Professionalism, quality, and safety have become essential components of pediatric otolaryngology. Professionalism, as defined by Osler, refers to the long tradition of physicians carrying out the ...noble cause of providing health care to patients and families. The importance of professionalism cannot be overstated and now is widely understood to be a core competency of every practicing physician. The attention to quality and safety is also a central tenet of current surgical practice. Quality is doing the right thing at the right time for the right persons. Safety is providing care to patients that is free from undue harm.
Pediatric tracheostomy for COVID-19 infections is uncommon and requires age-appropriate adaptations. This case adds to a limited body of literature related to tracheostomy placement and management in ...an adolescent. Thoughtful planning and communication by a dedicated tracheostomy team was crucial in obtaining a successful outcome.
Objective
The primary objective was to determine if treating pathogenic bacteria in bronchoalveolar lavage (BAL) cultures improves outcomes after pediatric double stage laryngotracheal reconstruction ...(dsLTR).
Study Design
Case series with chart review.
Setting
Tertiary children's hospital.
Methods
All children (<18 years) obtaining flexible bronchoscopy with BAL cultures before dsLTR between 2016 and 2022 were included. Cultures identified abnormal bacterial growth or normal respiratory flora. Thirty‐day postoperative surgical site or lung infections were captured and tracheostomy decannulation rates were obtained for children with at least 12 months of follow‐up.
Results
Twenty‐seven children obtained presurgical BAL cultures before dsLTR. Median age at reconstruction was 2.9 years (interquartile range: 2.3−3.5) and 89% (24/27) had high grade subglottic stenosis. Positive cultures were obtained in 56% of children (N = 15) with Pseudomonas aeruginosa (40%, 6/15) and methicillin‐resistant Staphylococcus aureus (33%, 5/15) the most frequent organisms. All children with positive cultures were treated based on culture and sensitivity data. Postoperative infections developed in 22% (6/27) of children with equal distribution of surgical site and respiratory infections among children with pathogenic bacteria and normal respiratory flora. At 12 months after surgery, the decannulation rate was no different between those treated and not treated for a presurgical positive BAL culture (47% vs. 58%, p = 0.70).
Conclusion
Pathogenic bacteria are common in BAL cultures from tracheostomy‐dependent children before dsLTR. Treatment keeps respiratory infections and decannulation rates similar to children with negative cultures, suggesting continued benefit of flexible bronchoscopy and BAL in preparation for these surgeries.
Objectives/Hypothesis
To determine the impact of race on outcomes after pediatric tracheostomy.
Study Design
Retrospective case series.
Methods
A case series of tracheostomies at an urban, tertiary ...care children's hospital between 2014 and 2019 was conducted. Children were grouped by race to compare neurocognition, mortality, and decannulation rate.
Results
A total of 445 children with a median age at tracheostomy of 0.46 (interquartile range IQR: 0.97) years were studied. The cohort was 32% Hispanic, 31% White, 30% Black, 2.9% Asian, and 4.3% other race. Black compared to White children had a lower median birth weight (2,022 vs. 2,449 g, P = .005), were more often extremely premature (≤28 weeks gestation: 62% vs. 57%, P = .007), and more frequently had bronchopulmonary dysplasia (BPD) (35% vs. 17%, P = .002). Hispanic compared to Black children had higher median birth weight (2,529 g, P < .001), less extreme prematurity (44%, P < .001), and less BPD (21%, P = .04). The proportion of Black children was higher (30% vs. 19%, P < .001), while the proportion of Hispanic children with a tracheostomy was lower (32% vs. 42%, P = .003) compared to the racial distribution of all pediatric admissions. Racial differences were not seen for rates of severe neurocognitive disability (P = .51), decannulation (P = .17), or death (P = .92) after controlling for age, sex, prematurity, and ventilator dependence.
Conclusion
Black children disproportionately underwent tracheostomy and had a higher comorbidity burden than White or Hispanic children. Hispanic children had proportionally fewer tracheostomies. Neurocognitive ability, decannulation, and mortality were similar for all races implying that health disparities by race may not change long‐term outcomes after pediatric tracheostomy. Laryngoscope, 132:1118–1124, 2022
To determine survival among critically ill children when caregivers decline tracheostomy placement.
Retrospective cohort.
All children (<18 years) obtaining a pre-tracheostomy consultation at a ...tertiary children's hospital between 2016 and 2021 were included. Comorbidities and mortality were compared between children of caregivers that declined or agreed to tracheostomy.
