Timing the First Pediatric Tracheostomy Tube Change: A Randomized Controlled Trial.

OBJECTIVE: The first pediatric tracheostomy tube change often occurs within 7 days after placement; however, the optimal timing is not known. The primary objective was to determine the rate of adverse events of an early tube change. Secondary objectives compared rates of significant peristomal wounds, sedation requirements, and expedited intensive care discharges. STUDY DESIGN: Prospective randomized controlled trial. SETTING: Tertiary children's hospital between October 2018 and April 2020. METHODS: A randomized controlled trial enrolled children under 24 months to early (day 4) or late (day 7) first tracheostomy tube changes. RESULTS: Sixteen children were enrolled with 10 randomized to an early change. Median age was 5.9 months (interquartile range, 5.4-8.3), and 86.7% required tracheostomy for respiratory failure. All tracheostomy tube changes were performed without adverse events. There were no accidental decannulations. Significant wounds developed in 10% of children with early tracheostomy tube changes and 83.3% of children with late tracheostomy tube changes (odds ratio [OR], 45.0; 95% CI, 2.3-885.6; P = .01). This significant reduction in wound complications justified concluding trial enrollment. Hours of dexmedetomidine sedation (P = .11) and boluses of midazolam during the first 7 days (P = .08) were no different between groups. After the first change, 90% of the early group were discharged from intensive care within 5 weeks compared to 33.3% of patients in the late group (OR, 18.0; 95% CI, 1.2-260.9; P = .03). CONCLUSION: The first tracheostomy tube change in children can occur without adverse events on day 4, resulting in fewer significant peristomal wounds and earlier intensive care discharge.

Pediatric adenoidectomy in the very young child and indications for postoperative inpatient admission.

OBJECTIVES: To determine the rate of significant respiratory events following adenoidectomy in young patients and to identify factors that would prompt inpatient admission postoperatively. METHODS: A retrospective chart review was performed of consecutive adenoidectomy surgeries at a high-volume, tertiary-care children's hospital between 2016 and 2018. Children under 3.5 years of age who had surgery for obstructive symptoms were included. Patients were grouped by age (youngest ≤1.5 years, middle 1.6-2.5 years, and oldest 2.6-3.5 years). We excluded patients having revision surgery, a concomitant tonsillectomy, or additional major surgical procedure. RESULTS: There were 353 patients that met inclusion criteria. The three age groups were similar with respect to all characteristics except age (p < .001), body mass index (p < .001), and percentage of Black or African American children (p = .02). Patients under 1.5 years more often had preoperative polysomnography (p = .02) with a lower oxygen saturation nadir (p = .04), and were more likely to have surgery for obstructive sleep apnea (p < .001). No differences were found between age groups with respect to recovery room issues, nurse triage calls, or readmissions within 30 days of surgery. An elective admission rate in the cohort was 35.1%, and this was age-group dependent with 79.5% of the youngest group being admitted (p < .001). On admission, 16.9% of all patients had admission events requiring positive pressure support, intensive care unit admission, or prolonged hospitalization, which was similar across all age groups (p = .67). Events were more common in younger patients (17 mos. vs 20 mos., p = .07), those with more comorbidities (74.8% vs 51.5%, p = .06) and significantly higher in those with severe preoperative polysomnogram variables (p < .001). Based on multivariate regression analysis, younger children (OR: 13.7, 95% CI: 6.5 - 29.0, p < .001) or children with an AHI over 5 events/hr (OR: 32.3, 95% CI: 3.4 - 303.2, p = .005) were more likely to have significant events on admission. CONCLUSIONS: Significant respiratory events are uncommon after adenoidectomy for obstructive symptoms, even in very young children. However, for children under 1.5 years of age or those with AHI scores above 5 events/hr, postoperative admission for monitoring is recommended. Clinical judgement should be used when considering outpatient surgery for older children or those with comorbidities.