Objective
To evaluate for differences in time to decannulation and survival rates for pediatric tracheotomy patients based on ventilator status upon discharge.
Study Design
Retrospective longitudinal ...cohort study.
Methods
A single‐institution longitudinal study of pediatric tracheostomy patients was conducted. Patients were categorized based on mechanical ventilation status on discharge and principal reason for tracheostomy. Survival rates were determined using the Kaplan‐Meier method. The Wilcoxon's Rank Sum test and Cox regression analysis evaluated differences in survival times and time to decannulation based on primary indication for tracheotomy and ventilation status.
Results
Chart review identified 305 patients who required a tracheostomy under the age of 3. The median age at the time of tracheotomy was 5.2 months. The indications for tracheotomy in these patients were airway obstruction in 145 (48%), respiratory failure in 214 (70%), and pulmonary toilet in 10 (3.3%). Seventy‐nine percent of patients were ventilator dependent at discharge. At the conclusion of the study period, 55% of patients were alive with tracheostomy in place, 30% patients were decannulated, and 15% patients were deceased. Patients with ventilator dependence at initial discharge, bronchopulmonary dysplasia, or airway obstruction were more likely to be decannulated. Hispanic patients were less likely to be decannulated. Patients had an equal probability of death regardless of ventilator status at discharge.
Conclusions
This study demonstrated that the time to decannulation and likelihood of decannulation varies based on the indication for the tracheostomy. The majority of patients with a tracheostomy were not decannulated at the conclusion of this study. Median time to decannulation was 2.5 years for patients with a median death time of 6 months.
Level of Evidence
2b Laryngoscope, 130:2319–2324, 2020
Objective
Obstructive sleep apnea (OSA) is prevalent in children with sickle cell disease (SCD). We compared the demographic, clinical, and polysomnographic characteristics of children with and ...without SCD.
Methods
This retrospective chart review included children with SCD (n = 89) and without SCD (n = 192) ages 1–18 years referred for polysomnography (PSG) for OSA.
Results
Children with SCD were predominantly African American when compared to the non‐SCD group (95% vs. 28%, p < 0.001). The non‐SCD group had a higher BMI z‐score (1.3 vs. 0.1, p < 0.001) and a higher percentage of patients classified as obese (52% vs. 13%, p < 0.001). In children with SCD, 43% had severe OSA and 5.6% had no OSA. In the non‐SCD group, 67% had severe OSA and 4.7% had no OSA. The SCD compared to the non‐SCD group had a lower mean apnea‐hypopnea index (AHI) (13.6 vs. 22.4, p = 0.006) but a higher percent sleep time below 90% oxygen saturation (10.5% vs. 3.5%, p < 0.001). Predicted probability for severe OSA in children with SCD decreased with increasing age (OR = 0.81, 95% CI: 0.70–0.93).
Conclusion
Children with SCD referred for PSG are at risk for severe OSA. Compared with the non‐SCD group, most children were African American with lower rates of obesity and lower AHIs but longer periods of nocturnal hypoxemia. Likelihood for severe OSA decreased with increasing age for the SCD group.
Level of Evidence
3, retrospective comparative study Laryngoscope, 133:1766–1772, 2023
Children with SCD referred for PSG are at risk for severe OSA. Compared to the non‐SCD group, most children were African American with lower rates of obesity and lower AHIs but longer periods of nocturnal hypoxemia. Likelihood for severe OSA decreased with increasing age for the SCD group.
Objectives/Hypothesis
Bronchopulmonary dysplasia (BPD) and invasive respiratory support is increasing among extremely preterm neonates. Yet, it is unclear if there is a corresponding increase in ...tracheostomies. We hypothesize that in extremely preterm neonates with BPD, the incidence of tracheostomy has increased.
Study Design
Retrospective cross‐sectional analysis.