Tracheostomy was declined for 58 children but was placed for 203 children. After consultation, mortality was 52% (30/58) when declining and 21% (42/230) when agreeing to tracheostomy (p < 0.001) at a mean of 10.7 months (standard deviation SD: 16) and 18.1 months (SD: 17.1), respectively (p = 0.07). For those declining, 31% (18/58) died during the hospitalization within a mean of 1.2 months (SD: 1.4) while 21% (12/58) died at a mean of 23.6 months (SD: 17.5) after discharge. Among children of caregivers declining tracheostomy, older age (odds ratio OR: 0.85, 95% confidence interval CI: 0.74-0.97, p = 0.01) and chronic lung disease (OR: 0.18, 95% CI: 0.04-0.82, P = .03) were associated with lower odds of mortality but sepsis (OR: 9.62, 95% CI: 1.161-57.43, p = 0.01) and intubation (OR: 4.98, 95% CI: 1.24-20.08, p = 0.02) were associated with higher odds of mortality. Median survival after declining tracheostomy was 31.9 months (interquartile range IQR: 2.0-50.7) and declining placement was associated with increased mortality risk (hazard ratio HR: 4.04, 95% CI: 2.49-6.55, p < 0.001).
When caregivers declined tracheostomy placement, less than half of critically ill children in this cohort survived with younger age, sepsis, and intubation associated with higher mortality. This information offers valuable insight for families weighing decisions pertaining to pediatric tracheostomy placement.
3 Laryngoscope, 133:3602-3607, 2023.
Objectives
To determine the incidence of tracheostomy accidental decannulations (AD) among pediatric inpatients and identify risks for these events.
Study Design
Prospective cohort.
Methods
All ...tracheostomy patients (≤18 years) admitted at a tertiary children's hospital between August 2018 and April 2021 were included. AD were recorded and patient harm was classified as no harm/minor, moderate, or severe. Monthly AD incidence was described as events per 1000 tracheostomy‐days.
Results
One‐hundred seventeen AD occurred among 67 children with 33% (22/67) experiencing multiple events (median: 2.5 events, range: 2–10). Mean age at AD was 4.7 years (SD: 4.4). AD resulted from patient movement (32%, 37/117), performing tracheostomy care (27%, 31/117), repositioning or transporting (15%, 17/117), or unclear reasons (27%, 32/117). A parent or guardian was involved in 28% (33/117) of events. Nearly all AD resulted in no more than minor harm (84%, 98/117) but moderate (12%, 14/117) and severe (4%, 5/117) events did occur. There were no deaths. Tracheostomy care or repositioning were frequently responsible in acute versus subacute events (48% vs. 26%, p = 0.04). Mean monthly AD incidence was 4.7 events per 1000 tracheostomy‐days (95% CI: 3.7–5.8) and after implementation of safety initiatives, the mean rate decreased from 5.9 events (95% CI: 4.2–7.7) to 3.7 events (95% CI: 2.5–5.0) per 1000 tracheostomy‐days (p = 0.04).
Conclusions
AD in children occur at nearly 5 events per 1000 tracheostomy‐days and often result in minimal harm. Quality initiatives targeting patient movement, provider education, and tracheostomy care might reduce the frequency of these complications.
Level of Evidence
3 Laryngoscope, 133:963–969, 2023
Accidental decannulations among pediatric tracheostomy patients can be a worrisome complication. A prospective study determined that the rate of these events is about 5 per 1000 tracheostomy days and that most events result in minor harm. This information can be used to design patient safety and quality improvement initiatives for this vulnerable population.
Objectives//Hypothesis
To characterize long‐term outcomes in pediatric patients requiring tracheotomy in the first year of life.
Study Design
Retrospective case series.
Methods
A retrospective ...longitudinal registry of tracheostomy patients was queried for patients who underwent tracheotomy from birth to 11 months. Primary outcomes were decannulation and survival. Secondary outcomes included neurocognitive quality of life assessed with the PedsQL Family Impact Module (scored from worst to best, 0 to 100 points).
Results
The study included 337 children. Thirty (8.90%) were neonates and 307 (91.10%) were infants. The population was 56.08% male (n = 189), and the racial and ethnicity composition were equally distributed (29.97% White, 31.45% Black, and 31.16% Hispanic). Significant differences between neonates and postneonates included birth weight in grams (2,731.40 vs. 1,950.44, P < .05), extreme prematurity (13.33% vs. 38.88%, P = .01), upper airway obstruction (80.00% vs. 42.67%, P < .05), and the need for mechanical ventilation (40.00% vs. 83.71%, P < .05). Despite these differences, long‐term outcomes were similar: decannulation (X2 = 2.19, P = .14), death (X2 = 2.63, P = .11), and neurocognitive quality of life (X2 = 2.63, P = .27). Having a child with a tracheostomy caused the most problems with being physically tired (mean = 75.32 ± 3.90), emotional frustration (mean = 77.31 ± 5.05), and worry (mean standard deviation = 74.23 ± 6.48).
