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Edwards L, McRae J. Transitions in tracheostomy care: from childhood to adulthood. Curr Opin Otolaryngol Head Neck Surg 2024; 32:172-177. [PMID: 37548524 DOI: 10.1097/moo.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to explore the evidence around children and young people who require a tracheostomy and transition into adult services, reflecting on the challenges and considerations for clinical practice as these needs increase. RECENT FINDINGS There are a lack of data on the incidence and prevalence of children and young people with a tracheostomy transitioning to adult services for ongoing care. There are significant variations in care needs, technology and previous experiences that demand more than a simple handover process. Examples of service models that support the transition of care exist, however these lack specificity for children and young people with a tracheostomy. SUMMARY Further exploration of the needs of children and young people requiring airway technology is indicated, particularly considering the short and long-term education, health, and social care needs.
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Affiliation(s)
| | - Jackie McRae
- Centre for Allied Health, St George's University of London
- University College Hospitals NHS Foundation Trust, London, UK
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Kamalaporn H, Preutthipan A, Coates AL. Weaning strategies for children on home invasive mechanical ventilation. Pediatr Pulmonol 2024. [PMID: 38593235 DOI: 10.1002/ppul.27008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/11/2024]
Abstract
Children who require home mechanical ventilation (HMV) with an artificial airway or invasive mechanical ventilation (HMV) have a possibility of successful weaning due to the potential of compensatory lung growth. Internationally accepted guidelines on how to wean from HMV in children is not available, we summarize the weaning strategies from the literature reviews combined with our 27-year experience in the Pediatric Home Respiratory Care program at the tertiary care center in Thailand. The readiness to wean is considered in patients with hemodynamic stability, having effective cough measured by maximal inspiratory pressure, requiring a fraction of inspired oxygen (FiO2) < 40%, positive end expiratory pressure <5 cmH2O, and acceptable arterial blood gases. The strategies of weaning is start weaning during the daytime while the child is awake and close monitoring is feasible. Disconnect time is gradually increased through naps and sleeping hours. Weaning from the conventional mechanical ventilator to Bilevel PAP or CPAP are optional. Factors affected the successful weaning are mainly the underlying diseases, complications, growth and development, caregivers, and resources. Weaning should be stopped during acute illness or increased work of breathing. The readiness for decannulation could be determined by using the speaking devices, tracheostomy capping, and measurement of end-expiratory pressure. Polysomnography and airway evaluation by bronchoscopy are recommended before decannulation. Weaning when the child is ready is crucial because living with HMV can be challenging and stressful. Failure to remove a tracheostomy when indicated can result in delayed speech, social problems as well as risk for infection.
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Affiliation(s)
- Harutai Kamalaporn
- Department of Pediatrics, Division of Pulmonology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Aroonwan Preutthipan
- Department of Pediatrics, Division of Pulmonology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Allan L Coates
- The Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Tabey M, Ghelab Z, Chebib E, Teissier N. Child-TRACH: Management of tracheostomy in children, a Yo-IFOS survey. Int J Pediatr Otorhinolaryngol 2024; 177:111873. [PMID: 38278064 DOI: 10.1016/j.ijporl.2024.111873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/14/2024] [Accepted: 01/20/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVES The number of tracheostomies in children has increased the last twenty years thanks to neonatal and pediatric intensive care improvement. As it is often a difficult situation to deal with for children and their caregivers, we wished to draw up the inventory of the management protocols of pediatric tracheostomies around the world. METHODS We performed an online international survey for ENTs managing children with tracheostomies. The survey was in English and diffused through ENT national and international societies (International Federation of Otorhinolaryngologists Societies, IFOS and French Society of Otorhinolaryngologists, SFORL). Answers were anonymized and collected online between September 2021 and January 2022. All data were analyzed as a whole and according to the continent. RESULTS 119 ENTs from the different continents responded to the survey: Europe (45.4 %), Asia (16 %), North America (14.3 %), South America (10.9 %), Africa (6.7 %) and Oceania (6.7 %). The most common indication for tracheostomy was laryngeal obstruction (77.3 %). Once initial management and surgical procedure performed, the majority of children returned home with their tracheostomy; tracheostomy was a contraindication for only 1.7 % of the responders. Concerning patient autonomy on daily care of the cannula at home, it was acquired in only 27.7 % of the cases, no difference was observed between countries (p = 0.22). Therapeutic patient education (TPE) was offered for 86.9 % of the patients taken care by the responders: it was dedicated to training the parents (96.8 %), with no differences between countries; however, in some countries, TPE for could also be offered to other caregivers. The mean delay between surgery and first change of cannula was 27.3 days (1-100) but varied depending on the country (4 days in Nigeria, 20 days in north America, 40 days in Europe, Asia and south America). CONCLUSION Although tracheostomies in children can encompass several indications, practices across the world are similar and aim to offer a life as normal as possible for these children.
