Acute Airway Obstruction: An Unusual Presentation of Posttransplant Lymphoproliferative Disorder in a Renal Transplant Recipient.

Posttransplant lymphoproliferative disorder is a life-threatening complication after solid-organ transplants. In adults, recipients of heart transplants have the highest risk, whereas renal transplant recipients have the lowest risk among all solid-organ transplants. The most common site for posttransplant lymphoproliferative disorders are gastrointestinal tract followed by the graft itself. Airway involvement in posttransplant lymphoproliferative disorder is rarely encountered. We report a case of a 26-year-old renal allograft recipient who presented to the emergency room with airway obstruction necessitating an emergency tracheostomy. Imaging revealed a left tonsillar mass extending into the nasopharynx and retropharyngeal space causing complete oropharyngeal occlusion. Endoscopic biopsy from nasopharyngeal mass showed a diffuse large B-cell lymphoma and was Ebstein-Barr virus positive. Reduction in immunosuppression and treatment with posttransplant lymphoproliferative disorder-1 risk-stratified approach resulted in complete remission.

Tracheal metallic hybrid stent removal via tracheostomy: an unconventional approach.

Increasing use of tracheal expandable metallic hybrid stents will lead to common encounters with these devices in emergency airway management. The presence of these stents qualifies any patient as a challenge when an emergency tracheostomy is needed. We report an unorthodox technique of tracheostomy with concomitant removal of tracheal stent, without any major complications. Although the combined approach with bronchoscopy and tracheostomy has been reported in similar cases, we present a safe procedure when rigid bronchoscopy is not available.

Cerebrocostomandibular syndrome: a diagnostic challenge.

A male infant born in a tertiary maternity facility was noted to have microretrognathia, a small mouth and macroglossia at delivery. He was born limp and apnoeic and required multiple attempts at intubation before a definitive airway was eventually sited. Chest X-rays, while in the paediatric intensive care unit, demonstrated dysplastic ribs with associated 'high-riding' clavicles. A later X-ray was reported as showing interrupted posterior ribs. A tracheostomy was formed on day of life 9 given the immediate risk to the baby's airway. Further imaging of the facial bones, skull and brain showed generous CSF spaces over the cerebral convexities and also marked hypoplasia of the mandible and mid-face. The baby's middle ear cavities were shown to be completely opacified. Genetic testing eventually went on to confirm a diagnosis of cerebrocostomandibular syndrome, with the detection of a pathogenic variant of the small nuclear ribonucleoprotein polypeptide B gene.

Prognostic Risks for Tracheostomy in Pierre Robin Sequence: A Cohort From a Tertiary Hospital in Thailand.

BACKGROUND: Pierre Robin sequence (PRS), characterized by micrognathia, glossoptosis, cleft palate, and obstructed airways, is one of the craniofacial conditions challenging various approaches to managing compromised airways, ranging from conservative measures to invasive airway surgery. This study was conducted to identify predictive risk factors for tracheostomy in the PRS. METHODS: A retrospective chart review was conducted at a tertiary referral hospital in Thailand. Children diagnosed with PRS from January 2010 to December 2021 were enrolled. Univariate and multivariate analysis methods were used to identify the risk factors. RESULTS: Sixty-five patients with PRS were identified in electronic medical records, but 6 were excluded. Thirteen of the remaining 59 patients underwent tracheostomy. There were no significant differences in sex, preterm gestational age, cleft palate, associated syndromes, chromosome abnormalities, or cardiac or neurological involvement between patients who received tracheostomy and those who did not. However, patients with oropharyngeal dysfunction who received tracheostomy tended to use a nasogastric tube or percutaneous gastrostomy 92.3% of the time ( P = 0.043). In addition, patients with abnormal airways from endoscopy were more likely to undergo tracheostomy (odds ratio, 2.17; 95% confidence interval [CI], 1.20-3.90). Interestingly, patients with a sum of Apgar scores at 1 and 5 minutes <15 were more likely to undergo tracheostomy (adjusted odds ratio, 9.91; 95% CI, 1.32-74.52). Furthermore, patients with at least 3 identified comorbidities were more likely to undergo tracheostomy (adjusted odds ratio, 11.34; 95% CI, 1.16-111.15). CONCLUSIONS: The need for tracheostomy depends on comorbidities, Apgar scores, and abnormal airway anatomy. Feeding methods can become more complex with tracheostomy. Prognostic risk factors can help guide treatment and counseling for health care workers and caregivers.

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications.

