(i) To determine the prevalence of echocardiographic abnormalities in children with very severe OSA defined by an apnea hypopnea index (AHI) ≥ 30 events/hour. (ii) To test the hypothesis that ...polysomnographic parameters predict echocardiographic variables in this population.
Children aged 1–17 years presenting with polysomnography demonstrating an AHI ≥30 and referred for pre-operative echocardiography performed within the 6 months prior to tonsillectomy and adenoidectomy (T&A), over a two-year period (January 1, 2016 to December 31, 2018) were evaluated. The exclusion criteria were the presence of (i) unrepaired congenital cardiac disease, (ii) tracheostomy, (iii) poorly controlled asthma, or (iv) neuromuscular disorder. The prevalence of echocardiographic abnormalities was determined for the study population. The impact of the severity of OSA on echocardiographic parameters was evaluated using Student's t-test. The relationships between polysomnographic variables and biventricular function as well as pulmonary hemodynamics were measured. A penalized regression model was used to identify the contributions of polysomnographic variables to each echocardiographic parameter by mitigating inter-variable relationships. P < .05 was considered significant.
Eighty-nine children were screened, of whom 47 were included for analysis. The mean age was 68.8 months 95% confidence interval, 56.0 to 81.6. Thirty-three (70.2%) were boys. Twenty (42.6%) were obese. All children had normal echocardiograms. The differences in echocardiographic variables between children grouped by the severity of OSA were not statistically significant (P: 0.18-0.98). Polysomnographic variables predicted only 4 out of 13 studied echocardiographic parameters.
Pre-operative echocardiography did not identify significant abnormalities in children with very severe OSA. Majority of the echocardiographic variables were not predicted by polysomnographic parameters. This study demonstrates the limited benefit associated with routine echocardiographic screening of children with very severe OSA solely based on polysomnographic indices.
Diagnosis of obstructive sleep apnea (OSA) in children with sleep-disordered breathing (SDB) requires hospital-based, overnight level I polysomnography (PSG). Obtaining a level I PSG can be ...challenging for children and their caregivers due to the costs, barriers to access, and associated discomfort. Less burdensome methods that approximate pediatric PSG data are needed. The goal of this review is to evaluate and discuss alternatives for evaluating pediatric SDB. To date, wearable devices, single-channel recordings, and home-based PSG have not been validated as suitable replacements for PSG. However, they may play a role in risk stratification or as screening tools for pediatric OSA. Further studies are needed to determine if the combined use of these metrics could predict OSA.
Objectives
To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence.
Study Design
Prospective cohort.
Methods
All successfully ...decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single‐stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation.
Results
A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy‐dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p = 0.002), congenital malformations (64% vs. 33%, p = 0.02), newborn complications (58% vs. 26%, p = 0.009), maternal complications (40% vs. 11%, p = 0.009) and chronic respiratory failure (72% vs. 41%, p = 0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05–0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06–0.99, p = 0.049) with failure to spontaneously close.
Conclusions
Two‐thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher‐risk children is necessary when caring for pediatric tracheostomy patients.
Level of Evidence
3 Laryngoscope, 133:417–422, 2023
Two‐thirds of children will develop a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Persistent TCF is correlated with longer duration of tracheostomy and congenital malformations.
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.
Mortality Among Children with a Tracheostomy Teplitzky, Taylor B.; Brown, Ashley F.; Brooks, Rebecca L. ...
The Laryngoscope,
February 2023, 2023-02-00, 20230201, Letnik:
133, Številka:
2
Journal Article
Recenzirano
Objectives
To characterize the cause of death among children with a tracheostomy.
Study Design
Prospective cohort.
Methods
All pediatric patients (<18 years) who had a tracheostomy placed at a ...tertiary care institution between 2015 and 2020 were included. The location and cause of death were recorded along with patient demographics and age.
Results
A total of 271 tracheostomies were placed with 46 mortalities reviewed for a mortality rate of 16.8%. Mean age at placement was 1.7 years (SD: 3.4) and mean age at death was 2.9 years (SD: 3.5). Most tracheostomies were placed for respiratory failure (N = 33, 72%). The mean time to death after tracheostomy was 1.2 years (SD: 1.2) and 28% (N = 13) occurred during the same admission as placement. Mean time to death after hospital discharge was 1.3 years (SD: 1.3). Etiology of death was respiratory failure (33%, N = 15), cardiopulmonary arrest (15%, N = 7), unknown (43%, N = 20), or secondary to a tracheostomy‐related complication for 9% (N = 4). Location of death was in intensive care units for 41% (N = 19) and 30% died at home (N = 14). Comfort care measures were taken for 37% (N = 17). Severe neurological disability (HR: 4.06, p = 0.003, 95% CI: 1.59–10.34) and congenital heart disease (HR: 2.36, p = 0.009, 95% CI: 1.24–4.48) correlated with time to death on Cox proportional hazard modeling.
Conclusions
Nearly one‐third of children with a tracheostomy who expire will do so during the same admission as tracheostomy placement. Although progression of underlying disease will lead to most deaths, 9% will be a result of a tracheostomy‐related complication, which represents a meaningful target for quality improvement initiatives.
Level of Evidence
3 Laryngoscope, 133:403–409, 2023
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.
