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ARTICLE

Tracheostomy for Infants Requiring Prolonged


Mechanical Ventilation: 10 Years Experience
AUTHORS: Alison E. Overman, BA,a Meixia Liu, MS,a
Stephen C. Kurachek, MD,b Michael R. Shreve, MD,b Roy C.
Maynard, MD,b,c Mark C. Mammel, MD,d,e and Brooke M.
Moore, MD, MPHb
aResearch

and Sponsored Programs, Childrens Hospitals and


Clinics of Minnesota, Minneapolis, Minnesota; bChildrens
Respiratory and Critical Care Specialists, Minneapolis,
Minnesota; cMedical Director, Pediatric Home Services, Roseville,
Minnesota; dDivision of Neonatology, Childrens Hospital and
Clinics of Minnesota, St. Paul, Minnesota; and eDepartment of
Pediatrics, University of Minnesota School of Medicine,
Minneapolis, Minnesota
KEY WORDS
tracheostomy, infant, bronchopulmonary dysplasia, ventilator,
prematurity
ABBREVIATIONS
BPDbronchopulmonary dysplasia
ELBWextremely low birth weight
LTRlaryngotracheal reconstruction
PPVpositive pressure ventilation
VLBWvery low birth weight
Ms Overman completed the data collection, drafted the initial
manuscript, and approved the nal manuscript as submitted;
Ms Liu carried out the statistical analyses, reviewed and revised
the manuscript, and approved the nal manuscript as
submitted; Drs Kurachek, Shreve, Maynard, and Mammel
conceptualized and helped design the study, edited the initial
manuscript, and approved the nal manuscript as submitted;
and Dr Moore designed the data collection instruments,
coordinated and supervised data collection, critically reviewed
the manuscript, and approved the nal manuscript as
submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-1943
doi:10.1542/peds.2012-1943
Accepted for publication Jan 15, 2013
Address correspondence to Brooke Moore MD, MPH, Childrens
Respiratory and Critical Care Specialists, PA, 2530 Chicago Ave S,
Suite 400, Minneapolis, MN 55404. E-mail: moore@crccs.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
FUNDING: No external funding.

WHATS KNOWN ON THIS SUBJECT: Advances in the treatment of


critically ill infants have increased survival of extremely low/very
low birth weight and medically complex infants. Improved survival
can result in prolonged mechanical ventilation and sometimes
tracheostomy. Current tracheostomy rates for these infants are
unknown.
WHAT THIS STUDY ADDS: This long-term review of infants
discharged from a NICU with tracheostomies is the rst to
describe tracheostomy rates specically in extremely low/very
low birth weight infants. It focuses on long-term clinical outcomes
and comorbidities rather than surgical complications.

abstract
BACKGROUND: Despite advances in care of critically ill neonates, extended mechanical ventilation and tracheostomy are sometimes required. Few studies focus on complications and clinical outcomes.
Our aim was to provide long-term outcomes for a cohort of infants
who required tracheostomy.
METHODS: This study is a retrospective review of 165 infants born between January 1, 2000 and December 31, 2010 who required tracheostomy and ventilator support. Children with complex congenital heart
disease were excluded.
RESULTS: Median gestational age was 27 weeks (range 2243), and birth
weight was 820 g (range 3604860). The number of male (53.9%) and female
(46.1%) infants was similar (P = .312). Infants were divided into 2 groups
based on birth weight #1000 g (A) and .1000 g (B). Group A: 87 (57.6%)
infants; group B 64 (42.4%). Overall tracheostomy rate was 6.9% (87/1345)
for group A versus 0.9% (64/6818) for B (P ,.001). Group A had a longer
time from intubation to positive pressure ventilation independence, 505 days
(range 621287) vs 372 days (range 151270; P = .011). Infants who had .1
reason for tracheostomy comprised 78.8% of the sample; 69.1% of infants
were discharged on ventilators. Birth weight did not affect time from
tracheostomy to decannulation (P = .323). More group A infants were
decannulated (P = .023). laryngotracheal reconstruction rate was 35.8%.
Five-year survival was 89%. Group B had higher mortality (P = .033).
64.2% of infants had developmental delays; 74.2% had $2 comorbidities.
CONCLUSIONS: Tracheostomy rates were higher for extremely low birth
weight infants than previously reported rates for all infants. Decannulation
rates and laryngotracheal reconstruction rates were consistent with previous studies. Survival rates were high, but developmental delay and
comorbidities were frequent. Pediatrics 2013;131:e1491e1496

