Outcomes of neonates with tracheostomy secondary to bronchopulmonary dysplasia

Abstract

Background: Bronchopulmonary dysplasia (BPD) is a disease that can affect preterm neonates. Infants with severe BPD may develop pulmonary hypertension (PHN) and may require chronic mechanical ventilation with tracheostomy. The outcomes of these infants have not been studied well. We proposed to review survival and outcomes of infants requiring tracheostomy secondary to severe BPD in our NICU at 24 months. Methods: We reviewed infants' charts who were diagnosed with BPD that underwent tracheostomy from January 2011 to May 2016 at our children's hospital NICU. Data were recorded from hospital stay as well as from follow up clinics. Institutional review board approval was obtained prior to beginning of study. Results: Forty-one babies (37 during initial hospitalization and 4 subsequently) requiring tracheostomy were identified from our database. Median gestational age at birth was 26 weeks (25-27 IQR), mean birthweight of 731 g (±245 SD) and 32% were small for gestational age (SGA). Median age of tracheostomy placement was 168 days (108-197 IQR), and median PMA 48 wks (40-56 IQR). 26% of infants requiring tracheostomy also had subglottic stenosis along with BPD. 34 infants (83%) survived to discharge from NICU. 66% (27/41) of our patients had a composite outcome of death, ventilator dependency and/or poor neurodevelopmental outcome at 2 years. We found that a higher respiratory severity score at the time of tracheostomy placement and later post-menstrual age at admission to level IV NICU was associated with a worse outcome. Small for gestational age infants were found to have worse outcomes as well. 41% (13/32) of infants had more than 3 hospital admissions after discharge. Conclusions: In our cohort about 80% of infants with severe BPD and tracheostomy survived to discharge with need for prolonged home ventilation in more than half of the survivors. Later postmenstrual age at admission to level 4 NICU was associated with a worse outcome. Our retrospective data may be inadequate to determine the causal relationship between postmenstrual age at admission and outcome. These patients continue to have high morbidity and recurrent hospitalizations.

Morbidity and respiratory outcomes in infants requiring tracheostomy for severe bronchopulmonary dysplasia

“…In comparison to other contemporary reports where tracheostomy placement occurred at a mean~45-51 weeks' CGA, tracheostomy placement at our institution was markedly earlier. 16,18,23,26 Furthermore, our timing of~120 days is at the threshold of the earlier window identified by the NRN as associated with a~50% reduction in the risk of death or neurodevelopmental impairment. 19 Indeed, compared to infants that survived, infants in our cohort that died received their tracheostomy significantly later (45.5 vs. 42.5 weeks' CGA, p < .03).…”

“…Death before initial discharge was most often the result of worsening pulmonary disease, and similar to previous reports, infants that were born SGA and/or receiving therapy for pulmonary hypertension as the time of tracheostomy suffered increased mortality. 17,18,28,29 Infants born SGA are at greater risk of severe BPD and death, and pulmonary hypertension has been independently associated with increased risk of mortality in premature infants with BPD. [30][31][32][33][34][35][36] Murthy et al 17 demonstrated that infants born at <32 weeks' gestation with severe BPD complicated by pulmonary hypertension had three times increased risk of tracheostomy or death.…”

“…12,[15][16][17][18] Additionally, associated morbidities resulting from both the severity of lung disease as well as complications from prolonged exposure to an artificial airway include highly variable but significant rates of neurodevelopmental impairment and structural upper airway disease. [18][19][20][21][22][23][24] Roughly half of the infants born extremely premature develop moderate or severe BPD. 3,4,9 The incidence is rising, indicating that an increasing number of infants will require prolonged ventilatory support, potentially via tracheostomy.…”

Chronic respiratory failure in bronchopulmonary dysplasia

“…Although chronic ventilation may give an infant with sBPD the best chance at a positive outcome, survival is not always possible 44,45 . In preterm infants with neuromuscular and congenital heart diseases, mortality before initial discharge has been described to be as high as 40% 46 .…”

Central Airway Issues in BPD

“…Indeed, neonates with subglottic stenosis may not tolerate extubation and are at high risk of undergoing tracheotomy. (20,59) Management of subglottic stenosis in neonates with BPD should focus on prevention. Recent efforts have increased the use of nasal CPAP at birth rather than intubation to minimize the risk of the development of BPD.…”