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage. This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required. The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.

Characteristics of tracheostomized patients followed up by a Palliative Care and Complex Chronic Patient Service.

INTRODUCTION AND OBJECTIVES: In recent years, there has been an increase in the number of children with tracheostomies. The objective was to describe the characteristics of paediatric patients with a tracheostomy followed up by the Department of Palliative Care and Chronic Medically Complex Illness (DPCCMCI) of a tertiary care hospital. METHODS: Single-centre retrospective observational study in patients aged less than 18 years with a tracheostomy followed up by the PCCCPS of a tertiary care hospital (November 2020-June 2022). We analysed epidemiological, clinical, microbiological and social data by reviewing the health records. RESULTS: The sample included 44 tracheostomized patients. The most frequent underlying disease was acquired upper airway disease (20.5%). The most common indication for tracheostomy was upper airway obstruction (66%). Bacterial isolates were detected in 84% of the tracheal aspirates, among which P. aeruginosa was the most frequent (56.8%). The most frequently prescribed antibiotic was ciprofloxacin (84%). In addition, 18.1% of the patients received at least 1 course of intravenous antibiotherapy and 29.5% received more than 3 systemic antibiotic regimens in the past 20 months. Fifty-nine percent of the children were schooled: 38.6% attended a regular school, 15.9% a special needs school and 4.5% were home-schooled. We identified social difficulties in 53.7%. Also, 22.7% of the families received financial support to care for a child with severe illness. CONCLUSIONS: Because of the complexity of caring for tracheostomized children, integral and coordinated management is essential. Schooling is possible and safe if caregivers are trained.

Long-term outcome of permanent tracheostomy management in two brachycephalic dogs using a commercial and a three-dimensional-printed silicone stent.

OBJECTIVE: To report the long-term outcome of utilization of a silicone stent to support the management of a permanent tracheostomy. STUDY DESIGN: Short case series. ANIMALS: Two client-owned brachycephalic dogs. METHODS: Two brachycephalic dogs with stage III laryngeal collapse underwent permanent tracheostomy. After the tracheostomy had healed, a silicone stent was inserted to support the stoma and facilitate home care. One dog wore a commercially available silicone stent for the follow-up period of 2 years. For the dog in Case 2, a 3D-printed, medical-grade silicone stent with an increased length was designed, as the dog had developed skin sores from the commercial device. RESULTS: Both dogs tolerated the silicone stent well. Stent care was managed by the owners without need for assistance. They reported that the silicone stent facilitated cleaning of the stoma surroundings and that they felt an increased confidence in airway patency, as the device prevented the tracheal stoma from collapsing. In Case 1, tracheoscopy 1 year after first stent insertion revealed minimal visible changes to the tracheal stoma. In Case 2, the 3D printed silicone stent led to a remission of skin sores and the dog wore the device comfortably until succumbing to an unrelated disease 13 months later. CONCLUSION: The insertion of a silicone stent is a simple and cost-effective method to improve home care of dogs with permanent tracheostomy. Larger dogs, as in Case 2, may benefit from custom-designed 3D-printed stents.

Healthcare service use and medical outcomes of tracheostomy-dependent children: a nationwide study.

BACKGROUND: Despite the rising trend of tracheostomies in children, there is a lack of comprehensive resources for families to navigate the challenges of living with a tracheostomy, emphasising the need for evidence-based support in understanding postoperative care and long-term adjustments. This study aimed to examine the pattern of using healthcare services and nationwide medical outcomes in children who underwent a tracheotomy before the age of 2 years. METHODS: This retrospective study used the National Health Insurance System database from 2008 to 2016 and included all children codified with tracheotomy procedure codes before their second birthday. Healthcare utilisation, such as medical costs, number of hospital visits, home healthcare nursing and medical diagnoses on readmission, in the first 2 years after tracheotomy was evaluated. Multivariable logistic regression analysis was used to determine the factors affecting mortality. RESULTS: In total, 813 patients were included in this study. Their use of healthcare services and the accompanying expenses were higher than the national medians for similar age groups; however, both metrics decreased in the second year. The major causes of admission within 2 years of surgery were respiratory and neurological diseases. The mortality rate within 2 years was 37.8%. Higher risks of mortality were associated with having two or more complex chronic conditions. Use of home healthcare nursing services was associated with a lower mortality risk. CONCLUSION: Paediatric patients with more complex chronic conditions tended to have higher mortality rates within 2 years after surgery. However, receiving home healthcare nursing was significantly associated with a reduced risk of death. Many causes of hospitalisation may be preventable with education and supportive care. Therefore, further research for establishing an integrated care system for these patients and their caregivers is required.

