International Journal of Pediatric Otorhinolaryngology 79 (2015) 15–17
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
A five year retrospective study of short term respiratory support outcomes for infants who received tracheostomy before one year of age Elizabeth Cottrill a,*, Janet Lioy b, Summer Elshenawy b, Jaclyn Rosenzweig b, Edward Hopkins b, John Chuo b, Steven Sobol c, Sara DeMauro b a
Otorhinolaryngology, University of Pennsylvania Health System, Philadelphia, PA, United States Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States c Otorhinolaryngology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 July 2014 Received in revised form 28 September 2014 Accepted 4 October 2014 Available online 19 October 2014
Objectives: This study aims to describe respiratory support requirements at the time of hospital discharge for infants who undergo tracheostomy, and to determine whether certain indications for tracheostomy are significantly associated with ventilator or oxygen dependence at the time of discharge. Methods: Retrospective chart review identified 150 patients who underwent tracheostomy before 1 year of age at a single center from 2007 to 2012 and were discharged alive. Patients were divided into groups based on primary indication for tracheostomy: chronic lung disease (CLD); cardiac; airway anomalies (e.g., tracheomalacia, subglottic stenosis); anatomic anomalies of head, neck and chest; neuro/muscular; mixed group (>1 primary indication). Chi-squared tests were used to compare respiratory support requirements at time of discharge, as well as need for supplemental oxygen. Results: Of the 150 patients included in the study, three were discharged on room air alone. Of those 147 who did require some form of support at discharge, significant differences were found between groups when comparing CPAP to ventilator support. For example, of the patients with CLD, 82% were discharged on ventilator support whereas of those with a primary airway indication nearly 54% were discharged on CPAP. Significant differences were also found among groups when comparing patients discharged on room air vs. supplemental oxygen. Patients with CLD were more likely to be discharged on supplemental oxygen (p = 0.001) whereas of the patients with anatomic indication 77% required no supplemental oxygen at the time of discharge. Conclusion: Respiratory support needs at the time of discharge for neonates who underwent tracheostomy varied significantly depending on the initial indication for tracheostomy. Information about respiratory requirements of infants who undergo tracheostomy can help clinicians counsel families and anticipate post-discharge needs. Published by Elsevier Ireland Ltd.
Keywords: Tracheostomy Airway Neonate Outcomes
1. Introduction 1.1. Background Multiple medical conditions may cause a neonate to require a tracheostomy. These include primary cardiac pathologies, pulmonary insufficiency (often due to prematurity and bronchopulmonary dysplasia), congenital malformations of the airway such as PierreRobin anomalies, and neurologic or neuromuscular deficiencies.
* Corresponding author. Tel.: +1 615 545 7226. E-mail address: [email protected] (E. Cottrill). http://dx.doi.org/10.1016/j.ijporl.2014.10.005 0165-5876/Published by Elsevier Ireland Ltd.
Improvements in neonatal care have resulted in increased survival rates for infants born prematurely as well as those with various congenital anomalies. Concurrently, the incidence of tracheostomies in infants has increased [1]. Of all children who require a tracheostomy, approximately 70% are under one year of age [1,2]. For those infants facing long term mechanical respiratory support, ventilation through a tracheostomy as compared to an endotracheal tube allows these infants to grow and develop better, develop facial expression and even phonation, learn sucking and swallowing, and importantly it allows many of these patients to be cared for in a home environment [3–6]. Once a patient has undergone tracheostomy, further respiratory support requirements range from supplemental oxygen to
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pressure support via continuous positive airway pressure (CPAP) to fully ventilator-supported breathing. Both short and long term respiratory support requirements vary depending on the underlying disease and indication for tracheostomy. Information about the respiratory needs of patients after tracheostomy may help clinicians counsel and educate families and patients and anticipate potential needs after discharge. In this study, we evaluate shortterm outcomes for patients who underwent tracheotomy before one year of age at a large stand-alone regional pediatric hospital. 1.2. Objective The aim of this five year retrospective study is to describe respiratory support requirements at the time of hospital discharge for infants who receive tracheostomy in the first year of life for any cause, and to determine whether certain indications for tracheostomy as compared to others are significantly associated with the need for mechanical ventilation or oxygen dependence at the time of hospital discharge after tracheostomy.
