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Tracheostomy Timing During Pediatric Cardiac Intensive Care: Single Referral Center Retrospective Cohort
Miriam T Fox1,2,3, Colin Meyer-Macaulay4,5, Hanna Roberts3
1Department of Pediatrics, Harvard Medical School, Boston, MA.
Insights
Early tracheostomy in pediatric cardiac ICU patients is linked to better survival and reduced sedative use. Delayed tracheostomy increases mortality risk, especially in younger patients with single ventricle physiology.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Thoracic Surgery
Background:
- Tracheostomy is a critical intervention for patients requiring prolonged mechanical ventilation.
- Decisions regarding tracheostomy timing in pediatric cardiac intensive care units (CICU) are complex and impact patient outcomes.
Purpose of the Study:
- To investigate the associations between the timing of tracheostomy and patient characteristics or outcomes in the CICU.
- To compare outcomes between early and late tracheostomy based on positive pressure ventilation duration.
Main Methods:
- Retrospective cohort study at a freestanding academic children's hospital.
- Analysis of CICU patients who underwent tracheostomy between July 2011 and July 2020.
- Defined early vs. late tracheostomy using receiver operating characteristic curve analysis of positive pressure ventilation duration.
Main Results:
- Late tracheostomy (≥7 weeks of positive pressure ventilation) was associated with a 4.2-fold increased mortality risk.
- Patients with late tracheostomy were younger, had single ventricle physiology, and greater respiratory severity.
- Pulmonary vein stenosis increased mortality risk, while upper airway obstruction was associated with lower mortality.
Conclusions:
- Pediatric CICU patients undergoing tracheostomy face high mortality rates.
- Earlier tracheostomy is associated with improved adjusted survival and reduced sedative exposure.
- Tracheostomy timing requires individualized risk-benefit assessment and family counseling.
Objectives:
To describe associations between the timing of tracheostomy and patient characteristics or outcomes in the cardiac ICU (CICU).
Design:
Single-institution retrospective cohort study.
Setting:
Freestanding academic children's hospital.
Patients:
CICU patients with tracheostomy placed between July 1, 2011, and July 1, 2020.
Interventions:
We compared patient characteristics and outcomes between early and late tracheostomy based on the duration of positive pressure ventilation (PPV) before tracheostomy placement, fitting a receiver operating characteristic curve for current survival to define a cutoff.
Measurements And Main Results:
Sixty-one patients underwent tracheostomy placement (0.5% of CICU admissions). Median age was 7.8 months. Eighteen patients (30%) had single ventricle physiology and 13 patients (21%) had pulmonary vein stenosis (PVS). Primary indications for tracheostomy were pulmonary/lower airway (41%), upper airway obstruction (UAO) (31%), cardiac (15%), neuromuscular (4%), or neurologic (4%). In-hospital mortality was 26% with 41% survival at the current follow-up (median 7.8 [interquartile range, IQR 2.6-30.0] mo). Late tracheostomy was defined as greater than or equal to 7 weeks of PPV which was equivalent to the median PPV duration pre-tracheostomy. Patients with late tracheostomy were more likely to be younger, have single ventricle physiology, and have greater respiratory severity. Patients with early tracheostomy were more likely to have UAO or genetic comorbidities. In multivariable analysis, late tracheostomy was associated with 4.2 times greater mortality (95% CI, 1.9-9.0). PVS was associated with higher mortality (adjusted hazard ratio [HR] 5.2; 95% CI, 2.5-10.9). UAO was associated with lower mortality (adjusted HR 0.2; 95% CI, 0.1-0.5). Late tracheostomy was also associated with greater cumulative opioid exposure.
Conclusions:
CICU patients who underwent tracheostomy had high in-hospital and longer-term mortality rates. Tracheostomy timing decisions are influenced by indication, disease, genetic comorbidities, illness severity, and age. Earlier tracheostomy was associated with lower sedative use and improved adjusted survival. Tracheostomy placement is a complex decision demanding individualized consideration of risk-benefit profiles and thoughtful family counseling.
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