Advances in neonatal intensive care have allowed successful resuscitation of children born at the border of viability. However, there has been little change in the incidence of bronchopulmonary ...dysplasia (BPD) and anatomical upper airway obstruction which may require a tracheostomy in that group. The benefits of the procedure are accompanied by sequelae that impact outcomes. Information about these issues can assist caregivers in making decisions and planning care after discharge from the neonatal intensive care unit (NICU). The objectives of this study were to describe the clinical characteristics of neonates born in the periviable period (≤25 weeks gestation) requiring tracheotomy and to highlight their hospital course, complications and status upon NICU discharge.
Retrospective analysis at four tertiary care academic children's hospitals. Medical records of neonates born ≤25 weeks gestation who required tracheotomy between January 1, 2012 and December 31, 2018 were reviewed. Demographics, medical comorbidities, and tracheostomy related complications were studied. Feeding, ventilation, and neurodevelopmental outcomes at time of transfer from NICU were evaluated.
Fifty-two patients were included. The mean gestational age was 24.3 (95% confidence interval, 24.1 to 24.5) weeks. The mean birth weight was 635 (95% CI: 603 to 667) grams and 50 (96.2%) children had BPD. At time of discharge from the NICU, 47 (90.4%) required mechanical ventilation, four (7.7%) required supplemental oxygen and one (1.9%) was weaned to room air. Forty-two (80.8%) were discharged with a gastrostomy tube, seven (28%) with a nasogastric tube, and three (5.8%) were on oral feeds. Two (3.8%) suffered hypoxic ischemic encephalopathy, 27 (51.9%) had neurodevelopmental delay, seven (13.5%) were diagnosed with another anomaly, and 16 (30.8%) were considered normal. Complications related to the procedure were observed in 28 (53.8%) neonates. Granulation tissue was seen in 17 (32.7%), wound break down or cellulitis in three (5.8%), one (1.9%) with tracheostomy plugging, three (5.8%) with dislodgement of the tracheostomy tube and four (7.7%) developed tracheitis.
Tracheostomy in infants born in the periviable period is primarily performed for BPD and portends extended ventilatory dependence. It is associated with non-oral alimentation at the time of discharge from the NICU and developmental delay. Mortality directly related to the procedure is rare. Minor complications are common but do not require surgical intervention. These data may aid in counseling caregivers about the procedure in this vulnerable population.
B cells are required for follicular Th (Tfh) cell development, as is the ICOS ligand (ICOS-L); however, the separable contributions of Ag and ICOS-L delivery by cognate B cells to Tfh cell ...development and function are unknown. We find that Tfh cell and germinal center differentiation are dependent on cognate B cell display of ICOS-L, but only when Ag presentation by the latter is limiting, with the requirement for B cell expression of ICOS-L overcome by robust Ag delivery. These findings demonstrate that Ag-specific B cells provide different, yet compensatory, signals for Tfh cell differentiation, while reconciling conflicting data indicating a requirement for ICOS-L expression on cognate B cells for Tfh cell development with those demonstrating that the latter requirement could be bypassed in lieu of that tendered by noncognate B cells. Our findings clarify the separable roles of delivery of Ag and ICOS-L by cognate B cells for Tfh cell maturation and function, and have implications for using therapeutic ICOS blockade in settings of abundantly available Ag, such as in systemic autoimmunity.
To describe the long-term outcomes related to breathing, feeding, and neurocognitive development in extremely premature infants requiring tracheostomy.
Pooled cross-sectional survey.
...Multi-institutional academic children's hospitals.
Extremely premature infants who underwent tracheostomy between January 1, 2012, and December 31, 2019, at four academic hospitals were identified from an existing database. Information was gathered from responses to a questionnaire by caregivers regarding airway status, feeding, and neurodevelopment 2–9 years after tracheostomy.
Data was available for 89/91 children (96.8%). The mean gestational age was 25.5 weeks (95% CI 25.2–25.7) and mean birth weight was 0.71 kg (95% CI 0.67–0.75). Mean post gestational age at tracheostomy was 22.8 weeks (95% CI 19.0–26.6). At time of the survey, 18 (20.2%) were deceased. 29 (40.8%) maintained a tracheostomy, 18 (25.4%) were on ventilatory support, and 5 (7%) required 24-h supplemental oxygen. Forty-six (64.8%) maintained a gastrostomy tube, 25 (35.2%) had oral dysphagia, and 24 (33.8%) required a modified diet. 51 (71.8%) had developmental delay, 45 (63.4%) were enrolled in school of whom 33 (73.3%) required special education services.
Tracheostomy in extremely premature neonates is associated with long term morbidity in the pulmonary, feeding, and neurocognitive domains. At time of the survey, about half are decannulated, with a majority weaned off ventilatory support indicating improvement in lung function with age. Feeding dysfunction is persistent, and a significant number will have some degree of neurocognitive dysfunction at school age. This information may help caregivers regarding expectations and plans for resource management.
•Children born extremely preterm (<28 weeks) who require tracheostomy have long term consequences of their prematurity.•Effects are persistent in several realms including feeding dysfunction and neurodevelopmental deficits.•Typically, lung function improves with age.•Persistent system wide outcomes are not directly related to the tracheostomy.
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