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abstract
BACKGROUND: Despite advances in care of critically ill neonates, extended mechanical ventilation and tracheostomy are sometimes required. Few studies focus on complications and clinical outcomes.
Our aim was to provide long-term outcomes for a cohort of infants
who required tracheostomy.
METHODS: This study is a retrospective review of 165 infants born between January 1, 2000 and December 31, 2010 who required tracheostomy and ventilator support. Children with complex congenital heart
disease were excluded.
RESULTS: Median gestational age was 27 weeks (range 2243), and birth
weight was 820 g (range 3604860). The number of male (53.9%) and female
(46.1%) infants was similar (P = .312). Infants were divided into 2 groups
based on birth weight #1000 g (A) and .1000 g (B). Group A: 87 (57.6%)
infants; group B 64 (42.4%). Overall tracheostomy rate was 6.9% (87/1345)
for group A versus 0.9% (64/6818) for B (P ,.001). Group A had a longer
time from intubation to positive pressure ventilation independence, 505 days
(range 621287) vs 372 days (range 151270; P = .011). Infants who had .1
reason for tracheostomy comprised 78.8% of the sample; 69.1% of infants
were discharged on ventilators. Birth weight did not affect time from
tracheostomy to decannulation (P = .323). More group A infants were
decannulated (P = .023). laryngotracheal reconstruction rate was 35.8%.
Five-year survival was 89%. Group B had higher mortality (P = .033).
64.2% of infants had developmental delays; 74.2% had $2 comorbidities.
CONCLUSIONS: Tracheostomy rates were higher for extremely low birth
weight infants than previously reported rates for all infants. Decannulation
rates and laryngotracheal reconstruction rates were consistent with previous studies. Survival rates were high, but developmental delay and
comorbidities were frequent. Pediatrics 2013;131:e1491e1496
e1491
Despite early surfactant therapy, optimizing ventilator strategies, and increased use of noninvasive positive
pressure ventilation, bronchopulmonary dysplasia (BPD) continues to be
a complication of premature births.
Survival of extremely low birth weight
(ELBW) and very low birth weight
(VLBW) infants has increased, contributing to an increased incidence of BPD.
Moreover, the care of critically ill infants
born at term with congenital anomalies
has also improved.1 Many of these
infants require mechanical ventilation
for extended periods. Some ultimately
require tracheostomy placement for
prolonged ventilation.24 Others require tracheostomy placement due to
congenital airway anomalies but have
minimal ventilatory needs.
infants in NICUs have signicantly improved the outlook for critically ill
newborns over the past 20 years.9,2225
Childrens Hospitals and Clinics of
Minnesota is a pediatric health care
system with 2 full-service pediatric
hospitals. At these institutions, pediatric pulmonologists are consulted annually on 50 patients (6.13% of all
NICU patients annually) for recommendations about management of
infants with prolonged mechanical
ventilation requirements and those
with congenital airway anomalies that
require tracheostomy with minimal
ventilatory needs. Of those infants, 15
to 20 will ultimately have a tracheostomy placed. Upon discharge, the
Studies have shown that early tracheostomy reduces the incidence of subglottic and tracheal stenosis in children
who are intubated for long periods.5 In
addition, tracheostomy results in improved comfort, decreased need for
sedation, decreased systemic corticosteroid exposure (which is associated
with poorer neurodevelopmental outcomes), improved nutrition and growth,
improved ability to attempt oral feeds,
and, once established, vocalization
with a speaking valve.57 Overall tracheostomy rates range from 0.55% to
2.7%813
Several studies focus on the surgical
indications, complications, and techniquesused for pediatrictracheostomy.814
Few studies focus on the complications
and long-term clinical outcomes for
infants that require tracheostomy
placement and prolonged mechanical
ventilation.1521 Most of the available
literature was published or conducted
before 2004, when many of the new
ventilator modalities and techniques
had not yet become incorporated into
clinical practice for the treatment of
respiratory failure. These advances in
respiratory care and the treatment of
e1492
FIGURE 1
Pressure control ventilation home weaning protocol: used to wean patients from mechanical ventilation
at home, without readmission to the hospital. CBG, capillary blood gas; PEEP, positive end expiratory
pressure; VBG, venous blood gas.
OVERMAN et al
ARTICLE
METHODS
This study involved a retrospective
chart review of 184 tracheostomized
NICU patients followed by a single pediatric pulmonary practice. Inclusion
criteria included birth between January 1, 2000 and December 31, 2010. To
better understand outcomes in patients
with pulmonary disease, upper airway
anomalies, and congenital lung abnormalities, patients with complex congenital heart disease (cyanotic heart
lesions and/or single ventricle physiology) were excluded. Our centers experience is that children who require
tracheostomy and ventilation for cyanotic heart lesions have a higher rate
of complications, more prolonged ventilatory needs, and a greater incidence
of morbidity and mortality. To allow for
comparison with previous studies and
gain a better understanding of the
outcomes for ELBW and VLBW infants,
the remaining 165 eligible patients
were subdivided into 2 groups: patients
who weighed ,1000 g at birth (Group
A) and those who weighed $1000 g at
birth (Group B).10,11 Data were obtained
from each patients inpatient and outpatient medical record. The study was
approved by the Institutional Review
Board at Childrens Hospitals and Clinics of Minnesota. Informed consent
was not required because it was a retrospective study that did not affect
patient care.