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e1491

Despite early surfactant therapy, optimizing ventilator strategies, and increased use of noninvasive positive
pressure ventilation, bronchopulmonary dysplasia (BPD) continues to be
a complication of premature births.
Survival of extremely low birth weight
(ELBW) and very low birth weight
(VLBW) infants has increased, contributing to an increased incidence of BPD.
Moreover, the care of critically ill infants
born at term with congenital anomalies
has also improved.1 Many of these
infants require mechanical ventilation
for extended periods. Some ultimately
require tracheostomy placement for
prolonged ventilation.24 Others require tracheostomy placement due to
congenital airway anomalies but have
minimal ventilatory needs.

infants in NICUs have signicantly improved the outlook for critically ill
newborns over the past 20 years.9,2225
Childrens Hospitals and Clinics of
Minnesota is a pediatric health care
system with 2 full-service pediatric
hospitals. At these institutions, pediatric pulmonologists are consulted annually on 50 patients (6.13% of all
NICU patients annually) for recommendations about management of
infants with prolonged mechanical
ventilation requirements and those
with congenital airway anomalies that
require tracheostomy with minimal
ventilatory needs. Of those infants, 15
to 20 will ultimately have a tracheostomy placed. Upon discharge, the

patients are managed by a single pediatric pulmonary practice. Before


discharge from the hospital the family
receives extensive training in tracheostomy care with manikins (including
changing the tracheostomy tube). Once
manikin training is complete the family
is required to change the tracheostomy
on their child, complete a skill checklist, and ultimately manage all cares
for the child for at least one 24-hour
shift before discharge. On an outpatient basis suitable candidates are
weaned from ventilator support and
decannulated (Fig 1). The purpose of this
study is to provide a descriptive report
of long-term outcomes for a cohort of
patients discharged from Childrens

Studies have shown that early tracheostomy reduces the incidence of subglottic and tracheal stenosis in children
who are intubated for long periods.5 In
addition, tracheostomy results in improved comfort, decreased need for
sedation, decreased systemic corticosteroid exposure (which is associated
with poorer neurodevelopmental outcomes), improved nutrition and growth,
improved ability to attempt oral feeds,
and, once established, vocalization
with a speaking valve.57 Overall tracheostomy rates range from 0.55% to
2.7%813
Several studies focus on the surgical
indications, complications, and techniquesused for pediatrictracheostomy.814
Few studies focus on the complications
and long-term clinical outcomes for
infants that require tracheostomy
placement and prolonged mechanical
ventilation.1521 Most of the available
literature was published or conducted
before 2004, when many of the new
ventilator modalities and techniques
had not yet become incorporated into
clinical practice for the treatment of
respiratory failure. These advances in
respiratory care and the treatment of
e1492

FIGURE 1
Pressure control ventilation home weaning protocol: used to wean patients from mechanical ventilation
at home, without readmission to the hospital. CBG, capillary blood gas; PEEP, positive end expiratory
pressure; VBG, venous blood gas.

OVERMAN et al

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ARTICLE

Hospitals and Clinics of Minnesota after


tracheostomy placement.

METHODS
This study involved a retrospective
chart review of 184 tracheostomized
NICU patients followed by a single pediatric pulmonary practice. Inclusion
criteria included birth between January 1, 2000 and December 31, 2010. To
better understand outcomes in patients
with pulmonary disease, upper airway
anomalies, and congenital lung abnormalities, patients with complex congenital heart disease (cyanotic heart
lesions and/or single ventricle physiology) were excluded. Our centers experience is that children who require
tracheostomy and ventilation for cyanotic heart lesions have a higher rate
of complications, more prolonged ventilatory needs, and a greater incidence
of morbidity and mortality. To allow for
comparison with previous studies and
gain a better understanding of the
outcomes for ELBW and VLBW infants,
the remaining 165 eligible patients
were subdivided into 2 groups: patients
who weighed ,1000 g at birth (Group
A) and those who weighed $1000 g at
birth (Group B).10,11 Data were obtained
from each patients inpatient and outpatient medical record. The study was
approved by the Institutional Review
Board at Childrens Hospitals and Clinics of Minnesota. Informed consent
was not required because it was a retrospective study that did not affect
patient care.
Data collected included gestational age
and birth weight, number of days
intubated before tracheostomy, weight
at tracheostomy, home ventilation requirements, time to positive pressure
independence (PPV), time to decannulation, rate of laryngotracheal reconstruction(LTR), neurologic outcomes,
comorbidities, presence of recurrent
wheezing, chronic nebulizer use, and
survival.

