Timing the First Pediatric Tracheostomy Tube Change: A Randomized Controlled Trial

Abstract

Objective The first pediatric tracheostomy tube change often occurs within 7 days after placement; however, the optimal timing is not known. The primary objective was to determine the rate of adverse events of an early tube change. Secondary objectives compared rates of significant peristomal wounds, sedation requirements, and expedited intensive care discharges. Study Design Prospective randomized controlled trial. Setting Tertiary children’s hospital between October 2018 and April 2020. Methods A randomized controlled trial enrolled children under 24 months to early (day 4) or late (day 7) first tracheostomy tube changes. Results Sixteen children were enrolled with 10 randomized to an early change. Median age was 5.9 months (interquartile range, 5.4-8.3), and 86.7% required tracheostomy for respiratory failure. All tracheostomy tube changes were performed without adverse events. There were no accidental decannulations. Significant wounds developed in 10% of children with early tracheostomy tube changes and 83.3% of children with late tracheostomy tube changes (odds ratio [OR], 45.0; 95% CI, 2.3-885.6; P = .01). This significant reduction in wound complications justified concluding trial enrollment. Hours of dexmedetomidine sedation ( P = .11) and boluses of midazolam during the first 7 days ( P = .08) were no different between groups. After the first change, 90% of the early group were discharged from intensive care within 5 weeks compared to 33.3% of patients in the late group (OR, 18.0; 95% CI, 1.2-260.9; P = .03). Conclusion The first tracheostomy tube change in children can occur without adverse events on day 4, resulting in fewer significant peristomal wounds and earlier intensive care discharge.

Assessment of Tracheostomy Tube Placement and Late Change Practices in an Academic Tertiary Care Center

“…It is important to note that some studies 8,12 advocate early changes as they have been shown to decrease the length of ICU and hospital stays. However, it is not within the practices of our institution to wait for the first change for patients to be transferred or discharged.…”

Clinical outcomes according to the timing of the first tracheostomy tube change

“…Most previous studies have focused on the first tracheostomy tube change in pediatric patients [ 12 ]. In most studies, the first tracheostomy tube is changed within approximately 2–4 days, and there are no respiratory complications, wound problems, and healing; thus, an early replacement was recommended [ [9] , [10] , [11] , 13 ]. However, there may be differences in wound healing between adults and pediatric patients.…”

“…The post-procedural pulmonary complications increased as the first tube change was delayed. In the case of delayed tracheostomy tube change, reports have demonstrated that complications increase due to the contamination of the tube strap and delayed detection of wound problems [ 10 , 11 ]. However, in this study, post-procedural pulmonary complications were determined only with the presence or absence of abnormal findings on the formal reading such as pneumothorax, emphysema, respiratory infection, pneumonia, aspiration pneumonitis, atelectasis, tracheal stenosis, and bronchospasm.…”

“…First, our study is one of the rare studies that provide important lessons on the timing of the first tracheostomy tube change. Most of the previous studies were in pediatric patients or small studies with very small number of patients [ [9] , [10] , [11] ]. Therefore, we can say that this study is valuable in dealing with relatively large-scaled data and the study of adult patients.…”

“…Moreover, it has been reported that if the replaced tracheostomy tube is incorrectly positioned in the anterior mediastinum, a large amount of subcutaneous emphysema, mediastinal emphysema, cardiac arrest, and in rare cases, damage to the innominate artery may occur [ 8 ]. In addition, there were studies regarding early change of the first tracheostomy tube in pediatric patients that can improve outcomes, such as fewer significant peristomal wounds, reduction intensive care unit stay, and reduction overall hospital stay [ [9] , [10] , [11] ]. However, studies about complications in adult patients remain insufficient.…”