Data collected included gestational age
and birth weight, number of days
intubated before tracheostomy, weight
at tracheostomy, home ventilation requirements, time to positive pressure
independence (PPV), time to decannulation, rate of laryngotracheal reconstruction(LTR), neurologic outcomes,
comorbidities, presence of recurrent
wheezing, chronic nebulizer use, and
survival.
RESULTS
Table 1 describes the patient characteristics. Median gestational age was
27 weeks (range 2243). Median birth
weight was 820 g (range 3604860).
The number of male and female infants
was similar (53.9% vs 46.1%, P = .312;
Table 1). There were 87 infants (57.6%)
in Group A and 64 (42.4%) in Group B
Median (range)
n (%)
27 (2243)
820 (3604860)
1 (0851)
159 (13593)
86 (0546)
94 (1591)
3.4 (0.811.8)
1 (06)
27 (22, 43)
50.7% (77)
151
151
164
163a
133, from initial admission
154
153
147
151
152
76 (46.1)
89 (53.9)
151
87 (57.6)
64 (42.4)
164
46 (28)
118 (72)
One patient was excluded due to transfer to another institution after tracheostomy placement.
Birth weight is unknown for 14 patients.
c Gestational age is unknown for 1 patient who transferred from an outside facility, and it was not documented in the medical
record.
b
e1493
P value
96 (58.2)
93 (56.4)
54 (32.7)
36 (21.8)
9 (5.5)
23 (13.9)
26 (15.7)
21 (12.7)
10 (6.1)
8 (4.8)
8 (4.8)
8 (4.8)
1 (0.6)
83 (95.4)
61 (70.1)
33 (37.9)
9 (10.3)
3 (3.4)
9 (10.3)
1 (1.1)
6 (6.9)
5 (5.7)
0 (0)
0 (0)
4 (4.6)
0
11 (17.2)
29 (45.3)
17 (26.6)
20 (31.3)
5 (7.8)
13 (20.3)
19 (29.7)
15 (23.4)
4 (6.2)
8 (12.5)
5 (7.8)
4 (6.2)
1 (1.6)
,.001
.002
.142
.001
.285
.086
,.001
.004
1.0
.001
.012
.723
NA
BPD
Uncomplicated congenital heart defect
Subglottic stenosis
Respiratory failure
Laryngomalacia
Tracheomalacia
Upper airway obstruction/abnormality
Pulmonary hypoplasia
Chronic aspiration
Congenital diaphragmatic hernia
Neuromuscular weakness
Vocal cord paralysis
Arnold-Chiari malfunction
a
#1000 g (n = 87)
.1000 g (n = 64)
186 (5490)
112 (18573)
370 (21067)
505 (621287)
479 (481376)
130 (6593)
57 (1385)
307 (11058)
372 (151270)
436.5 (1961611)
.001
,.001
.367
.011
.323
DISCUSSION
TABLE 4 Reasons for Laryngotracheal
Reconstruction
Reason
n (%)
Subglottic stenosis
Tracheomalacia
Laryngomalacia
Laryngeal cleft
Supraglottic stenosis
44 (75.9)
16 (27.6)
4 (6.9)
1 (1.7)
1 (1.7)
e1494
Comorbidities
n (%)
Developmental delay
106 (64.2)
Gastrointestinal (GERD, swallow
76 (46.3)
dysfunction, feeding dysfunction,
ileal/bowel perforation, oral
aversion, necrotizing enterocolitis,
malrotation, omphalocele)
Other neurologic disease
42 (25.5)
(microcephaly, static
encephalopathy, hydrocephalus, VP
shunt, craniosynostosis, stroke,
cerebral palsy, absent septum
pellucidum, optic nerve hypoplasia)
Retinopathy of prematurity
41 (24.8)
Chromosome abnormality (n = 138)
34 (24.6)
Pulmonary hypertension
36 (21.8)
Seizures
22 (13.3)
Renal/genitourinary anomalies
15 (9.1)
Swallow dysfunction/feeding
15 (9.1)
difculties
Endocrine
13 (7.9)
GERD, gastroesophageal reux disease; VP, ventriculoperitoneal.
OVERMAN et al
ARTICLE
ACKNOWLEDGMENTS
The contributions of Bonnie Giacomini,
RN, Emma Halbrooks, Thomas Wheeler,
and Erin Zielinski are gratefully acknowledged.
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OVERMAN et al
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