Bronchopulmonary dysplasia and ventilation-associated outcomes after pediatric tracheostomy.

OBJECTIVES: The objective of this study is to determine the time to ventilator liberation and decannulation after tracheostomy placement in children with bronchopulmonary dysplasia (BPD) and pulmonary hypertension. METHODS: A prospective cohort study included all children (<18 years old) who underwent tracheostomy between 2015 and 2021 with or without a diagnosis of BPD. The primary outcomes were time to ventilator liberation, tracheostomy decannulation, or death with tracheostomy in place. RESULTS: A total of 303 children met inclusion with a median (interquartile range [IQR]) age at tracheostomy of 6.9 (IQR: 4.0-49.5) months. A diagnosis of BPD was made for 42% (N = 127) and this group was younger (5.1 vs. 24.5 months, p < .001) and more often had pulmonary hypertension (68% vs. 24%, p < .001). Children with BPD spent a median of 2.9 years (IQR: 1.6-4.0) on ventilation compared to 1.9 years (IQR: 0.9-3.7) for children without BPD (p = .009). The time to decannulation was greater among children with BPD (3.4 vs. 1.8 years, p < .001). However, unadjusted estimates of ventilator liberation (hazard ratio [HR]: 1.05, 95% confidence interval [95% CI]: 0.77-1.44) and decannulation (HR: 1.11, 95% CI: 0.74-1.66) over time were not prolonged by BPD. Pulmonary hypertension was associated with shorter time to death (adjusted HR [aHR] = 1.99, 95% CI: 1.17-3.38, p = .01), while BPD was associated with longer time to death (aHR: 0.38, 95% CI: 0.22-0.67, p = .001). CONCLUSION: BPD is associated with increased ventilation and duration of tracheostomy but over time many children with BPD will wean off the ventilator and be decannulated. Pulmonary hypertension and not BPD is associated with increased time to death after tracheostomy.

Preventing pediatric accidental decannulation events: A quality improvement initiative.

OBJECTIVE: To describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3. METHODS: A retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented: using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases. RESULTS: Prior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases). CONCLUSION: This data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.

Subglottic Stenosis After Pediatric Tracheostomy.

OBJECTIVES: To determine the incidence of subglottic stenosis (SGS) in children after tracheostomy and identify risk factors for development. STUDY DESIGN: Retrospective cohort. METHODS: All patients (<18 years) undergoing tracheostomy at a tertiary children's hospital between 2015 and 2020 were included. Patients with a direct laryngoscopy (DL) concurrent with tracheostomy and a subsequent DL were included. Medical records, including operative reports, were reviewed to identify subglottic stenosis and associated risk factors. RESULTS: A total of 140 patients were included with mean age at tracheostomy of 2.4 years (standard deviation [SD]: 4.3) (median: 0.5 years, interquartile range [IQR]: 0.3-1.5 years) and gestational age of 33.8 weeks (SD: 5.9) (median: 36 weeks, IQR: 28-39 weeks). At initial DL, 24% (N = 34) had subglottic injury and 26% (N = 37) developed SGS. The incidence of SGS after tracheostomy was 11.5 cases per 100 patients per year. At tracheostomy, lower birth weight (1.8 vs. 2.3 kg, p = 0.005), shorter gestational age (31.8 vs. 34.6 weeks, p = 0.01), younger age (0.8 vs. 2.9 years, p = 0.01), lower weight (5.8 vs. 14.7 kg, p = 0.01), and subglottic injury (44% vs. 21%, p = 0.01) were associated with the development of SGS. Multivariable logistic regression analysis associated birth weight (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.31-0.75, p = 0.001) and early subglottic injury (OR: 3.22, 95% CI: 1.31-7.88, p = 0.01) with SGS development. CONCLUSIONS: The incidence of SGS after pediatric tracheostomy is estimated at 11.5 cases per 100 patients per year. Low birth weight and subglottic injury at the time of tracheostomy were associated with SGS in this vulnerable population of children. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

The Safety of Pediatric Bedside Tracheostomy.