Methods
We analyzed the 2006 to 2012 Kids’ Inpatient Databases (KID) for hospital discharges of nonextremely preterm neonates (gestational age >28 weeks and <37 weeks or birth weight >1,500 g) and extremely preterm neonates (gestational age ≤28 weeks or birth weight ≤1,500 g). We studied tracheostomy placement trends in these two populations to see if they are increasing among extremely preterm neonates, especially those with BPD.
Results
The study included 1,418,681 preterm neonates (52% male, 50% white, 19% black, 20% Hispanic, 4.2% Asian), of whom 118,676 (8.4%) were extremely preterm. A total of 2,029 tracheostomies were performed, of which 803 (0.68%) were in extremely preterm neonates. The estimated percent change of occurrence of extremely preterm neonates with BPD increased 17% between 2006 and 2012, and tracheostomy placement increased 31%. Amongst all who received tracheostomies, mortality rate was higher in extremely preterm neonates compared to nonextremely preterm neonates (18% vs. 14%, P = .05). However, in extremely preterm neonates, those with tracheostomies had a lower mortality rate compared to those without (18% vs. 24%, P = .002).
Conclusions
Extremely preterm neonates, compared to nonextremely preterm neonates, experienced a marked increase in tracheostomies placed from 2006 to 2012 as well as an increased incidence of BPD, confirming our primary study hypothesis.
Level of Evidence
4 Laryngoscope, 130: 2056–2062, 2020
To evaluate outcomes of tonsillectomy and predictors for persistent obstructive sleep apnea (OSA) in children with Down syndrome in an ethnically diverse population.
Case series with chart review.
UT ...Southwestern/Children's Medical Center Dallas.
Polysomnographic, clinical, and demographic characteristics of children with Down syndrome ages 1 to 18 years were collected, including pre- and postoperative polysomnography. Simple and multivariable regression models were used for predictors for persistent OSA.
≤ .05 was considered significant.
Eighty-one children were included with a mean age of 6.6 years, 44 of 81 (54%) males, and 53 of 81 (65%) Hispanic. Preoperatively, 60 of 81 (74%) patients had severe OSA. Posttonsillectomy improvements occurred for apnea-hypopnea index (27.9 to 14.0,
< .001), arousal index (25.2 to 18.8,
= .004), percent time with oxygen saturations <90% (8.8% to 3.4%,
= .003), and oxygen nadir (81.4% to 85%,
< .001). Forty-seven children (58%) had persistent OSA. Fifteen children (18.5%) had increased apnea-hypopnea index postoperatively: 2 from mild to moderate, 2 from mild to severe, and 2 from moderate to severe obstructive sleep apnea. Persistent OSA predictors were asthma (odds ratio, 4.77; 95% CI, 1.61-14.09;
= .005) and increasing age (odds ratio, 1.25; 95% CI, 1.09-1.43;
= .001).
Children with Down syndrome are at high risk for persistent OSA after tonsillectomy with about 20% worsening after tonsillectomy. Asthma and increasing age are predictors for persistent OSA in children with Down syndrome.
In 2012, Black or African American children constituted 21% of pediatric tracheostomies while representing approximately 15% of the US population. It is unclear if this discrepancy is due to ...differences in associated diagnoses. This study aimed to analyze the incidence of pediatric tracheostomy in the United States from 2003 to 2016 and to determine the odds of placement among Black children when compared with other children.
Retrospective.
Academic hospital.
We used the 2003 to 2016 Kid Inpatient Database to determine the incidence of pediatric tracheostomy in the United States and determine the odds of tracheostomy placement in Black children when compared with other children.
A total of 26,034 pediatric tracheostomies were performed between 2003 and 2016, among which, 21% were Black children. The median age was 7 years (interquartile range IQR = 0 to 17); 43% were ≤2 years old, and 62% were male. The most common principal diagnosis was respiratory failure (72%). When compared with other children, Black children were more likely to undergo tracheostomy (odds ratio OR = 1.2; 95% CI, 1.1-1.3), which increased among children younger than 2 years old (OR = 1.5; 95% CI, 1.4-1.5). Black children with tracheostomies were also more likely to be diagnosed with laryngeal stenosis and bronchopulmonary dysplasia and to have an extended length of stay (
< .001).
