Children and Young Adults Who Received Tracheostomies or Were Initiated on Long-Term Ventilation in PICUs*

Abstract

Objectives To characterize patients who received tracheostomies for airway compromise or were initiated on long-term ventilation for chronic respiratory failure in pediatric intensive care units (PICU), and to examine variation in the incidence of initiation, patient characteristics, and modalities across sites. Design Retrospective cross-sectional analysis. Settings Seventy three North American PICUs that participated in the Virtual Pediatric Intensive Care Unit Performance System. Patients PICU patients admitted between 2009 and 2011. Interventions None. Measurements and Main Results Among 115,437 PICU patients, 1.8% received a tracheostomy or were initiated on long-term ventilation; 1034 received a tracheostomy only, 717 were initiated on invasive ventilation (IV), and 381 were initiated on noninvasive ventilation (NIV). Ninety percent had substantial chronic conditions and comorbidities, including more than 50% with moderate or worse cerebral disability upon discharge. Seven percent were initiated after a catastrophic injury/event. Across sites, there was variation in incidence of tracheotomy and initiation of long-term ventilation, ranging 0–4.6%. There also was variation in patient characteristics, time to tracheotomy, number of extubations prior to tracheostomy, and the use of IV versus NIV. Conclusions While the PICU incidence of initiation of tracheostomies and long-term ventilation was relatively uncommon, it suggests that thousands of children and young adults receive these interventions each year in North American PICUs. The majority of them have conditions and comorbidities that impose on-going care needs, beyond those required by artificial airways and long-term ventilation themselves.

A multi‐institutional analysis of children on long‐term non‐invasive respiratory support and their outcomes

“…Cancelhina et al reported that 7.4% of non‐invasive patients transitioned to transtracheal ventilation, and Amin et al reported that 7.6% of patients requiring transtracheal ventilation had previously required non‐invasive respiratory support. The median age of index discharge and bimodal distribution of ages of our cohort was similar to that reported in Edwards et al, Chatwin et al, and Amin et al and is consistent with the pathophysiology of chronic respiratory failure . This study augments previous ones by being multi‐institutional, concentrating on transitions to transtracheal ventilation (as opposed to mortality), and providing granular data on multiple disorders associated with chronic respiratory failure.…”

“…Patients were included in this study if they had one or more inpatient admissions during the study period, had a chronic condition that is associated with chronic respiratory failure, and were discharged using non‐invasive respiratory support to home or to a non‐acute care facility (eg, chronic care facility). Chronic conditions associated with chronic respiratory failure were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9) codes (Supplementary Table S1) based on previous literature and by consensus of study investigators . Because our population of interest was patients with chronic respiratory failure, patients were excluded if they had an ICD‐9 code for obstructive sleep apnea or upper airway obstruction in the absence of a chronic respiratory failure diagnosis .…”

Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both

“…Thus, LOS analyses were repeated using only this patient sub-group, for the subgroup of sites with data that allowed identification of patients using chronic ventilation via tracheostomy[15]. For this analysis, sites with IMCUs that accepted/transferred PICU patients on chronic ventilation were compared to sites with an IMCU that did not accept such patients combined with sites without an IMCU.…”

Tracheostomy in Infants and Children

“…A more recent retrospective analysis of 73 North American pediatric ICUs reported that among 115,437 admitted pediatric ICU patients between 2009 and 2011, 1.37% (1,583 subjects) received a new tracheostomy during that admission, and 0.6% (168 subjects) had a tracheostomy already in place. 38 The majority of children in this study had complex chronic conditions that contributed to their airway compromise or chronic respiratory failure, and most tracheostomy placements were initiated during unplanned pediatric ICU admissions and after acute/acute-on-chronic critical illness. Elective tracheostomy is rare in the pediatric setting.…”