OBJECTIVE: Traditionally, pediatric tracheostomy has been viewed as a technically demanding procedure with a high complication rate, requiring the routine use of a formal operating room. Pediatric bedside tracheostomy in an intensive care unit (ICU) setting has not been widely reported, in contrast to the widespread adult bedside ICU tracheostomy. Transport of these critically ill, multiple life support systems dependent patients can be technically difficult, labor intensive, and potentially risky for these patients. Our study aimed to demonstrate the safety and efficacy of bedside tracheostomy in the pediatric ICU. MATERIALS AND METHODS: A retrospective analysis of all pediatric patients undergoing tracheostomy at a tertiary care center, between 1st of January 2013 and 31st of December 2019. RESULTS: During the study period, 117 pediatric patients underwent tracheostomy, 57 (48.7%) were performed bedside while 60 (51.3%) were performed in the operating room. Patients' ages ranged from 2 weeks to 17 years of age, with a median age of 16 months. No case of bedside tracheostomy necessitated a shift to the operating room. There was no difference in 30-day morbidity and mortality between the 2 groups. CONCLUSIONS: Our results suggest that pediatric open bedside tracheostomy in an ICU setting is a safe procedure, with similar complications and outcomes compared to tracheostomy performed in the operating room.

Tracheostomy-Related Swallowing Issues in Children.

Children with tracheostomies have multiple challenges with respect to achieving normal deglutition. These children may have underlying neurologic or genetic conditions that can predispose to dysphagia, but even in children without underlying comorbidities, the presence of a tracheostomy tube impacts the mechanics of swallowing, leading to difficulty with different consistencies as well as management of normal oral secretions. Intubation prior to tracheostomy also impacts sensation in the upper aerodigestive tract increasing the risk of aspiration. Occlusion of the tracheostomy with a speaking valve or cap improves outcomes in swallow and prognosis for oral feeding.

Time considerations and outcomes in pediatric tracheostomy decannulation.

OBJECTIVE: The study objective is to identify factors that impact the time to decannulation in pediatric patients ages 0 through 18 years who are tracheostomy-dependent. METHODS: This retrospective chart review from January 1, 2005 through December 31, 2020 identified pediatric tracheostomy patients at a single pediatric institution. Data extracted included demographic, socioeconomic factors, and clinical characteristics. Multivariate regression and survival analysis were used to identify factors associated with successful decannulation and decreased time with tracheostomy. RESULTS: Of the 479 tracheostomy-dependent patients identified, 162 (33.8%) were decannulated. Time to decannulation ranged from 0.5 months to 189.2 months with median of 24 months (IQR 12.91-45.71). In the multivariate analysis, patients with bronchopulmonary dysplasia (p = 0.021) and those with Passy-Muir® Valve at discharge (p = 0.015) were significantly associated with decannulation. In contrast, neurologic comorbidities (p = 0.06), presence of gastrostomy tube (p < 0.001), or discharged on a home ventilator (p < 0.001) were associated with indefinite tracheostomy. When adjusting for age, sex, race, ethnicity, and insurance status, for every one month delay in establishment of outpatient otolaryngology care, time to decannulation was delayed by 0.5 months (p = 0.010). For each additional outpatient otolaryngology follow-up visit, time to decannulation increased by 3.36 months (p < 0.001). CONCLUSIONS: Decannulation in pediatric tracheostomy patients is multifactorial. While timely establishment of outpatient care did correlate with quicker decannulation, factors related to medical complexity may have a greater impact on time to decannulation. Our results can help guide institutional decannulation protocols, as well as provide guidance when counseling families regarding tracheostomy expectations.

Tracheal A-frame deformity and suprastomal collapse after pediatric tracheostomy.