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.

Mediação de saberes na sobrevivência ao câncer de laringe: a experiência de pessoas Laringectomizadas Totais / Mediation of knowledge in surviving laryngeal cancer: the experience of Total Laryngectomized persons / Mediación del conocimiento en la supervivencia al cáncer de laringe: la experiencia de las personas sometidas a Laringectomía Total

O presente estudo parte de reflexões acerca da sobrevivência ao câncer e da experiência estigmatizante vivenciada por pessoas diagnosticadas com câncer de laringe no Hospital Nacional do Câncer/Instituto Nacional do Câncer, submetidas à cirurgia de Laringectomia Total e participantes do Grupo de Laringec-tomizados Totais. O objetivo foi compreender as mediações de saberes e de informações produzidas pelos participantes do grupo na interface com os profissionais de saúde, considerando a sua dupla condição de estigma: o câncer e a deficiência. Parte-se de uma abordagem socioantropológica de caráter qualitativo e ex-ploratório que empregou os métodos de entrevista narrativa com cinco participantes. A análise foi realizada pelo método hermenêutico-dialético. Nos resultados destacam-se a busca pelo reconhecimento individual e social e a valorização da experiência frente aos saberes oficiais e o quanto as mediações extrapolam o espaço institucional. A mediação de saberes faz emergirem elementos significativos para o enfrentamento de uma cultura informacional dominante.

This study is based on reflections on surviving cancer and the stigmatizing experience of people diagnosed with laryngeal cancer at the Hospital Nacional do Câncer/Instituto Nacional do Câncer, who underwent Total Laryngectomy surgery and participated in the Total Laryngectomy Group. The goal was to understand the mediations of knowledge and information produced by the group participants, in the interface with health professionals, considering their double condition of stigma: cancer and disability. It is based on a socio-anthropological approach, of qualitative and exploratory nature that employed the narrative interview method with five participants. The analysis was carried out through the hermeneutic-dialectic method. The results highlight the search for individual and social recognition and the appreciation of experience in relation to official knowledge, and how the mediations go beyond the institutional space. The mediation of knowledge brings out significant elements to confront a dominant informational culture.

El presente estudio se basa en las reflexiones sobre la supervivencia al cáncer y la experiencia estigmatiza-dora de personas diagnosticadas de cáncer de laringe en el Hospital Nacional do Câncer/Instituto Nacional do Câncer, que se sometieron a una Laringectomía Total y participaron en el Grupo de Laringectomía Total. Objetivo: comprender las mediaciones de conocimiento e información producidas por los participantes del grupo, en la interfaz con los profesionales de salud, considerando su doble estigma: cáncer y discapacidad. Se basa en un abordaje socioantropológico, cualitativo y exploratorio, que utilizó métodos de entrevista narrativa con cinco participantes. El análisis ocurrió a través del método hermenéutico-dialéctico. Los resultados destacan la búsqueda de reconocimiento individual y social y la valorización de la experiencia en relación con el conocimiento oficial y la medida en que las mediaciones van más allá del espacio insti-tucional. La mediación del conocimiento pone de manifiesto elementos significativos sobre una cultura informacional dominante.

Descripción de las intervenciones broncoscópicas en estenosis traqueales posterior a infección por COVID-19 / Description of Bronchoscopic Interventions in Post-COVID Tracheal Stenosis

Introducción: La infección por SARS-CoV-2 puede presentar síndrome de distrés res-piratorio agudo con requerimiento de ventilación mecánica prolongada y retraso en la realización de traqueostomía. Esto trae como consecuencia un incremento en casos de estenosis traqueal y la necesidad de métodos menos invasivos para su abordaje. Métodos: Estudio descriptivo de corte transversal, desde marzo 2020 hasta diciem-bre 2021 en el Hospital Universitario Nacional de Colombia, en adultos con estenosis traqueal postintubación asociado SARS-CoV-2. Se realizó análisis univariado entre los grupos con infección o no por SARS-CoV-2 como control, y reintervención, grado de estenosis, uso de inyección intramucosa con dexametasona intratraqueal o múltiples estenosis como desenlaces de importancia. Se usó test exacto de Fisher, t Student y Man-Whitney según la naturaleza de variables. Se consideró p estadísticamente significativo menor a 0.05.Resultados: Se identificaron 26 pacientes, 20 tenían COVID-19 y 6 no. Se encontraron diferencias en edad (p=0,002), epilepsia (p=0,007) y estenosis múltiple (p= 0,04). En 85% de los casos se utilizó láser blue más dilatación con balón pulmonar, en 35% inyección intramucosa con dexametasona intratraqueal y reintervención en 35%, sin diferencias significativas entre grupos. Conclusiones: Se observó un incremento tres veces mayor de pacientes con estenosis múltiple en el grupo de infección por COVID-19, así mismo se encontró que el método más utilizado en este grupo para la recanalización fue el uso de láser blue más dilatación con balón pulmonar y la innovación en el uso de inyección intramucosa.