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Affiliation(s)
- Maxime Tabey
- Otolaryngology and Head and Neck Surgery Department, Robert Debre Hospital, University Hospital of Reims, France.
| | - Zina Ghelab
- Pediatric Otorhinolaryngology Department, Robert Debre University Hospital, Paris, France
| | - Emilien Chebib
- Pediatric Otorhinolaryngology Department, Robert Debre University Hospital, Paris, France
| | - Natacha Teissier
- Pediatric Otorhinolaryngology Department, Robert Debre University Hospital, Paris, France
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Young A, Walsh K, Ida J, Thompson DM, Hazkani I. Transtracheal Pressure for Evaluation of Decannulation Readiness. Laryngoscope 2024. [PMID: 38214415 DOI: 10.1002/lary.31280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/08/2023] [Accepted: 12/29/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Pediatric tracheostomy decannulation protocols vary among institutions and may include toleration of Passy Muir Valve (PMV), microlaryngoscopy and bronchoscopy (MLB) findings, and polysomnography evaluation. Transtracheal pressure (TTP) is an objective measurement utilized to evaluate PMV toleration. We aimed to investigate the role of TTP in decannulation candidates and compare TTP measurements with polysomnography and MLB findings. METHODS A retrospective cohort study of children who underwent TTP measurement during PMV trial between December 2012 and November 2022. RESULTS A total of 79 patients underwent TTP measurement and MLB evaluation; of these, 16 (20.3%) patients had a capped polysomnography. Twenty-eight (35.4%) patients had TTPs ≤10 cm H2 O, and 51 (64.6%) patients had TTPs >10 cm H2 O. The most common indication for tracheostomy was upper airway obstruction (n = 41, 51.9%), followed by a need for mechanical ventilation (n = 24, 30.4%). Twenty-five (31.6%) patients were decannulated. Patients with TTPs ≤10 cm H2 O had a mean Apnea-Hypopnea Index of 0.17 ± 0.26/h compared with 6.93 ± 7.67/h in those with TTPs >10 cm H2 O, p = 0.0365. Patients with TTPs >10 cm H2 O were found to have a significantly higher occurrence of airway obstruction (96.1% vs. 46.4%, p < 0.0001) and multilevel airway obstruction (70.6% vs. 21.4%, p < 0.0001) on MLB. Neither TTP measured at time of PMV assessment nor capped polysomnography was associated with successful decannulation. CONCLUSIONS TTP measurements at time of PMV evaluation are associated with polysomnography and MLB findings. One-time PMV measurements were not indicative of decannulation success. LEVEL OF EVIDENCE 4 Laryngoscope, 2024.
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Affiliation(s)
- Ashley Young
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Katie Walsh
- Department of Audiology and Speech-Language Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jonathan Ida
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head & Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Dana M Thompson
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head & Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Inbal Hazkani
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head & Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Obayashi J, Fukumoto K, Yamoto M, Miyake H, Nomura A, Kanai R, Nemoto Y, Tsukui T. Safety evaluation of a stepwise tracheostomy decannulation program in pediatric patients. Pediatr Surg Int 2023; 39:260. [PMID: 37658905 DOI: 10.1007/s00383-023-05549-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE In the event of failed tracheostomy decannulation, patients might have a tragic course of events. We retrospectively evaluated our stepwise tracheostomy decannulation program and examined its safety. METHODS A 12-year retrospective study of pediatric patients was conducted. The decannulation program was performed on patients who had airway patency by laryngobronchoscopy and whose cannula could be capped during the day. A stepwise decannulation program was performed: continuous 48-h capping trial during hospitalization (Phase 1), removal of the tracheostomy tube for 48 h during hospitalization (Phase 2), and outpatient observation (Phase 3). If a persistent tracheocutaneous fistula existed, the fistula was closed by surgery (Phase 4). RESULTS The 77 patients in the study underwent 86 trials. The age at the first time of the decannulation program was 6.5 ± 3.6 years. Sixteen trials failed (18.6%): 8 trials in Phase 1, 2 trials in Phase 2, 4 trials in Phase 3, and 2 trials in Phase 4. Most decannulation failures were due to desaturation in Phase 1/2 and dyspnea in Phase 3/4. The time to reintubation after decannulation was 15-383 days in Phase 3/4. CONCLUSIONS Patients could fail at every phase of the program, suggesting that a stepwise decannulation program contributes to safety.