Objectives: To determine the incidence of A-frame deformity and suprastomal collapse after pediatric tracheostomy. Study design: Retrospective cohort. Methods: All patients (<18 years) that had a tracheostomy placed at a tertiary institution between 2015 and 2020 were included. Children without a surveillance bronchoscopy at least 6 months after tracheostomy were excluded. Operative reports identified tracheal A-frame deformity or suprastomal collapse. Results: A total of 175 children met inclusion with 18% (N = 32) developing A-frame deformity within a mean of 35.8 months (SD: 19.4) after tracheostomy. For 18 children (18/32, 56%), A-frame developed within a mean of 11.3 months (SD: 15.7) after decannulation. There were 96 children developing suprastomal collapse (55%) by a mean of 17.7 months (SD: 14.2) after tracheostomy. All suprastomal collapse was identified prior to decannulation. Older age at tracheostomy was associated with a lower likelihood of collapse (OR: 0.92, 95% CI: 0.86-0.99, p = .03). The estimated 5-year incidence of A-frame deformity after tracheostomy was 32.8% (95% CI: 23.0-45.3) and the 3-year incidence after decannulation was 36.1% (95% CI: 24.0-51.8). Highly complex children had an earlier time to A-frame development (p = .04). At 5 years after tracheostomy, the estimated rate of suprastomal collapse was 73.7% (95% CI: 63.8-82.8). Conclusions: Tracheal A-frame deformity is estimated to occur in 36% of children within 3 years after tracheostomy decannulation. Suprastomal collapse, which approaches 74% at 5 years after tracheostomy, is more common when tracheostomy is placed at a younger age. Surgeons caring for tracheostomy-dependent children should recognize acquired airway obstruction and appropriately monitor these outcomes. Level of evidence: 3.

Pediatric Tracheotomy Stomal Maturation and Tracheocutaneous Fistulas.

OBJECTIVE: The purpose of this study is to determine whether tracheostomy stomal maturation affects the risk of tracheocutaneous fistula (TCF) in children. METHODS: A retrospective chart review was conducted for all children who both underwent a tracheostomy and were decannulated between 2012 and 2021 at a tertiary children's hospital. Charts were analyzed for demographics, surgical technique, and development of a TCF. TCF was defined as a persistent fistula following 3 months after decannulation. RESULTS: 179 children met inclusion criteria. The median (interquartile range) age at tracheostomy was 1.5 (82.4) months, average (standard deviation [SD]) duration of tracheotomy was 20.0 (20.6) months, and length of follow-up after decannulation (range; SD) was 39.3 (4.4-110.0; 26.7) months. 107 patients (60.0%) underwent stomal maturation and 98 patients developed a TCF (54.7%). Younger age at tracheostomy placement was significantly associated with increased risk of TCF, mean (SD) age 28.4 (51.4) version 80.1 (77.5) months (p < 0.001). Increased duration of tracheostomy was significantly associated with increased risk of TCF, 27.5 (18.4) version 11.0 (18.2) months (p < 0.001). Stomal maturation was not significantly associated with the risk of TCF, including on multivariable analysis adjusting for age at tracheostomy and duration of tracheostomy (p = 0.089). CONCLUSION: Tracheostomy stomal maturation did not affect the risk of TCF in children, even after adjusting for age and duration of tracheostomy. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2941-2944, 2024.

Economic Evaluation of Pediatric Tracheostomy: A Cost of Illness Analysis.

