Early versus late tracheostomy in pediatric intensive care unit: does it matter? A 6-year experience

Abstract

BacKgroUnD: the aim of this study is to examine the clinical data of children who underwent tracheostomy during their stay in Pediatric intensive care Unit (PicU), in order to describe the relationship between the timing of tracheostomy, the length of PicU stay and the occurrence of ventilator-associated pneumonia (vaP). MetHoDs: this is a retrospective cohort study that collects all patients undergoing tracheostomy during their PicU stay over a six-year period. Data collection included PicU length of stay, days of intubation, days of mechanical ventilation, primary indication for tracheostomy, information about vaP and decannulations. the early tracheostomy group was defined as patients who had ten or fewer days of continuous ventilation, whereas the late tracheostomy group had more than ten days of continuous ventilation. RESULTS: A significant decrease in the rate of VAP incidence was noticed in the early tracheostomy group vs. late group (P=0.004, or=0.39, 95% ci: 0.18-0.85). no differences were observed about decannulation, need of long-term ventilation and death rate. Significant decreases of days of mechanical ventilation and PICU stay were found in subgroup of patients who underwent early tracheostomy and were decannulated within 18 months. conclUsions: no standard timing for tracheostomy placement has been established in the pediatric population. early tracheostomy can shorten the days of ventilation and hospitalization in PicU and reduce the incidence of vaP, but further studies are needed to identify patient categories in which it can be of benefit.

Tracheostomy practices in children on mechanical ventilation: a systematic review and meta-analysis

“…For long-term ventilation after tracheostomy, the meta-analysis of Pizza, McLaughlin, and Lee showed a non-significant risk ratio ( p = 0.32) for late and early tracheostomy. 65 , 66 , 67 For successful decannulation, the meta-analysis of Lee and Pizza also showed no difference ( p = 0.98). 66 , 67 Early tracheostomy was associated with higher probabilities of discharge to home in McLaughlin (29.8% versus 14.9%), and Sheehan (50% versus 9.2%, p < 0.001).…”

“…The search did not return any randomized trials. The authors found eight studies 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 that compared the prognoses of patients undergoing “early” or “late” tracheostomy: in five, “early tracheostomy” was defined as being performed before 14 days of mechanical ventilation, and “late,” after this period. In two studies, “early” was defined as before seven days post-trauma injury, and, in one, as before ten days of ventilation ( Table 2 ).…”

“… < 7 days post-trauma 43/48 Death in hospital 14 (9.7) 21 (10.3) 7 Sheehan et al, 2019 64 Retrospective cohort Traumatic brain injury patients, <16 y. < 7 days post-trauma 16/111 Death in hospital 9.7 (6.5) 27.1 (28.9) 7 McLaughlin et al, 2019 65 Retrospective, propensity score matching Children with severe traumatic brain injury, <15 years ≤ 14 days of MV 121/121 Death in hospital 14 (7.4) 26 (11.8) 9 Pizza et al, 2017 66 Retrospective cohort General PICU Age range: 0 y. – 18 y.…”

Optimal Timing of Tracheostomy in Injured Adolescents*

“…Motor vehicle collision was the most common mechanism of injury (54.1%), and 47.0% had a severe thoracic injury and 19.3% had a severe abdominal injury. Median ISS was 22 (IQR, [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]. In the TBI group, median GCS was 7 (IQR, 3-12, includes only n = 3,270 with valid arrival GCS), and 18.6% underwent craniotomy.…”

“…Some studies have shown fewer ventilator days, shorter ICU and hospital length of stay, and/or lower risk of pneumonia in patients with early tracheostomy compared with those with later tracheostomy; however, other studies have shown no difference (20)(21)(22)(23)(24)(25)(26). These studies are limited by not accounting for differences in tracheostomy indication (e.g., traumatic brain injury [TBI], prolonged respiratory failure, spinal cord injury, or craniofacial injury) (14,22,23,26). An additional limitation of prior studies is the heterogeneity in the definition of "early" versus "late" tracheostomy.…”