Descriptive statistics were calculated


for frequency of categorical data
(gender), mean (SD), median (range),
and continuous variables (gestational
age, birth weight, time to decannulation). Two-sample t tests were
used to compare the time to PPV independence and decannulation. The
rates of complications between
patients were compared by x 2 analysis. A Kaplan-Meier curve was used to
estimate survival, and log-rank test
results were used to compare the
survival rates between groups. A twosided P value of ,.05 was considered
signicant. All statistical analyses were
conducted with the SPSS version 15.0
software (IBM SPSS Statistics, IBM
Corporation, Armonk, NY).

RESULTS
Table 1 describes the patient characteristics. Median gestational age was
27 weeks (range 2243). Median birth
weight was 820 g (range 3604860).
The number of male and female infants
was similar (53.9% vs 46.1%, P = .312;
Table 1). There were 87 infants (57.6%)
in Group A and 64 (42.4%) in Group B

(Table 1). The overall tracheostomy


rate was 1.8% (Group A 6.9% (87/1345);
Group B 0.9% (64/6818; P , .001).
Table 2 describes the reasons for tracheostomy and compares reasons for
tracheostomy based on birth weight.
One hundred thirty infants (78.8%) had
.1 reason for a tracheostomy. Compared with Group B patients, Group A
patients were more likely to require
tracheostomy because of BPD (95.4% vs
17.2%, P , .001) and/or noncomplicated
congenital heart disease (70.1% vs 45.3%,
P = .002).
Table 3 reports the length of hospital
stay, days intubated before tracheostomy, time to PPV independence, and
time to decannulation based on birth
weight. Of 165 patients, 114 (69.1%)
were discharged from the hospital on
mechanical ventilation (Group A: 69
[79.3%]; Group B: 39 [60.9%], P = .013).
Four patients required mechanical
ventilation for ,5 days after tracheostomy placement. All had upper airway anomalies that resulted in the
need for tracheostomy (including
obstructing phayrngolaryngomalacia
and subglottic stenosis). Group A

TABLE 1 Patient Characteristics (n = 165)


Gestational age (wk)
Birth wt (g)
Age at admission (d)
Total length-of-hospital stay (d)
Length-of-stay in ICU (days)
Mean no. of days intubated before tracheostomy
Mean wt at tracheostomy (kg)
Mean no. of failed extubations before tracheostomy
Average gestational age at tracheostomy (wk)
Percent of infants with betamethasone treated mothers
Gender
Female
Male
Birth wtb
#1000 g
.1000 g
Gestational agec
,25 wk
$25 wk

Median (range)

n (%)

27 (2243)
820 (3604860)
1 (0851)
159 (13593)
86 (0546)
94 (1591)
3.4 (0.811.8)
1 (06)
27 (22, 43)
50.7% (77)

151
151
164
163a
133, from initial admission
154
153
147
151
152
76 (46.1)
89 (53.9)
151
87 (57.6)
64 (42.4)
164
46 (28)
118 (72)

One patient was excluded due to transfer to another institution after tracheostomy placement.
Birth weight is unknown for 14 patients.
c Gestational age is unknown for 1 patient who transferred from an outside facility, and it was not documented in the medical
record.
b

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TABLE 2 Reasons for Tracheostomy

TABLE 5 Rate of Comorbidities (n = 165)


Total, n (%);
(n = 165)

Birth wta #1000 g,


n (%); (n = 87)

Birth wta .1000 g,


n (%); (n = 64)

P value

96 (58.2)
93 (56.4)
54 (32.7)
36 (21.8)
9 (5.5)
23 (13.9)
26 (15.7)
21 (12.7)
10 (6.1)
8 (4.8)
8 (4.8)
8 (4.8)
1 (0.6)