Objective: This study aimed to determine the direct costs of pediatric tracheostomy care within a health care system. Study Design: Prospective analysis. Setting: Academic children's hospital. Methods: Costs associated with caring for pediatric tracheostomy patients under 18 years were analyzed between 2015 and 2021. Direct costs were calculated using the Medicare/Medicaid charges-to-costs ratio for various visit types. Costs were estimated using generalized linear equations, accounting for confounders. Results: A total of 297 children underwent tracheostomy at a median age of 0.94 years. The median follow-up was 2.5 years, resulting in 13,966 visits (mean = 41). The total cost was $321 million. The initial admission accounted for 72% ($231 million) of costs while other inpatient admissions added 24% ($78 million). Emergency department, observation, and outpatient visits comprised 4% of costs. The length of stay (LOS) was the primary cost driver for inpatient visits. Each additional hospital day increased costs by roughly $1195, and each extra admission added about $130,223 after adjusting for confounders. Respiratory failure and infections were the primary reasons for 67% of subsequent admissions. Conclusion: Pediatric tracheostomy care generated over $300 million in direct costs over 5 years. Inpatient stays constituted 96% of these costs, with the LOS being a major factor. To reduce direct health expenditures for these patients, the focus should be on minimizing admissions.

Neighborhood Socioeconomic Disadvantage and Long-Term Outcomes After Pediatric Tracheostomy.

OBJECTIVES: To determine whether long-term outcomes after pediatric tracheostomy are impacted by neighborhood socioeconomic disadvantage. METHODS: A prospective cohort of children with tracheostomies was followed at an academic pediatric hospital between 2015 and 2020. Patients were grouped into low or high socioeconomic disadvantage using their neighborhood area deprivation index (ADI). Survival and logistic regression analyses determined the relationship between ADI group, decannulation, and mortality. RESULTS: A total of 260 children were included with a median age at tracheostomy of 6.6 months (interquartile range [IQR], 3.9-42.3). The cohort was 53% male (N = 138), 55% White race (N = 143), and 35% Black or African American (N = 90). Tracheostomy was most frequently indicated for respiratory failure (N = 189, 73%). High neighborhood socioeconomic disadvantage was noted for 66% of children (N = 172) and 61% (N = 158) had severe neurocognitive disability. ADI was not associated with time to decannulation (HR = 0.90, 95% confidence interval [95% CI]: 0.53-1.53) or time to death (HR = 0.92, 95% CI: 0.49-1.72). CONCLUSIONS: Neighborhood socioeconomic disadvantage was not associated with decannulation or mortality among children with a tracheostomy. These findings suggest that long-term outcomes after pediatric tracheostomy are less dependent on socioeconomic factors in an individual community. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2415-2421, 2024.

A systematic review of antimicrobial therapy in children with tracheostomies.

Tracheostomies are indicated in children to facilitate long-term ventilatory support, aid in the management of secretions, or manage upper airway obstruction. Children with tracheostomies often experience ongoing airway complications, of which respiratory tract infections are common. They subsequently receive frequent courses of broad-spectrum antimicrobials for the prevention or treatment of respiratory tract infections. However, there is little consensus in practice with regard to the indication for treatment/prophylactic antimicrobial use, choice of antimicrobial, route of administration, or duration of treatment between different centers. Routine antibiotic use is associated with adverse effects and an increased risk of antimicrobial resistance. Tracheal cultures are commonly obtained from pediatric tracheostomy patients, with the aim of helping guide antimicrobial therapy choice. However, a positive culture alone is not diagnostic of infection and the role of routine surveillance cultures remains contentious. Inhaled antimicrobial use is also widespread in the management of tracheostomy-associated infections; this is largely based on the theoretical benefits of higher airway antibiotic concentrations. The role of prophylactic inhaled antimicrobial use for tracheostomy-associated infections remains largely unproven. This systematic review summarizes the current evidence base for antimicrobial selection, duration, and administration route in pediatric tracheostomy-associated infections. It also highlights significant variation in practice between centers and the urgent need for further prospective evidence to guide the management of these vulnerable patients.

Pediatric Custom Tracheostomies: A Ten-Year Experience.