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Affiliation(s)
- Juma Obayashi
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan.
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Akiyoshi Nomura
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Risa Kanai
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Yuri Nemoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
| | - Takafumi Tsukui
- Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka, 420-8660, Japan
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Böschen E, Wendt A, Müller-Stöver S, Piechnik L, Fuchs H, Lund M, Steindor M, Große-Onnebrink J, Keßler C, Grychtol R, Rothoeft T, Bieli C, van Egmond-Fröhlich A, Stehling F. Tracheostomy decannulation in children: a proposal for a structured approach on behalf of the working group chronic respiratory insufficiency within the German-speaking society of pediatric pulmonology. Eur J Pediatr 2023:10.1007/s00431-023-04966-6. [PMID: 37121990 DOI: 10.1007/s00431-023-04966-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 03/22/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023]
Abstract
The number of children with tracheostomies with and without home mechanical ventilation has grown continuously in recent years. For some of these children, the need for tracheostomy resolves and the child can be weaned from the tracheal cannula. Choosing the optimal time point for decannulation after elaborated prior diagnostic work-up needs careful consideration. The decannulation process requires an interdisciplinary team; however, these specialized structures for the experienced care of these children with tracheostomy are not available in all areas. The Working Group on Chronic Respiratory Insufficiency in the German Speaking Pediatric Pneumology Society (GPP) developed these recommendations to guide through a decannulation process. Initial evaluation of decannulation feasibility starts in the outpatient clinic with a detailed history, examination, and a speaking valve trial and is followed by an inpatient workup including sleep study, airway endoscopy and possibly modifications of the tracheal cannula. Downsizing the tracheal cannula allows a stepwise controlled weaning prior to removal of the tracheal cannula. After shrinking of the tracheostomy, the final surgical closure is performed. Conclusion: An algorithm with diagnostic and therapeutic procedures for a safe and successful decannulation process is proposed. What is Known: • In children tracheostomy decannulation is a complex process that requires careful preparation and surveillance. What is New: • This statement of the German speaking society of pediatric pulmonology provides an expert practice guidance on the decannulation procedure and the value of one-way speaking valves.
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Affiliation(s)
- Eicke Böschen
- Department of Respiratory Care, Pediatric Pulmonology and Sleep Medicine, Childrens Hospital, Altonaer Kinderkrankenhaus, Bleickenallee 38, 22763, Hamburg, Germany.
| | - Anke Wendt
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité, Berlin, Germany
| | - Sarah Müller-Stöver
- Department of Respiratory Care, Pediatric Pulmonology and Sleep Medicine, Childrens Hospital, Altonaer Kinderkrankenhaus, Bleickenallee 38, 22763, Hamburg, Germany
| | - Lydia Piechnik
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité, Berlin, Germany
| | - Hans Fuchs
- Center for Pediatrics, Department of Neonatology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Madeleine Lund
- Department of Respiratory Care, Pediatric Pulmonology and Sleep Medicine, Childrens Hospital, Altonaer Kinderkrankenhaus, Bleickenallee 38, 22763, Hamburg, Germany
| | - Mathis Steindor
- Department of Pediatric Pulmonology and Sleep Medicine, Childrens Hospital, University of Duisburg-Essen, Essen, Germany
| | | | - Christina Keßler
- Department of General Pediatrics, University Hospital Munster, Munster, Germany
| | - Ruth Grychtol
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School; Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Tobias Rothoeft
- Department of Neonatology and Pediatric Intensive Care, University Childrens Hospital, Ruhr-University, Bochum, Germany
| | - Christian Bieli
- Department of Paediatric Pulmonology, University Childrens Hospital, Zurich, Switzerland
| | | | - Florian Stehling
- Department of Pediatric Pulmonology and Sleep Medicine, Childrens Hospital, University of Duisburg-Essen, Essen, Germany
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Rolfs-Schrum K, Scheidmann R, Flügel T, Böschen E, Betz C, Stock P. [Infantile laryngeal fracture - Its surgical management and tracheal cannula management]. Laryngorhinootologie 2023; 102:124-129. [PMID: 36126934 DOI: 10.1055/a-1873-2584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Kari Rolfs-Schrum
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Scheidmann
- Pädiatrische Pneumologie und Intensivmedizin, AKK Altonaer Kinderkrankenhaus gGmbH, Hamburg, Germany
| | - Till Flügel
- Klinik und Poliklinik für Hör-, Stimm- und Sprachheilkunde, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Eicke Böschen