83 (95.4)
61 (70.1)
33 (37.9)
9 (10.3)
3 (3.4)
9 (10.3)
1 (1.1)
6 (6.9)
5 (5.7)
0 (0)
0 (0)
4 (4.6)
0

11 (17.2)
29 (45.3)
17 (26.6)
20 (31.3)
5 (7.8)
13 (20.3)
19 (29.7)
15 (23.4)
4 (6.2)
8 (12.5)
5 (7.8)
4 (6.2)
1 (1.6)

,.001
.002
.142
.001
.285
.086
,.001
.004
1.0
.001
.012
.723
NA

BPD
Uncomplicated congenital heart defect
Subglottic stenosis
Respiratory failure
Laryngomalacia
Tracheomalacia
Upper airway obstruction/abnormality
Pulmonary hypoplasia
Chronic aspiration
Congenital diaphragmatic hernia
Neuromuscular weakness
Vocal cord paralysis
Arnold-Chiari malfunction
a

Birth weight is unknown for 14 patients.

TABLE 3 Time Partitions Based on Birth Weight


Birth wta, median (range)

Length of hospital stay (d)


Days intubated before tracheostomy
Time from tracheostomy to PPV independence (d)
Time from intubation to PPV independence (d)
Time to decannulation (d)
a

#1000 g (n = 87)

.1000 g (n = 64)

186 (5490)
112 (18573)
370 (21067)
505 (621287)
479 (481376)

130 (6593)
57 (1385)
307 (11058)
372 (151270)
436.5 (1961611)

.001
,.001
.367
.011
.323

Birth weight is unknown for 14 patients.

patients had a longer time from intubation to PPV independence than


Group B (P = .011). Birth weight did not
affect time from tracheostomy placement to decannulation (P = .323); however, more Group A infants were
decannulated (88.5% vs 71.4%, P = .008).
The overall rate of LTR was 35.8%.
(Group A 47.1%, Group B 25%; P = .006).
The reasons for the need for LTR are
shown in Table 4. Fifteen patients with
tracheomalacia had an anterior tracheal reconstruction using a costochondral cartilage graft. One patient
with tracheomalacia had an anterior
and posterior tracheal reconstruction
using costochondral cartilage grafts.

The rate of comorbidities is shown in


Table 5; 74.2% had $2 comorbidities,
and 64.2% of patients presented had
some degree of developmental delay.
Sixty-two infants (37.6%) were diagnosed with recurrent wheezing, and
133 infants (80.6%) were on chronic
nebulizer therapy with budesonide.
The average survival rates for patients
living to 1, 3, and 5 years of life were 96%,
91%, and 90%, respectively. Group B had
a higher mortality rate than Group A
(P = .033). Ninety-four percent of Group
A patients survived to a minimum of
5 years compared with 85% of Group B
patients (P = .195).

DISCUSSION
TABLE 4 Reasons for Laryngotracheal
Reconstruction
Reason

n (%)

Subglottic stenosis
Tracheomalacia
Laryngomalacia
Laryngeal cleft
Supraglottic stenosis

44 (75.9)
16 (27.6)
4 (6.9)
1 (1.7)
1 (1.7)

e1494

This study provides a descriptive report


of long-term outcomes for a cohort of
infants discharged from a single pediatric health care facility after tracheostomy for prolonged mechanical
ventilation. To our knowledge this study
is the longest review and largest cohort

Comorbidities

n (%)

Developmental delay
106 (64.2)
Gastrointestinal (GERD, swallow
76 (46.3)
dysfunction, feeding dysfunction,
ileal/bowel perforation, oral
aversion, necrotizing enterocolitis,
malrotation, omphalocele)
Other neurologic disease
42 (25.5)
(microcephaly, static
encephalopathy, hydrocephalus, VP
shunt, craniosynostosis, stroke,
cerebral palsy, absent septum
pellucidum, optic nerve hypoplasia)
Retinopathy of prematurity
41 (24.8)
Chromosome abnormality (n = 138)
34 (24.6)
Pulmonary hypertension
36 (21.8)
Seizures
22 (13.3)
Renal/genitourinary anomalies
15 (9.1)
Swallow dysfunction/feeding
15 (9.1)
difculties
Endocrine
13 (7.9)
GERD, gastroesophageal reux disease; VP, ventriculoperitoneal.