OBJECTIVES: To describe the use of customized and custom tracheostomies at our institution, and to identify trends in patient presentation and tracheostomy design. METHODS: A retrospective review was conducted for patients at our institution for whom a customized or custom tracheostomy tube was ordered between January 2011 and July 2021. Customized tracheostomy tubes allow for a small selection of alterations to trach design, such as cuff length and flange type. Custom tracheostomies have a unique design created by tracheostomy tube engineers in collaboration with the clinical provider, and are built specifically for a single patient. RESULTS: A total of 235 patients were included, of whom 220 (93%) received customized tracheostomies and 15 custom (7%). The most common indications for customized tracheostomy were tracheal or stomal breakdown on a standard tracheostomy (n = 73, 33%) and ventilation difficulties (n = 61, 27%). The most frequent customization was shaft length (n = 126, 57%). The most common indication for custom tracheostomies was a persistent air leak on a standard or customized trach (n = 9) and the most frequent designs were custom cuffs (n = 8), flanges (n = 4), and anteriorly curved shafts (n = 4). Patients treated with a customized tracheostomy had a 5-year overall survival of 75.3%, compared to 51.4% for custom. CONCLUSION: These are the first cohorts of pediatric patients with customized and custom tracheostomies to be described. Modifications to tracheostomies, in particular shaft length and cuff design, can address common complications of extended tracheostomy, and may help improve ventilation in the most challenging cases. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:452-458, 2024.

Pediatric Patients with Tracheostomies and Its Multifacet Association with Lower Airway Infections: An 8-Year Retrospective Study in a Large Tertiary Center.

Background: Lower respiratory tract infections frequently complicate the care of children with chronic tracheostomies. Pediatric patients have significantly more risk to have tracheostomy infections than adults. Better understanding of modifiable risk factors for pulmonary exacerbations may improve the care of technology-dependent children. Methods: A retrospective single-center cohort study conducted on children with tracheostomy and chronic home ventilator to determine the incidence of pulmonary exacerbations leading to hospitalizations, emergency room (ER) visits, and antibiotic prescriptions. Oral and nebulized antibiotic prescriptions were collected and correlated to the type of exacerbation. Results: Gram-negative enteric organisms were the most common microbes seen in the lower airways, with Pseudomonas aeruginosa cultured in 86% of the subjects. P. aeruginosa presence predicted a 4-fold increased rate of pulmonary-related hospitalization. In pediatric patients with chronic respiratory failure, 64% of readmissions were pulmonary or tracheostomy related. When compared to standard care subjects on dual agent, alternating monthly nebulized antibiotic therapy (for chronic pseudomonas colonization) experienced 41% fewer hospitalizations [incidence rate ratios (IRR) 0.59 (0.18), P = 0.08], 46% fewer ER visits [IRR 0.56 (0.16), P = 0.04], and 41% fewer pulmonary-related ER visits [IRR 0.59 (0.19), P = 0.94]. Discussion: Children who require artificial airways are at an increased risk for bacterial bronchopulmonary infections. Most notable risk factors for hospitalization in tracheostomized children included neurologic impairment, dysphagia, aspiration, gastrotomy tube dependence, and gastroesophageal reflux disease. Pathogenic microbes such as P. aeruginosa species, certain gram-negative bacteria, candida, and yeast also predicted increased hospitalizations. Use of nebulized antibiotics prophylaxis in a subset of patients predicted lower rates of hospitalization or ER visits. More studies are needed to assess whether there is increased antimicrobial resistance with this strategy, and whether the benefits persist in the long-term nebulized antibiotics utilization.

Factors Affecting the Quality of Life of Parents Caring for Pediatric Patients with a Tracheostomy.