2. Materials and methods Data was collected through retrospective chart review of all patients who underwent a tracheostomy before 1 year of age at a large pediatric quaternary care center between 2007 and 2012. There were 168 patients total in this 5-year span. Of these, 15 died prior to discharge and 3 were still in-patient at the time of data review. Excluding these left a total of 150 patients. It is important to note that this group of patients represents a high risk with 8.9% mortality prior to discharge. The 150 included patients were divided into 6 groups based on primary indication for tracheostomy: chronic lung disease (CLD) which includes broncho-pulmonary dysplasia characteristic of many premature infants; cardiac anomalies; airway anomalies (e.g., tracheomalacia, subglottic stenosis, laryngomalacia); anatomic anomalies of head, neck and chest (e.g., pectus, severe micro/retrognathia, floor of mouth or neck masses such as lymphatic malformations); neuromuscular deficiencies; and finally a mixed group (patients with >1 indication). Chi-squared tests were used to compare respiratory
support requirements at time of discharge, and the incidence of ventilator dependence vs. CPAP use among the groups. 3. Results Of the 150 patients included in the study, only three were discharged on no support and room air: one patient from the airway category, one from the anatomic category, and one from the mixed category. Excluding these three and focusing on those 147 who did require some form of respiratory support at discharge, significant differences were found between groups with regard to discharge with CPAP support vs. ventilator support. As we would expect, those groups with primary cardiac and pulmonary indications required full ventilator support more frequently than those with airway or anatomic indications. For example, of the 35 patients with CLD as their indication for tracheostomy, 82% were discharged on ventilator support whereas of the 26 with a primary airway indication nearly 54% were discharged on CPAP and only 46% on ventilator support (Fig. 1). We also found that significant differences among groups exist when comparing those discharged on room air vs. supplemental oxygen (Fig. 2). More specifically, patients with chronic lung disease were more likely to be discharged on supplemental oxygen than room air (p = 0.001). Additionally, of the 10 patients with neuromuscular indication and of the 22 patients with anatomic indication, 60% and 77% respectively were on room air at the time of discharge. 4. Discussion Based on our study population, it was rare for patients who underwent tracheostomy prior to one year of age to require neither supplemental oxygen nor mechanical ventilator support of some kind upon discharge. Furthermore, significant differences were seen in those patients who suffered from cardiac and pulmonary anomalies as compared to those patients with primarily structural airway anomalies, many of which could be bypassed or overcome by the tracheostomy itself. This brings to light the importance of preparing families for the prospects of long term ventilator requirement and home care for the tracheostomy. The difference
Fig. 1. Significant differences were found between groups with regard to discharge with CPAP support vs. ventilator support. Of the 35 patients with CLD as their indication for tracheostomy, 82% were discharged on ventilator support whereas for those with primary airway indication nearly 54% were discharged on CPAP and only 46% on ventilator support.
E. Cottrill et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 15–17
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Fig. 2. Significant differences were also found among groups when comparing those discharged on room air vs. supplemental oxygen. More specifically, patients with CLD were more likely to be discharged on supplemental oxygen than room air (p = 0.001). Additionally, of the patients with neuromuscular indication or anatomic indication, 60% and 77% respectively were on room air at the time of discharge.
between CPAP requirement and full ventilator requirement is significant when considering the size and portability of the equipment that the patient will require upon discharge and the technical skill and understanding needed to operate this equipment outside of the hospital setting. Discussions with parents and caretakers should happen at the time that plans for tracheostomy are being discussed so that realistic expectations are established from the start. Education on tracheostomy care and use of appropriate equipment should begin as early as possible to ensure a safe transition upon discharge. 5. Conclusion Of the 150 patients at one large quaternary care center who required tracheostomy prior to 1 year of age and who were discharged alive, nearly all patients required at least some form of respiratory support at the time of discharge, however these
requirements varied significantly depending on the initial indication for tracheostomy. This is the first report of respiratory status at discharge for a large population of infants who have undergone tracheostomy and these data may be helpful when planning for long-term care and counseling families. References [1] S.E. Sittig, J.E. Pringnitz, Tracheostomy: evolution of an airway, AARC Times (February 2001) 48–51. [2] C.S. Butnaru, M.P. Colreavy, S. Ayari, P. Froehlich, Tracheostomy in children: evolution in indications, Int. J. Pediatr. Otorhinolaryngol. 70 (1) (2006) 115–119. [3] R.A. Joseph, Tracheostomy in infants: parent education for home care, Neonatal Netw. 30 (4) (2011) 231–242. [4] P.T. Engles, S.M. Bragshaw, M. Merier, P.G. Brindley, Tracheostomy: from insertion to decannulation, Can. J. Surg. 52 (5) (2009) 427–433. [5] C.G. Durbin, Indications for and timing of tracheostomy, Respir. Care 50 (4) (2005) 483–487. [6] E. Fiske, Effective strategies to prepare infants and families for home tracheostomy care, Adv. Neonatal Care 4 (1) (2004) 42–53.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