Black children are 1.2 times more likely to undergo tracheostomy in the United States compared with other children. Further investigation is warranted to evaluate if there are underlying anatomical, environmental, or psychosocial factors that contribute to this discrepancy.
Objectives/Hypothesis
To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity.
Study Design
Retrospective case series.
Methods
All patients that underwent ...tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy‐related complications, in‐hospital mortality, and 30‐day readmissions were recorded among complex and non‐complex patients.
Results
A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14–51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post‐tracheostomy admission length.
Conclusions
Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children.
Level of Evidence
4 Laryngoscope, 131:E2469–E2474, 2021
Objectives/Hypothesis
To study rates of respiratory complications/interventions among inpatient tonsillectomy patients in the United States and identify risk factors for these events.
Study Design
...Retrospective database review.
Methods
Children (age < 18 years) undergoing tonsillectomy with or without adenoidectomy in 2006, 2009, and 2012 were studied using the Kids Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Outcomes were analyzed for respiratory events (complications/interventions) and racial disparities. Pearson χ test was used to analyze categorical data and regression analysis was used for continuous variables. Respiratory events were analyzed by racial identity using logistic regression analysis. A P < .05 was considered significant.
Results
The study included 30,617 patients (41% female, 51% white, 24% African American, 23% Hispanic, 3.0% Asian). The mean age was 5.2 years, and mean length of stay 2.3 days. The overall complication rate was 6.0%, and overall intervention rate was 3.6%. Respiratory events were more common among African American children (odds ratio OR: 1.5, 95% confidence interval CI: 1.3‐1.6) and less common among white children (OR: 0.8, 95% CI: 0.8‐0.9). These differences were significant after controlling for age, gender, obesity, obstructive sleep apnea, and asthma. The mortality rate was 0.05% with no ethnic predilection.
Conclusions
Respiratory events after inpatient tonsillectomy included laryngo/bronchospasm, pneumonia, pulmonary edema, intubation, prolonged intubation, and ventilation. Although uncommon, these were more common among African American children. Further research is needed to understand the etiology of this disparity.
Level of Evidence
NA Laryngoscope, 129:995–1000, 2019
To describe the demographic and clinical characteristics of children with autism spectrum disorder (ASD) referred for polysomnography (PSG) and to look for predictors of obstructive sleep apnea (OSA) ...and severe OSA in these children.
This is a retrospective case series of children ages 2 to 18 years who underwent PSG between January 2009 and February 2015. Children were excluded if they had major comorbidities, prior tonsillectomy, or missing data. The following information was collected: age, sex, race, height, weight, tonsil size, and prior diagnosis of allergies, asthma, gastroesophageal reflux disease, seizure disorder, developmental delay, cerebral palsy, or attention deficit hyperactivity disorder. Predictors of OSA were evaluated.
A total of 45 children were included with a mean (standard deviation SD) age of 6.1 years (2.8). The patients were 80% male, 49% Hispanic, 27% African American, 22% Caucasian, and 2.2% other. Of these children 26 (58%) had OSA (apnea-hypopnea index AHI > 1 event/h) and 15 (33%) were obese (body mass index, body mass index z-score ≥ 95th percentile). The mean (SD) AHI was 7.7 (15.0) events/h (range 1.0-76.6). A total of 9 (20%) had severe OSA (AHI ≥ 10 events/h). There were no demographic or clinical predictors of OSA in this group. However, increasing weight served as a predictor of severe OSA and African American or Hispanic children were more likely obese.
The absence of demographic or clinical predictors of OSA supports using general indications for PSG in children with ASD.
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