Introduction: SARS-CoV-2 infection can lead to acute respiratory distress syndrome with a prolonged need for mechanical ventilation and delayed tracheostomy, resulting in an increase in cases of tracheal stenosis and the necessity for less invasive approaches.Methods: A descriptive cross-sectional study was conducted from March 2020 to December 2021 at the Hospital Universitario Nacional de Colombia, focusing on adults with post-intubation tracheal stenosis associated with SARS-CoV-2. Univariate analysis was performed between groups with or without SARS-CoV-2 infection as a control, considering reintervention, degree of stenosis, use of intratracheal steroids, or multiple stenoses as important outcomes. Fisher's exact test, Student's t-test, and Mann-Whit-ney test were employed based on the nature of variables. A p-value less than 0.05 was considered statistically significant.Results: A total of 26 patients were included, with 20 having COVID-19 and 6 without. Significant differences were found in age (p=0.002), epilepsy (p=0.007), and multiple stenosis (p=0.04). In 85% of cases, laser blue plus balloon pulmonary dilation was used, intratracheal dexamethasone in 35%, and reintervention in 35%, with no significant differences between groups.Conclusions: A threefold increase in subglottic stenosis was observed during the SARS-CoV-2 pandemic, with more instances of multiple stenosis and predominantly the use of laser blue plus balloon pulmonary dilation as a successful recanalization technique. There was a higher use of intratracheal dexamethasone in this group compared to oth-er pathologies causing tracheal stenosis.

The Effect of Delay Following the Clinical Decision to Perform Tracheostomy in the Critical Care Setting.

BACKGROUND: Tracheostomy in patients who are critically ill is generally performed due to prolonged mechanical ventilation and expected extubation failure. However, tracheostomy criteria and ideal timing are poorly defined, including equivocal data from randomized controlled trials and median intubation to tracheostomy times that range from 7-21 d. However, a consistent finding is that only ∼50% of late tracheostomy groups actually undergo tracheostomy, with non-performance due to recovery or clinical deterioration. Unlike in many jurisdictions, elective surgical procedures in our institution require a court-appointed guardian, which necessitates an approximately 1-week delay between the decision to perform tracheostomy and surgery. This offers a unique opportunity to observe patients with potential tracheostomy during a delay between the decision and the performance. METHODS: ICU patients who were ventilated were identified for inclusion retrospectively by an application for guardianship relating to tracheostomy, the intention-to-treat point. The main outcomes of tracheostomy, extubation, or death/palliative care after inclusion were noted. Demographics, outcomes, and event timing were compared for the 3 outcome groups. RESULTS: Tracheostomy-related guardianship requests were made for 388 subjects. Of these, 195 (50%) underwent tracheostomy, whereas 127 (33%) were extubated and 66 (17%) either died before tracheostomy (46 [12%]) or were transitioned to palliative care (20 [5%]). The median time (interquartile range) from guardianship request until a defining event was the following: 6.2 (4.0-11) d for tracheostomy, 5.0 (2.9-8.2) d for extubation (P < .001 as compared to tracheostomy group), and 6.5 (2.5-11) d for death/palliative care (P = .55 as compared to tracheostomy). Neurological admissions were more common in the tracheostomy group and less common in the palliative group. Other admission demographics and hospitalization characteristics were similar. Hospital mortality was higher for subjects undergoing tracheostomy (58/195 [30%]) versus extubation (24/127 [19%]) (P = .03). CONCLUSIONS: Delay in performing tracheostomy due to legal requirements was associated with a 50% decrease in the need for tracheostomy. This suggests that decision-making with regard to ideal tracheostomy timing could be improved, saving unnecessary procedures.

Safety of cricotracheostomy with skin and tracheal membrane flaps for severe COVID-19 patients.