Objectives This study aimed to evaluate factors affecting the quality of life (QOL) of parents of children who underwent placement of a tracheostomy while in the pediatric intensive care unit (PICU) through postdischarge use of a standardized questionnaire, Functional Status Scale (FSS) for patients, and WHOQoL-BREF (a QOL scale) for parents. Methods The parents were initially contacted by telephone, postdischarge, during which the standardized questionnaire was completed. The functional status of the patients was evaluated using the FSS, and the QOL of parents was determined through use of the WHOQoL-BREF scale. Results From 2011 to 2021, tracheostomy was performed in 119 PICU patients. Overall, 93 patients were excluded due to death in 66 (56%), decannulation in 24 (20%) and, 3 (2%) were not available for follow-up. The parents of 26 (22%) patients were available for follow-up and for which the standardized questionnaire FSS and WHOQoL-BREF QOL scales were completed. The mean FSS score of the patients was elevated at 17.84. In comparison, reduced mean scores were observed for parental physical health of 20.61, psychological health of 20.57, social health of 11.15, and environmental health of 29.00. As a result, a moderate ( r < 0.80), yet significant ( p ≤ 0.004) negative correlation was found between the FSS scores of patients and the physical, social relationships, environmental, and psychological health QOL scores of parents. Conclusion This study is unique in that, to our knowledge, it is the first to compare parental QOL with the FSS of pediatric patients who have undergone a tracheostomy while hospitalized in the PICU. Our findings indicate that the parental QOL was reduced in four areas and correlates with an elevation in FSS score (indicating a greater functional disorder) of pediatric patients who had previously undergone a tracheostomy while hospitalized in the PICU.

Pediatric Tracheostomy: A Quality-of-Life Assessment Study in Saudi Arabia.

INTRODUCTION: The pediatric population undergoes tracheostomy for a variety of reasons. For a child and their family, having a tracheostomy means learning a new way of life and facing several social, psychological, medical, and economic challenges. Our analysis of the literature indicates that this is the first study of its kind, using the Pediatric Tracheotomy Health Status Instrument (PTHSI) tool to assess the quality of life (QoL) following tracheostomy in pediatric patients and their caregivers in the Kingdom of Saudi Arabia (KSA). METHODS: This was a descriptive cross-sectional study for tracheostomized children's QoL evaluation. The medical records of the Maternity and Children Hospital, Dammam, KSA, were used to identify the patients and their caregivers. A higher score on the validated PTHSI indicated a better result. RESULTS: From a total of 56 patients, 24 were included in this study. Based on the PTHSI tool, the overall mean score was 93.3/150 (62.28%) and this indicated a good QoL score. Analysis of the correlation between the PTHSI score and other variables indicated no association between the total PTHSI score and the age or gender of the patient or the duration of the tracheostomy (p-value > 0.05). However, we found families of children with major medical comorbidities had lower scores (p-value = 0.03) and their QoL was affected much more than families of patients who did not have major medical comorbidities. CONCLUSION: Tracheostomy care for pediatric patients can significantly affect the QoL of patients and their families. Our findings using the validated PTHSI tool showed poorer QoL compared to other studies, suggesting the need for future home care training programs to support tracheostomized children and their families, particularly those with comorbidities, who tend to have lower QoL scores and require more organized support.

Pediatric tracheostomy audiometric outcomes - A quality improvement initiative.

OBJECTIVE: Pediatric tracheostomy patients disproportionately experience hearing loss and are at risk for delayed identification due to their medical complexity. Nonetheless, protocols to monitor hearing in these children are lacking. This quality improvement (QI) initiative aimed to increase the rates of audiometric testing within 12 months of pediatric tracheostomy placement. METHODS: A retrospective cohort study included children who underwent tracheostomy under 18 months of age between 2012 and 2020. Rates of audiometric assessments before and after QI project implementation (2015) were reported along with hearing loss characteristics. RESULTS: A total of 253 children met inclusion. Before project initiation (2012-2014), 32% of children (28/87) obtained audiometric testing within 12 months after tracheostomy. During the first three years of implementation (2015-2017), 39% (38/97) were tested, while 55% (38/69) were tested during the subsequent three years (2018-2020) (P = .01). A passing newborn hearing screen was obtained for 70% of the 210 children with a recorded result, and 198 survived at least 12 months to receive audiometric testing at a median of 11.3 months (IQR: 6.2-22.8) after tracheostomy. Hearing loss was identified for 44% of children (N = 88), of which 42 children initially passed newborn hearing screen. A second assessment was obtained for 62% of children (123/198) at a median of 11.3 months (IQR: 4.5-17.5) after the initial test. In this group, 23% with a previously normal audiometric exam were found to have hearing loss (15/66). CONCLUSIONS: QI initiatives designed to monitor hearing loss in children with a tracheostomy can result in improved rates of audiometric assessments. This population has disproportionately high rates of hearing loss, including delayed onset hearing loss making audiometric protocols valuable to address speech and language development delays.