A five year retrospective study of short term respiratory support outcomes for infants who received tracheostomy before one year of age Elizabeth Cottrill a,*, Janet Lioy b, Summer Elshenawy b, Jaclyn Rosenzweig b, Edward Hopkins b, John Chuo b, Steven Sobol c, Sara DeMauro b a
Otorhinolaryngology, University of Pennsylvania Health System, Philadelphia, PA, United States Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States c Otorhinolaryngology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 July 2014 Received in revised form 28 September 2014 Accepted 4 October 2014 Available online 19 October 2014
Objectives: This study aims to describe respiratory support requirements at the time of hospital discharge for infants who undergo tracheostomy, and to determine whether certain indications for tracheostomy are significantly associated with ventilator or oxygen dependence at the time of discharge. Methods: Retrospective chart review identified 150 patients who underwent tracheostomy before 1 year of age at a single center from 2007 to 2012 and were discharged alive. Patients were divided into groups based on primary indication for tracheostomy: chronic lung disease (CLD); cardiac; airway anomalies (e.g., tracheomalacia, subglottic stenosis); anatomic anomalies of head, neck and chest; neuro/muscular; mixed group (>1 primary indication). Chi-squared tests were used to compare respiratory support requirements at time of discharge, as well as need for supplemental oxygen. Results: Of the 150 patients included in the study, three were discharged on room air alone. Of those 147 who did require some form of support at discharge, significant differences were found between groups when comparing CPAP to ventilator support. For example, of the patients with CLD, 82% were discharged on ventilator support whereas of those with a primary airway indication nearly 54% were discharged on CPAP. Significant differences were also found among groups when comparing patients discharged on room air vs. supplemental oxygen. Patients with CLD were more likely to be discharged on supplemental oxygen (p = 0.001) whereas of the patients with anatomic indication 77% required no supplemental oxygen at the time of discharge. Conclusion: Respiratory support needs at the time of discharge for neonates who underwent tracheostomy varied significantly depending on the initial indication for tracheostomy. Information about respiratory requirements of infants who undergo tracheostomy can help clinicians counsel families and anticipate post-discharge needs. Published by Elsevier Ireland Ltd.
Keywords: Tracheostomy Airway Neonate Outcomes
1. Introduction 1.1. Background Multiple medical conditions may cause a neonate to require a tracheostomy. These include primary cardiac pathologies, pulmonary insufficiency (often due to prematurity and bronchopulmonary dysplasia), congenital malformations of the airway such as PierreRobin anomalies, and neurologic or neuromuscular deficiencies.
* Corresponding author. Tel.: +1 615 545 7226. E-mail address: [email protected] (E. Cottrill). http://dx.doi.org/10.1016/j.ijporl.2014.10.005 0165-5876/Published by Elsevier Ireland Ltd.
Improvements in neonatal care have resulted in increased survival rates for infants born prematurely as well as those with various congenital anomalies. Concurrently, the incidence of tracheostomies in infants has increased [1]. Of all children who require a tracheostomy, approximately 70% are under one year of age [1,2]. For those infants facing long term mechanical respiratory support, ventilation through a tracheostomy as compared to an endotracheal tube allows these infants to grow and develop better, develop facial expression and even phonation, learn sucking and swallowing, and importantly it allows many of these patients to be cared for in a home environment [3–6]. Once a patient has undergone tracheostomy, further respiratory support requirements range from supplemental oxygen to
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E. Cottrill et al. / International Journal of Pediatric Otorhinolaryngology 79 (2015) 15–17
pressure support via continuous positive airway pressure (CPAP) to fully ventilator-supported breathing. Both short and long term respiratory support requirements vary depending on the underlying disease and indication for tracheostomy. Information about the respiratory needs of patients after tracheostomy may help clinicians counsel and educate families and patients and anticipate potential needs after discharge. In this study, we evaluate shortterm outcomes for patients who underwent tracheotomy before one year of age at a large stand-alone regional pediatric hospital. 1.2. Objective The aim of this five year retrospective study is to describe respiratory support requirements at the time of hospital discharge for infants who receive tracheostomy in the first year of life for any cause, and to determine whether certain indications for tracheostomy as compared to others are significantly associated with the need for mechanical ventilation or oxygen dependence at the time of hospital discharge after tracheostomy.