OBJECTIVE: Airway surgery is performed for COVID-19 patients who require long-term tracheal intubation and mechanical ventilation. Tracheostomy sometimes causes postoperative complications represented by bleeding at a relatively high rate in COVID-19 patients. As an alternative surgical procedure to tracheostomy, cricotracheostomy may reduce these complications, but few studies have examined its safety. METHODS: Data were retrospectively collected for sixteen COVID-19 patients (11 underwent tracheostomy, 5 underwent modified cricotracheostomy). In addition to patients' backgrounds and blood test data, the frequency of complications and additional care required for postoperative complications were collected. Statistical analysis was conducted by the univariate analysis of Fischer analysis and Mann-Whitney U test. RESULTS: Five cases experienced postoperative bleeding, four cases experienced peristomal infection, and one case experienced subcutaneous emphysema in the tracheostomy patients. These complications were not observed in the cricotracheostomy patients. The number of additional cares for postoperative complications was significantly lower in cricotracheostomy than in tracheostomy patients (p < 0.05). CONCLUSIONS: Modified cricotracheostomy could be a safe procedure in airway surgery for patients with COVID-19 from the point of fewer postoperative complications and additional care. It might be necessary to select the cricotracheostomy depending on patients' background to reduce postoperative complications.

Update on pediatric tracheostomy.

Pediatric tracheostomy has been widely performed since the 1800s, and in recent years, with advances in neonatal medicine, it has been performed at younger ages, starting at 0. In addition, advances in surgical techniques and postoperative tube management have reduced complications. This review will discuss the entire process of pediatric tracheostomy, starting with the history of tracheostomy and ending with indications, contraindications, techniques (slit, Björk, EXIT), complications, tube management, and decannulation. Pediatric tracheostomy patients require long-term care and management as they grow after the surgery itself, so otolaryngologists and pediatric tracheostomists are particularly involved in tube management and decannulation. We believe that sharing this information with all healthcare professionals will lead to better care for children with tracheostomies.

Perioperative risk factors for major complications after bone replacement in decompressive craniectomy.

INTRODUCTION: Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS: A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS: A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS: Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

Outcomes for Pediatric Oncology and Hematopoietic Stem Cell Transplantation Patients Who Undergo Tracheostomy Placement: A Pediatric Health Information System Database Cohort Study, 2009-2020.

OBJECTIVES: To describe the epidemiology, surgical complications, and long-term outcomes after tracheostomy in pediatric oncology and/or hematopoietic stem cell transplantation (HSCT) patients in U.S. Children's Hospitals. DESIGN: Retrospective cohort from the Pediatric Health information System (PHIS) database, 2009-2020. SETTING: The PHIS dataset incorporates data from 48 pediatric hospitals in the Children's Hospital Association. PATIENTS: Patients 0-21 years old with an oncologic diagnosis and/or underwent HSCT, received a tracheostomy, and were discharged from hospital between January 1, 2009, and December 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1061 patients included in the dataset, and 217 (20.5%) had undergone HSCT. The annual prevalence in tracheostomy usage did not change over the study period. The majority of patients (62.2%) underwent tracheostomy early (< 30 d) in the admission and those who underwent the procedure later (> 90 d) had a significant increase in mortality (52.6% vs. 17.6%; p < 0.001) and mechanical ventilation (MV) at discharge (51.9% vs. 24.5%; p < 0.001) compared with the early tracheostomy patients. Complications reported included tracheostomy site bleeding (< 1%) and infection (24%). The overall rate of MV at discharge was 32.6% and significantly associated with chronic lung (adjusted odds ratio [OR], 1.54; 95% CI, 1.03-2.32) and acute lung disease (OR, 2.18; 95% CI, 1.19-3.98). The overall rate of mortality was 19.6% within the cohort and significantly associated with HSCT (OR, 5.45; 95% CI, 3.88-7.70), diagnosis of sepsis (OR, 2.09; 95% CI, 1.28-3.41), and requirement for renal replacement therapy (OR, 2.76; 95% CI, 1.58-4,83). CONCLUSIONS: This study demonstrated a static prevalence of tracheostomy placement in the cohort population relative to the increasing trends in other reported groups. Regardless of underlying diagnosis, the study patients incurred substantial morbidity and mortality. However, tracheostomy specific complication rates were comparable with that of the general pediatric population and were not associated with increased odds of mortality within this population.

Adolescents with Rett syndrome at critical care pathway junctures: Examining clinicians' decision to initiate invasive long-term ventilation.