Outcomes of pediatric tracheostomy after surgery for congenital heart disease: A 20-year experience.

Objective: Children with congenital heart defects (CHD) requiring cardiovascular surgery (CVS) rarely require tracheostomy placement; however the mortality rate remains high. The study aimed to analyze the incidence of tracheostomy in children with CHD, and to determine factors contributing to postoperative outcomes, decannulation rates, and mortality. Methods: Retrospective case series of children ≤18 years old with CHD status post-CVS who underwent tracheostomy placement between January 1, 2001 and December 31, 2020. Variables analyzed included demographic information, presence of comorbidities including prematurity, respiratory diseases, presence of genetic syndromes, decannulation status, type of repair (univentricular vs. biventricular), and need for cardiopulmonary bypass. Adverse events analyzed included all-cause mortality, development of mediastinitis, fatal decannulation, and persistence of tracheocutaneous fistula. Results: Fifty-one patients were analyzed. The incidence of tracheostomy was 0.8%. Median age at tracheostomy was 5.3 months. The 5-year survival estimate was 56.3% (95% confidence interval 43.6%, 72.6%). Age ≤6 months at the time of tracheostomy placement (p = .03), and the presence of tracheomalacia (p = .04) were factors significantly associated with 5-year survival. Two patients (3.9%) experienced fatal decannulation, and one patient (2.0%) developed postoperative mediastinitis. The 10-year decannulation rate estimate was 47.8% (30.5%, 63.2%). Seven patients (13.7%) had a persistent tracheocutaneous fistula. Conclusions: This study corroborates high mortality rates in this population. Factors associated with improved survival were younger age at the time of tracheostomy and presence of tracheomalacia. Decannulation rates were low, but estimates improved over 10 years. Further studies are needed to determine optimal indications and timing for tracheostomy placement in this patient population. Level of Evidence: 4.

Long-Term Outcomes of Tracheostomy-Dependent Children.

OBJECTIVE: To estimate the 1-, 5-, and 10-year survival and decannulation rates of children with a tracheostomy. STUDY DESIGN: Ambidirectional cohort. SETTING: Tertiary children's hospital. METHODS: All patients (<18 years) that had a tracheostomy placed between 2009 and 2020 were included and followed until 21 years of age, decannulation, or death. The Kaplan-Meier method estimated cumulative probabilities of death and decannulation. RESULTS: A total of 551 children underwent tracheostomy at a median age of 7.2 months (interquartile range [IQR]: 3.8-49.2). Children were followed for a median of 2.1 years (IQR: 0.7-4.2, range 0-11.5). The cumulative probability of mortality at 1 year was 11.9% (95% confidence interval [CI]: 9.4-15.1), at 5 years was 26.1% (95% CI: 21.6-31.3), and at 10 years was 41.6% (95% CI: 32.7-51.8). Ventilator dependence at index discharge (hazard ratio [HR]: 2.04, 95% CI: 1.10-3.81, p = .03), severe neurologic disability (HR: 2.79, 95% CI: 1.61-4.84, p < .001), and cardiac disease (HR: 1.69, 95% CI: 1.08-2.65, p = .02) were associated with time to death. The cumulative probability of decannulation was 10.4% (95% CI: 8.0-13.5), 44.9% (95% CI: 39.4-50.9), and 54.1% (95% CI: 47.4-61.1) at 1 year, 5 years, and 10 years, respectively. Ventilator dependence (HR: 0.43, 95% CI: 0.31-0.60, p < .001), severe neurologic disability (HR: 0.20, 95% CI: 0.14-0.30, p < .001), and tracheostomy indicated for respiratory failure (HR: 0.68, 95% CI: 0.48-0.96, p = .03) correlated with longer decannulation times. CONCLUSION: After tracheostomy, estimated mortality approaches 42% by 10 years and decannulation approaches 54%. Children with ventilator support at discharge and severe neurological disability had poorer long-term survival and longer times to decannulation.