Conclusion
There were demographic differences between neonatal and infantile tracheostomy patients, but they did not affect long‐term outcomes. The presence of a tracheostomy caused a significant impact on a family's quality of life.
Level of Evidence
3 Laryngoscope, 131:2115–2120, 2021
Objective
To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy.
Methods
A prospective cohort of children (<18 years) with a ...tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits).
Results
A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory‐related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18–3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35–5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47–10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy‐related complications, which accounted for 4.8% of all encounters. A sub‐analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure.
Conclusion
Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy‐related visits are uncommon, strategies to anticipate and decrease respiratory‐related admissions may have the most impact.
Level of evidence
3 Laryngoscope, 133:2018–2024, 2023
Children with tracheostomy require frequent emergency department (ED) visits and hospitalizations after placement. Strategies to anticipate and decrease respiratory‐related admissions may have the most impact.
To determine the cumulative 24-month incidence of middle ear effusion (MEE) among tracheostomy-dependent children requiring ventilatory support.
A prospective longitudinal cohort study included all ...children under 2 years of age with a tracheostomy placed at a tertiary care children's hospital between 2015 and 2020 that obtained at least one tympanometry exam. The development of MEE, defined as a flat tympanogram with normal external canal volume, and mechanical ventilation requirement at examination were recorded.
Ninety-four children with a mean age at tracheostomy of 5.4 months (SD: 3.7) were included. During a mean follow-up of 18.3 months (SD: 14.6) (median: 14.1 months, interquartile range: 6.6–27.8), 192 tympanometry examinations were obtained with 59% (114/192) while requiring mechanical ventilation. Within 24 months after tracheostomy, 56.5% (95% CI: 48.9–64.4%) of children developed at least one MEE. Among those on mechanical ventilation, 74.0% (95% CI: 65.6–82.5%) developed MEE compared to 31.2% (95% CI: 21.4–44.0%) not on mechanical ventilation (HR: 2.97, 95% CI: 1.46–6.05, P = .003). A persistent MEE on two consecutive exams was not statistically more common for children on a ventilator (OR: 0.64, 95% CI: 0.01–6.95, P = .70). When controlling for age at exam, craniofacial syndrome, and newborn hearing test results on logistic regression, ventilator-dependence significantly predicted the presence of MEE (OR: 2.34, 95% CI: 1.18–4.68, P = .02).
Children with a tracheostomy were more likely to develop MEE when requiring mechanical ventilation. Clinicians should recognize this risk factor and appropriately assess for development of MEE to mitigate adverse speech and language development outcomes in this vulnerable population.
Objectives
Thyroglossal duct cyst (TGDC) is the most common pediatric congenital neck mass. The Sistrunk procedure is the standard method of excision and is associated with low rates of recurrence. ...This study aimed to review our institution's outcomes following the Sistrunk procedure, specifically the rates of wound complications and cyst recurrence.
Methods
This was a retrospective case series of pediatric patients undergoing the Sistrunk procedure from June 2009 to April 2021.
Results
A total of 273 patients were included. Of these, 139 (53%) patients were male and 181 (66%) were white. The average age at the time of surgery was 7.1 years. The overall cyst recurrence rate was 11%. The most common wound complications were seroma (14%) and surgical site infections (SSIs) (12%). Wound complications were associated with prior history of cyst infection (odds ratio OR 1.97, 95% confidence interval CI 1.07–3.60, z‐test 2.2, p = .03). Pediatric surgery was associated with fewer wound complications (OR 0.18; 95% CI 0.05–0.6, z‐test −2.78, p = .005). However, pediatric surgery operated on fewer patients with a history of cyst infection (36% vs. 55%, p = .012). Drain placement and postoperative antibiotics did not affect rates of wound complications.
Conclusions
Prior cyst infection is associated with increased rates of postoperative wound complications. Postoperative antibiotics and drain placement did not significantly affect complication rates.
Level of Evidence
4.
This is a retrospective case series of pediatric patients undergoing the Sistrunk procedure from June 2009 to April 2021 at a tertiary care referral center. Preoperative cyst infection is associated with increased rates of postoperative wound complications. Postoperative antibiotics and drain placement did not significantly affect complication rates.
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