BACKGROUND: The initiation of invasive long-term ventilation (I-LTV) for an adolescent with Rett Syndrome (RTT) involves many serious bioethical considerations. In moving towards a more inclusive model of patient participation, transparency surrounding the main influencing factors around this decision is important. OBJECTIVE: We aimed to identify the main drivers influencing a clinician's decision to support initiation of I-LTV for an adolescent with RTT. METHOD: We used an anonymous online vignette-based factorial survey. The survey was distributed internationally through eight professional multi-disciplinary organisations to reach clinicians working in paediatrics. RESULTS: We analysed 504 RTT vignettes completed by 246 clinicians using mixed effect regression modelling. The main three significant influencing factors identified were: parental agreement with the decision to support initiation, the family's support network, and proximity to a tertiary care centre. Additional comments from participants focused on family support, and the importance of on-going communication with the family. CONCLUSION: As the rights of those with disabilities improve and participation of adolescents in decision-making becomes more established, effective communications with the family around goals of care and particular sensitivity and reflective practice around methods of consensus building will likely contribute to a positive decision-making process at this difficult time.

Impact of Early Tracheostomy After Lung Transplantation: A National Analysis.

BACKGROUND: Prolonged mechanical ventilation is common among lung transplant recipients, affecting nearly one-third of patients. Tracheostomy has been shown as a beneficial alternative to endotracheal intubation, but delays in tracheostomy tube placement persist. To date, no large-scale study has investigated the effect of tracheostomy timing on posttransplant outcomes. METHODS: All adults receiving tracheostomy after primary, isolated lung transplantation were identified in the 2016 to 2020 Nationwide Readmissions Database. Early tracheostomy was defined as placement before postoperative day 8 based on exploratory cohort analysis. Multivariable regression was used to evaluate the association of early tracheostomy with in-hospital mortality, select posttransplant complications, and resource utilization. RESULTS: Of an estimated 11,048 patients undergoing first-time lung transplantation, 1509 required a tracheostomy in the postoperative period, with 783 (51.9%) comprising the early cohort. After entropy balancing and risk adjustment, early tracheostomy placement was associated with reduced odds of death (adjusted odds ratio, 0.59; 95% CI, 0.36-0.97) and posttransplant infection (adjusted odds ratio, 0.54; 95% CI, 0.35-0.82). Further, tracheostomy within 1 week of transplantation was associated with decreased length of stay (ß-coefficient, -16.5 days; 95% CI, -25.3 to -7.6 days) and index hospitalization costs (ß-coefficient, -$97,600; 95% CI, -$153,000 to -$42,100). CONCLUSIONS: The present study supports the safety of early tracheostomy among lung transplant recipients and highlights several potential benefits. Among appropriately selected patients, tracheostomy placement before postoperative day 8 may facilitate early discharge, lower costs, and reduced odds of posttransplant infection.

Lessons for the next pandemic: analysis of the timing and outcomes including post-discharge decannulation rates for tracheostomy in severe COVID-19 respiratory failure.

PURPOSE: COVID-19 patients with respiratory failure frequently require prolonged ventilatory support that would typically warrant early tracheostomy. There has been significant debate on timing, outcomes, and safety of these procedures. The purpose of this study was to determine the epidemiological, hospital, and post-discharge outcomes of this cohort, based on early (ET) versus late (LT) tracheostomy. METHODS: Retrospective review (March 2020-January 2021) in a 5-hospital system of ventilated patients who underwent tracheostomy. Demographics, hospital/ICU length of stay (LOS), procedural characteristics, APACHE II scores at ICU admission, stabilization markers, and discharge outcomes were analyzed. Long-term decannulation rates were obtained from long-term acute care facility (LTAC) data. RESULTS: A total of 97 patients underwent tracheostomy (mean 61 years, 62% male, 64% Hispanic). Despite ET being frequently performed during active COVID infection (85% vs. 64%), there were no differences in complication types or rates versus LT. APACHE II scores at ICU admission were comparable for both groups; however, > 50% of LT patients met PEEP stability at tracheostomy. ET was associated with significantly shorter ICU and hospital LOS, ventilator days, and higher decannulation rates. Of the cohort discharged to an LTAC, 59% were ultimately decannulated, 36% were discharged home, and 41% were discharged to a skilled nursing facility. CONCLUSIONS: We report the first comprehensive analysis of ET and LT that includes LTAC outcomes and stabilization markers in relation to the tracheostomy. ET was associated with improved clinical outcomes and a short LOS, specifically on days of pre-tracheostomy ventilation and in-hospital decannulation rates.