closure, four of whom needed revision closure.

CONCLUSIONS

This study shows that a first tube change on day 2 post-operatively is safe, facilitating earlier discharge from intensive care, allowing shorter length of sedation, earlier start to parent/carer training and wound assessment.