2. Materials and methods Data was collected through retrospective chart review of all patients who underwent a tracheostomy before 1 year of age at a large pediatric quaternary care center between 2007 and 2012. There were 168 patients total in this 5-year span. Of these, 15 died prior to discharge and 3 were still in-patient at the time of data review. Excluding these left a total of 150 patients. It is important to note that this group of patients represents a high risk with 8.9% mortality prior to discharge. The 150 included patients were divided into 6 groups based on primary indication for tracheostomy: chronic lung disease (CLD) which includes broncho-pulmonary dysplasia characteristic of many premature infants; cardiac anomalies; airway anomalies (e.g., tracheomalacia, subglottic stenosis, laryngomalacia); anatomic anomalies of head, neck and chest (e.g., pectus, severe micro/retrognathia, floor of mouth or neck masses such as lymphatic malformations); neuromuscular deficiencies; and finally a mixed group (patients with >1 indication). Chi-squared tests were used to compare respiratory
support requirements at time of discharge, and the incidence of ventilator dependence vs. CPAP use among the groups. 3. Results Of the 150 patients included in the study, only three were discharged on no support and room air: one patient from the airway category, one from the anatomic category, and one from the mixed category. Excluding these three and focusing on those 147 who did require some form of respiratory support at discharge, significant differences were found between groups with regard to discharge with CPAP support vs. ventilator support. As we would expect, those groups with primary cardiac and pulmonary indications required full ventilator support more frequently than those with airway or anatomic indications. For example, of the 35 patients with CLD as their indication for tracheostomy, 82% were discharged on ventilator support whereas of the 26 with a primary airway indication nearly 54% were discharged on CPAP and only 46% on ventilator support (Fig. 1). We also found that significant differences among groups exist when comparing those discharged on room air vs. supplemental oxygen (Fig. 2). More specifically, patients with chronic lung disease were more likely to be discharged on supplemental oxygen than room air (p = 0.001). Additionally, of the 10 patients with neuromuscular indication and of the 22 patients with anatomic indication, 60% and 77% respectively were on room air at the time of discharge. 4. Discussion Based on our study population, it was rare for patients who underwent tracheostomy prior to one year of age to require neither supplemental oxygen nor mechanical ventilator support of some kind upon discharge. Furthermore, significant differences were seen in those patients who suffered from cardiac and pulmonary anomalies as compared to those patients with primarily structural airway anomalies, many of which could be bypassed or overcome by the tracheostomy itself. This brings to light the importance of preparing families for the prospects of long term ventilator requirement and home care for the tracheostomy. The difference
Fig. 1. Significant differences were found between groups with regard to discharge with CPAP support vs. ventilator support. Of the 35 patients with CLD as their indication for tracheostomy, 82% were discharged on ventilator support whereas for those with primary airway indication nearly 54% were discharged on CPAP and only 46% on ventilator support.
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Fig. 2. Significant differences were also found among groups when comparing those discharged on room air vs. supplemental oxygen. More specifically, patients with CLD were more likely to be discharged on supplemental oxygen than room air (p = 0.001). Additionally, of the patients with neuromuscular indication or anatomic indication, 60% and 77% respectively were on room air at the time of discharge.
between CPAP requirement and full ventilator requirement is significant when considering the size and portability of the equipment that the patient will require upon discharge and the technical skill and understanding needed to operate this equipment outside of the hospital setting. Discussions with parents and caretakers should happen at the time that plans for tracheostomy are being discussed so that realistic expectations are established from the start. Education on tracheostomy care and use of appropriate equipment should begin as early as possible to ensure a safe transition upon discharge. 5. Conclusion Of the 150 patients at one large quaternary care center who required tracheostomy prior to 1 year of age and who were discharged alive, nearly all patients required at least some form of respiratory support at the time of discharge, however these
requirements varied significantly depending on the initial indication for tracheostomy. This is the first report of respiratory status at discharge for a large population of infants who have undergone tracheostomy and these data may be helpful when planning for long-term care and counseling families. References [1] S.E. Sittig, J.E. Pringnitz, Tracheostomy: evolution of an airway, AARC Times (February 2001) 48–51. [2] C.S. Butnaru, M.P. Colreavy, S. Ayari, P. Froehlich, Tracheostomy in children: evolution in indications, Int. J. Pediatr. Otorhinolaryngol. 70 (1) (2006) 115–119. [3] R.A. Joseph, Tracheostomy in infants: parent education for home care, Neonatal Netw. 30 (4) (2011) 231–242. [4] P.T. Engles, S.M. Bragshaw, M. Merier, P.G. Brindley, Tracheostomy: from insertion to decannulation, Can. J. Surg. 52 (5) (2009) 427–433. [5] C.G. Durbin, Indications for and timing of tracheostomy, Respir. Care 50 (4) (2005) 483–487. [6] E. Fiske, Effective strategies to prepare infants and families for home tracheostomy care, Adv. Neonatal Care 4 (1) (2004) 42–53.