External airway splint placement for severe pediatric tracheobronchomalacia.

OBJECTIVE: To present external airway splinting with bioabsorbable airway supportive devices (ASD) for severe, life-threatening cases of pediatric tracheomalacia (TM) or tracheobronchomalacia (TBM). METHODS: A retrospective cohort was performed for 5 pediatric patients with severe TM or TBM who underwent ASD placement. Devices were designed and 3D-printed from a bioabsorbable material, polycaprolactone (PCL). Pre-operative planning included 3-dimensional airway modeling of tracheal collapse and tracheal suture placement using nonlinear finite element (FE) methods. Pre-operative modeling revealed that triads along the ASD open edges and center were the most effective suture locations for optimizing airway patency. Pediatric cardiothoracic surgery and otolaryngology applied the ASDs by suspending the trachea to the ASD with synchronous bronchoscopy. Respiratory needs were trended for all cases. Data from pediatric patients with tracheostomy and diagnosis of TM or TBM, but without ASD, were included for discussion. RESULTS: Five patients (2 Females, 3 Males, ages 2-9 months at time of ASD) were included. Three patients were unable to wean from respiratory support after vascular ring division; all three weaned to room air post-ASD. Two patients received tracheostomies prior to ASD placement, but continued to experience apparent life-threatening events (ALTE) and required ventilation with supraphysiologic ventilator settings. One patient weaned respiratory support successfully after ASD placement. The last patient died post-ASD due to significant respiratory co-morbidity. CONCLUSION: ASD can significantly benefit patients with severe, unrelenting tracheomalacia or tracheobronchomalacia. Proper multidisciplinary case deliberation and selection are key to success with ASD. Pre-operative airway modeling allows proper suture placement to optimally address the underlying airway collapse.

Parental Perception and Barriers Regarding COVID-19 Vaccination in Technology Dependent Children.

INTRODUCTION: Children who use chronic home mechanical ventilation are at high risk for respiratory infections and mortality. They are also at increased risk for developing severe COVID-19 infection. The primary goal of this study was to evaluate the parental perception of the COVID-19 vaccine in pediatric patients with technology dependence. METHOD: We conducted a cross-sectional survey at a children's hospital between September 2021 and February 2022. A telephone or in-person interview was conducted to assesss parental attitudes toward the COVID-19 vaccine for their technology-dependent child. Technology-dependent groups included patients requiring (1) invasive mechanical ventilation via tracheostomy and (2) noninvasive mechanical ventilation via a facial interface. RESULTS: Fourteen of 44 participants (32%) of technology-dependent children were vaccinated for COVID-19 despite high parental vaccination and influenza vaccination rates. Twenty-eight patients (63% of total participants) were tracheostomy dependent. In the tracheostomy group, the COVID-19 vaccine rate was 28% versus 54% in the nontracheostomy group.  Concern for vaccine side effects was the major reason for vaccine hesitancy (53%). More parents of vaccinated children than unvaccinated children were counseled by their primary care provider (85.7% vs. 46.7%; p = .02) or subspecialist (93% vs. 47%; p = .003). CONCLUSIONS: Our findings suggest counseling by primary care providers and subspecialists is important in overcoming COVID-19 vaccine hesitancy. Social media was identified as a major source of information, particularly among parents of unvaccinated patients.