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Timing of Tracheostomy in Critically Ill Infants and Children With Respiratory Failure: A Pediatric Health
Priyanka Mehrotra1, Charlene Thomas2, Linda M Gerber2
1Department of Pediatrics, New York-Presbyterian/Columbia University Medical Center, New York, NY.
Insights
Early tracheostomy (ET) within 14 days of mechanical ventilation (MV) in pediatric patients with respiratory failure is linked to better outcomes. This includes reduced mortality, shorter hospital stays, fewer hospital-acquired pneumonias, and lower costs.
Area of Science:
- Pediatric critical care medicine
- Respiratory medicine
- Health services research
Background:
- Tracheostomy is increasingly used for pediatric respiratory failure, but optimal timing remains unclear.
- Existing literature lacks consensus on the best timing for tracheostomy in pediatric patients.
- This study addresses the need for evidence-based guidelines on tracheostomy timing.
Purpose of the Study:
- To describe tracheostomy timing and patient characteristics in a large pediatric intensive care unit (ICU) cohort.
- To compare clinical outcomes based on tracheostomy timing (early, late, extended).
- To identify associations between tracheostomy timing and patient outcomes.
Main Methods:
- Retrospective observational study using the Pediatric Health Information System (PHIS) from 2010-2020.
- Included pediatric patients (<18 years) requiring mechanical ventilation (MV) before tracheostomy.
- Categorized tracheostomy timing: early (MV day ≤14), late (MV days 15-60), extended (MV day >60).
Main Results:
- Analyzed 10,295 pediatric patients across 52 children's hospitals.
- Early tracheostomy (ET) was performed in 39%, late (LT) in 40%, and extended (ExT) in 21%.
- ET was independently associated with lower in-hospital mortality, shorter hospital and ICU length of stay (LOS), decreased hospital-acquired pneumonia (HAP), and reduced hospital costs.
Conclusions:
- Tracheostomy placement within 14 days of MV initiation in pediatric patients with respiratory failure is associated with improved in-hospital outcomes.
- Early tracheostomy (ET) demonstrated significant reductions in mortality, LOS, HAP, and hospital costs.
- These findings support earlier consideration of tracheostomy in select pediatric patients.
Objectives:
Tracheostomy placement in infants and children with respiratory failure has steadily increased over time, yet there is no consensus for optimal timing. We sought to: 1) describe tracheostomy timing and associated demographic and clinical characteristics in a large ICU cohort and 2) compare clinical outcomes between subgroups based on tracheostomy timing.
Design:
Retrospective observational study using the Pediatric Health Information System (PHIS).
Setting:
Neonatal ICUs and PICUs in the United States.
Patients:
PHIS was queried for patients less than 18 years who underwent tracheostomy from 2010 to 2020. Patients were included if admitted to an ICU with need for mechanical ventilation (MV) prior to tracheostomy in the same hospitalization. Patients were categorized as early tracheostomy (ET) (placement at MV day ≤ 14), late tracheostomy (LT) (MV days 15-60), and extended tracheostomy (ExT) (MV day > 60). Primary endpoints included demographic and clinical characteristics. Secondary endpoints included patient outcomes: in-hospital mortality, length of stay (LOS), hospital-acquired pneumonia (HAP), and hospital costs.
Interventions:
None.
Measurements And Main Results:
Sixteen thousand one hundred twenty-one patients underwent tracheostomy at 52 children's hospitals. Ten thousand two hundred ninety-five had complete data and were included in the analysis. Thirty-nine percent (4,006/10,295) underwent ET, 40% (4,159/10,295) underwent LT, and 21% (2,130/10,295) underwent ExT. Majority of patients in all subgroups had complex chronic conditions. Median age was significantly different between subgroups with ET being the oldest ( p < 0.001). A multivariable regression analysis showed that ET was associated with lower in-hospital mortality ( p < 0.001), shorter hospital LOS ( p < 0.001), shorter ICU LOS ( p < 0.001), shorter post-tracheostomy LOS ( p < 0.001), decreased HAP ( p < 0.001), and lower hospital costs ( p < 0.001) compared with those who underwent LT or ExT.
Conclusions:
In a large cohort of pediatric patients with respiratory failure, tracheostomy placement within 14 days of MV was associated with improved in-hospital outcomes. ET was independently associated with decreased mortality, LOS, HAP, and hospital costs.
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