Timing of Tracheostomy in Pediatric Patients: A Systematic Review and Meta-Analysis*

Abstract

Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation. Data Sources: We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational studies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. Included articles were subjected to manual searching. Study Selection: Studies in mechanically ventilated children that compared early with late tracheostomy were included. Data Extraction: Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). Data Synthesis: Data were meta-analyzed using an inverse variance, random effects model. Continuous outcomes were calculated as mean differences with 95% CIs, and dichotomous outcomes were calculated as Mantel-Haenszel risk ratios with 95% CIs. We included eight studies (10 study arms). These studies were all retrospective cohort studies. Early tracheostomy was associated with significant reductions in mortality, days on mechanical ventilation, and length of intensive care and total hospital stay, although the lack of randomized, controlled trials limits the validity of these findings. Although variance was imputed for some studies, these conclusions did not change after removing these studies from the analysis. Conclusions: In children on mechanical ventilation, early tracheostomy may improve important medical outcomes. However, our data demonstrate the urgent need for high-quality, randomized controlled trials in the pediatric population.

Tracheostomy Practices and Outcomes in Children During Respiratory Extracorporeal Membrane Oxygenation

“…In adults with respiratory failure, early tracheostomy (< 7–10 d of mechanical ventilation) has been associated with lower mortality, less risk of ventilator-associated pneumonia, reduced length of mechanical ventilation, and shorter ICU stay (32, 33). In a meta-analysis of retrospective studies of tracheostomy timing in pediatric patients with critical illness, early tracheostomy was associated with fewer days of mechanical ventilation, shorter length of stay, and lower mortality (8). Despite this, pediatric physicians are less likely to recommend tracheostomy in the setting of prolonged mechanical ventilation (34).…”

“…Proposed benefits to tracheostomy include reduced sedation, improved mobility, and reduced healthcare utilization (6)(7)(8)(9)(10). However, these benefits need to be balanced with the risks, including bleeding, airway injuries, and the need for future airway operations (11).…”

Update on Pediatric Tracheostomy: Indications, Technique, Education, and Decannulation

“…A recent survey [22] of Canadian pediatric intensivists, neonatologists, pulmonologists, and otolaryngologists revealed that practice patterns have shifted toward recommending earlier tracheostomy compared to 11 years prior [23]. A recent meta-analysis [24] identified eight retrospective studies evaluating outcomes of early versus late tracheostomy in mechanically ventilated patients. While the early tracheostomy group had statistically significant reductions in days of mechanical ventilation, ICU stay, hospital stay, and hospital-acquired pneumonia, the improvement in risk of mortality did not reach statistical significance.…”

Report of two cases of Schaaf‐Yang syndrome: Same genotype and different phenotype

“…An earlier diagnosis can also have a significant impact in care outcomes by guiding decision‐making in the acute care setting, especially now with some available knowledge about certain phenotype–genotype associations that could influence those decisions. An example of this would be earlier tracheostomy placement based on the expected prognosis associated with the p.Gln666ProfsTer47 MAGEL2 variant, as multiple studies (in both children and adults) have reported improved medical outcomes associated with earlier tracheostomy in critically ill patients 23‐25 …”