of infants with tracheostomy. The information collected was complete and


comprehensive.
Overall tracheostomy rates in our study
were comparable to the highest rates
reported in the literature. However, tracheostomy rates in Group A were nearly
4 times higher than the overall rate.
Heroy reported at 2.7% overall incidence
of tracheostomy for patients admitted to
a NICU. More recent studies, with smaller
numbers of patients than were included
in our study, have shown a decline
in tracheostomy for airway obstruction but an increase for prolonged
ventilation.5,10,11,2628 Most of the available
literature focuses on complications from
tracheostomies. Few report on overall
tracheostomy rates. None of the currently available literature analyzes tracheostomy rates based on birth weight.
The studies that report tracheostomy
rates have small sample sizes, and thus
caution ought to be used in generalization. The high rate found in our study for
Group A infants is likely reective of the
need for prolonged need for mechanical
ventilation in ELBW and VLBW infants.
Group A patients had a longer time from
intubation to tracheostomy placement

OVERMAN et al

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ARTICLE

and intubation to decannulation than


Group B. This is not surprising because
the standard of care at our institution is
to wait until the patient is near a corrected gestational age of 40 weeks
before placing a tracheostomy. Multiple
attempts to wean PPV and noninvasive
positive pressure ventilation are made
before tracheostomy placement is
recommended.
LTR rates were comparable to that
reported by Sidman et al when
they reviewed tracheostomy and decannulation rates at the same institution
from 1991 through 2002. Thus despite
the high rate of tracheostomy in Group
A, there has been no signicant change
in the rate of surgical procedures required to achieve decannulation.7
Five-year survival was high, with higher
mortality rates in Group B, likely related
to the severity of their comorbid conditions and prevalence of chromosomal
abnormalities. Although survival rates

were high, a signicant number of


patients had some degree of developmental delay. Unfortunately, because this was a retrospective study
and different developmental screening
evaluations were used, to a variable
degree, we were unable to subdivide
patients on the basis of the severity of
their delays.
This study has several limitations. It is
a retrospective study that relied heavily
on chart review. Three individuals who
were trained in data collection completed the chart review. Weekly meetings were held to review progress and
answer questions to ensure that all
persons were abstracting data similarly. The data are from a single pediatric facility and outpatient practice.
The ability to generalize to other
practices may, therefore, be limited.
That being said, nearly all our ndings
were similar to that reported in the
literature.

Despite the limitations of this study, it


has several strengths. It adds up-to-date
information about current tracheostomy rates. It is the rst to describe
tracheostomy rates in in ELBW and VLBW
infants. Moreover, the study focuses
on long-term clinical outcomes and
comorbidities of infants who require
tracheostomies rather than purely
focusing on surgical complications.
Future prospective studies should determine the appropriate timing of tracheostomy placement in ELBW and
VLBW infants and seek to determine if
early tracheostomy results in improved
developmental outcomes, decreased
systemic steroid exposure, and improved lung function later in life.

ACKNOWLEDGMENTS
The contributions of Bonnie Giacomini,
RN, Emma Halbrooks, Thomas Wheeler,
and Erin Zielinski are gratefully acknowledged.

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OVERMAN et al

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Tracheostomy for Infants Requiring Prolonged Mechanical Ventilation: 10


Years' Experience
Alison E. Overman, Meixia Liu, Stephen C. Kurachek, Michael R. Shreve, Roy C.
Maynard, Mark C. Mammel and Brooke M. Moore
Pediatrics 2013;131;e1491; originally published online April 8, 2013;
DOI: 10.1542/peds.2012-1943
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References

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Grove Village, Illinois, 60007. Copyright 2013 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Tracheostomy for Infants Requiring Prolonged Mechanical Ventilation: 10


Years' Experience
Alison E. Overman, Meixia Liu, Stephen C. Kurachek, Michael R. Shreve, Roy C.
Maynard, Mark C. Mammel and Brooke M. Moore
Pediatrics 2013;131;e1491; originally published online April 8, 2013;
DOI: 10.1542/peds.2012-1943

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/131/5/e1491.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2013 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on February 14, 2015