The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients.

OBJECTIVE: To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC). METHODS: An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative. RESULTS: In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality. DISCUSSION: We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative. IMPLICATION FOR PRACTICE: Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.

Surveillance endoscopy after tracheostomy placement in children: Findings and interventions.

OBJECTIVES/HYPOTHESIS: The Seattle Children's Hospital implemented the Trach Safe Initiative to improve airway safety in tracheostomy-dependent children (TDC). A key tenet of this initiative is surveillance endoscopy. The objectives of this study were to describe the prevalence of abnormal airway changes in TDC, identify risk factors for these changes, and describe the frequency of airway interventions. STUDY DESIGN: Retrospective case series. METHODS: This is a review of children 0 to 21 years old who underwent tracheostomy and surveillance endoscopy from February 1, 2014 to January 1, 2019. Descriptive statistics were used to report the prevalence of abnormal airway changes and interventions following tracheostomy. Pearson χ2 tests and logistic regression were used to identify risk factors for the development of abnormal changes. RESULTS: There were 127 children identified. The median time from tracheostomy to initial surveillance endoscopy was 1.6 months (interquartile range = 1.3-2.4 months). At initial endoscopy, 86.6% of patients had at least one abnormal airway finding. The most common findings were subglottic edema/stenosis (57.3%), glottic edema (37.3%), and suprastomal granulation tissue (31.8%). Prematurity and a history of failed extubations were significantly associated with abnormal findings on endoscopy (odds ratio [OR] = 7.2, P = .01 and OR = 4.1, P = .03, respectively). Of those with abnormal findings, 32.7% underwent an intervention to improve airway patency and safety. The most common interventions performed were suprastomal granuloma excision (44.4%), steroid injection (22.2%), and balloon dilation of the glottis or subglottis (19.4%). CONCLUSIONS: The prevalence of early abnormal airway changes in TDC is high, particularly in young children with a history of prematurity and failed extubation. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1327-1332, 2020.

Use of a lung model to assess mechanical in-exsufflator therapy in infants with tracheostomy.

BACKGROUND: The mechanical in-exsufflator (MIE) is commonly used to augment cough in patients with neuromuscular disease from infancy to adulthood. Little is known about the alveolar pressures, lung volumes, and expiratory flow rates generated by the MIE when used via tracheostomy tube in infants and children. METHODS: A high-fidelity mechanical lung model was programmed to simulate infants with tracheostomy tubes. Generated pressures, volumes, and expiratory flows using the MIE device at variable insufflation/exsufflation pressures and times were recorded. The primary measure of interest was maximal expiratory flow (MEF). RESULTS: Pressure equilibration across the tracheostomy tube did not occur with insufflation time <1 sec. Longer insufflation time significantly increased measured alveolar pressures, lung volume, and MEF until TLC was reached. Longer exsufflation time did not significantly increase MEF. Higher insufflation pressures resulted in greater lung volumes, with >70% vital capacity attained at insufflation pressures as low as 20 cmH2 O. Though higher insufflation pressures resulted in increased expiratory flow rates, more negative exsufflation pressure had a greater absolute impact on MEF. CONCLUSIONS: Using the MIE via tracheostomy tube in an infant lung model, we found that an insufflation time of >1 sec is required for equilibration of insufflation pressure and alveolar pressure. Longer exsufflation time does not significantly alter MEF. Higher insufflation and exsufflation pressures both increased MEF, but greater exsufflation pressure had more substantial impact.

Sleep-disordered breathing in children with thoracic insufficiency syndrome.

Thoracic insufficiency syndrome (TIS) is a collection of chest and spine malformations that results in progressively restrictive pulmonary mechanics and an inability of the thorax to adequately support lung growth. Many children with TIS are too young to perform standard pulmonary function tests, yet need functional assessments of their restrictive thoracic disease. We report on the sleep architecture and frequency of sleep-related breathing abnormalities in 11 children with TIS who underwent overnight polysomnography from retrospective chart review. Ten of 11 (92%) had sleep disordered breathing as defined by currently accepted criteria of apnea-hypopnea index (AHI) >2 events/hr. The median AHI was 4.3 events/hr, with obstructive hypopneas (median 3.7 events/hr) accounting for 75% of abnormalities. Respiratory events occurred most frequently during REM sleep (median REM-AHI 17.3 events/hr), and were associated with oxyhemoglobin desaturation, and rarely carbon dioxide retention. Sleep disordered breathing with hypoxemia appears to be a common but under recognized problem among children with TIS. Polysomnogram may have a role as a non-invasive screening tool used in conjunction with other functional respiratory assessments in children with TIS, and warrants further study in a prospective manner.

Prenatal bilateral extravaginal testicular torsion--a case presentation.

A newborn male presented at birth with findings consistent with bilateral testicular torsion. Preoperative ultrasound demonstrated no flow to either testicle, and he underwent surgery, during which bilateral extravaginal testicular torsion was confirmed. The right testicle was grossly necrotic and orchidectomy was performed, whereas the left testicle was indeterminate and underwent detorsion and orchidopexy. At 6-month follow-up, the left testicle remained within normal clinical limits with good flow on ultrasound examination.

Perinatal extravaginal torsion of the testis in the first month of life is a salvageable event.

OBJECTIVES: To determine the effectiveness of immediate surgical exploration in salvaging perinatal testicular torsion. METHODS: A retrospective analysis from 1995 to 2000 of boys younger than 30 days of age with surgically documented extravaginal testicular torsion was conducted. All cases were diagnosed after a normal testicular examination by a neonatologist, and all patients underwent urgent exploration to confirm the exact diagnosis and attempt testicular salvage by detorsion with bilateral orchiopexy. If a nonviable testis was determined intraoperatively, it was removed and contralateral orchiopexy was performed. Success was determined by physical examination at 6 months of follow-up. RESULTS: Ten patients with 10 affected testes were identified and a total of 4 (40%) were salvaged. All the studied testes were right-sided, and of the 4 salvaged testes, all were palpably normal and equal in size to their mate at the 6-month follow-up examination. Of the 6 removed testes, 1 was potentially viable by permanent pathologic section analysis despite preoperative ultrasonography demonstrating no flow and a negative intraoperative bleed test. CONCLUSIONS: Boys younger than 30 days old presenting with clinical findings suggestive of extravaginal testicular torsion who are expeditiously explored surgically may have a salvageable event in at least 40% to 50%. These statistics are similar to the salvage rates found with the similar management approach of intravaginal torsion.