- Pädiatrische Pneumologie und Intensivmedizin, AKK Altonaer Kinderkrankenhaus gGmbH, Hamburg, Germany
| | - Christian Betz
- Klinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Philippe Stock
- Pädiatrische Pneumologie, AKK Altonaer Kinderkrankenhaus gGmbH, Hamburg, Germany
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kou YF, Teplitzky T, Johnson RF, Chorney SR. Assessment of socioeconomic disadvantage in laryngotracheoplasty outcomes among pediatric patients. Int J Pediatr Otorhinolaryngol 2022; 162:111326. [PMID: 36174480 DOI: 10.1016/j.ijporl.2022.111326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/10/2022] [Accepted: 09/17/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine whether socioeconomic disadvantage impacts outcomes after pediatric laryngotracheoplasty. STUDY DESIGN Case series with chart review. METHODS All laryngotracheoplasty procedures at a tertiary children's hospital between 2010 and 2019 were included. Primary zip code determined Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure, and children were grouped based on less or more community disadvantage. Primary outcomes included complication and decannulation rates. RESULTS Eighty-four procedures were included with 69% (58/84) double-stage and 31% (26/84) single-stage reconstructions. Median age at surgery was 3.2 (IQR 2.2-4.9) years, 56% (47/84) were male, and median gestational age was 25 (IQR 24-28) weeks. Children from more disadvantaged communities represented 67% (56/84) of surgeries and were more likely to have higher grade stenosis (89% vs. 64%, P = .02). Postoperative airway complications (20% vs. 18%, P = .99), non-airway complications (14% vs. 18%, P = .75), and total length of stay (7 vs. 6 days, P = .26) were not impacted by ADI grouping. While children from higher community disadvantage were just as likely to be decannulated after double stage surgeries (76% vs. 76%, P = .99), it more often took longer than six months to achieve (90% vs. 61%, P = .04). CONCLUSIONS Community disadvantage is associated with higher grade airway stenosis and longer times to successful decannulation in children requiring expansion airway surgery. Encouragingly, ADI grouping did not impact complication and decannulation rates. Continued work is needed to understand how socioeconomic metrics influence pediatric open airway surgery.
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Affiliation(s)
- Yann-Fuu Kou
- University of Texas Southwestern Medical Center, Department of Otolaryngology - Head & Neck Surgery, United States; Children's Health Airway Management Program, Children's Medical Center of Dallas, Department of Pediatric Otolaryngology, United States.
| | - Taylor Teplitzky
- University of Texas Southwestern Medical Center, Department of Otolaryngology - Head & Neck Surgery, United States
| | - Romaine F Johnson
- University of Texas Southwestern Medical Center, Department of Otolaryngology - Head & Neck Surgery, United States; Children's Health Airway Management Program, Children's Medical Center of Dallas, Department of Pediatric Otolaryngology, United States
| | - Stephen R Chorney
- University of Texas Southwestern Medical Center, Department of Otolaryngology - Head & Neck Surgery, United States; Children's Health Airway Management Program, Children's Medical Center of Dallas, Department of Pediatric Otolaryngology, United States
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Xiao L, Kaspy K, Zielinski D, Amin R. Pediatric tracheostomy tube decannulation with or without polysomnography: A PRO-CON debate. Pediatr Pulmonol 2022; 57:609-615. [PMID: 34825785 DOI: 10.1002/ppul.25773] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 11/06/2022]
Abstract
Determining the timing for decannulation in children with a tracheostomy is a complex process, as the appropriate timing varies based on the initial indication for the tracheostomy tube as well as individual patient characteristics. The original condition for which a tracheostomy was created may improve over time with decannulation being a very important long-term goal for many families and multidisciplinary teams. However, decannulation is an inherently risky procedure associated with morbidity and mortality. Therefore, careful planning is required to ensure the safety of the procedure. Although routine airway endoscopy is an important component of decannulation protocols, guidelines are less prescriptive regarding the definition of a complete endoscopic airway evaluation and the routine use of polysomnography. This review will summarize the important PRO and CON arguments of integrating polysomnography into pediatric decannulation protocols.
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Affiliation(s)
- Lena Xiao
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Respiratory Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Kimberley Kaspy
- Division of Respiratory Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - David Zielinski
- Division of Respiratory Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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