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Timing the First Pediatric Tracheostomy Tube Change: A Randomized Controlled Trial
Stephen R Chorney1,2, Rosemary C Patel1, Allison E Boyd1
1Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Insights
Early tracheostomy tube changes in children (day 4) are safe and reduce wound complications. This pediatric tracheostomy timing also leads to faster intensive care discharge, improving patient outcomes.
Area of Science:
- Pediatric Surgery
- Otolaryngology
- Critical Care Medicine
Background:
- The optimal timing for the first pediatric tracheostomy tube change is not well-established, with current practices varying.
- Early tube changes are often performed within 7 days post-placement, but evidence supporting this timing is limited.
Purpose of the Study:
- To determine the rate of adverse events associated with an early (day 4) versus late (day 7) first tracheostomy tube change in children.
- To compare the incidence of significant peristomal wounds, sedation requirements, and the speed of intensive care unit (ICU) discharge between early and late tube change groups.
Main Methods:
- A prospective randomized controlled trial was conducted involving children under 24 months of age requiring tracheostomy.
- Participants were randomized to undergo their first tracheostomy tube change on either day 4 (early group) or day 7 (late group).
- Outcomes assessed included adverse events, wound complications, sedation use, and time to ICU discharge.
Main Results:
- No adverse events or accidental decannulations occurred in any tracheostomy tube changes.
- The early change group showed a significantly lower rate of significant peristomal wounds (10% vs. 83.3%, P = .01).
- Patients in the early group had a significantly higher rate of ICU discharge within 5 weeks post-tracheostomy (90% vs. 33.3%, P = .03).
Conclusions:
- The first tracheostomy tube change in pediatric patients can be safely performed as early as day 4 without adverse events.
- An early (day 4) tracheostomy tube change is associated with a significant reduction in peristomal wound complications.
- Early tracheostomy tube changes facilitate earlier discharge from the intensive care unit in pediatric patients.
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.
