Retrospective Study Reports Mean Age at Tracheostomy and Decannulation
Multidisciplinary Home Ventilator Program May Improve Survival, Growth and Time to Decannulation
Pediatric Tracheostomy Increasing
Pediatric tracheostomy is increasing, with 40% of tracheostomies performed in children <1 year of age.1 The significant increase in the rate of tracheostomy in infants is partly attributed to the increased survival of extremely preterm infants with severe BPD who require long-term ventilation for several years.2,3
Significant variation in practice has led to conflicting opinions on indications, feasibility and long-term prognosis of infants <1 year old undergoing tracheostomy.1,4 Decannulation time, mortality and neurodevelopmental outcomes vary significantly based on the indication for tracheostomy and underlying diagnosis.4
Home Ventilator Program Provides Unique Opportunity to Study Tracheostomy Population
The outcomes of infants with tracheostomy have not been well described in the literature. However, Children’s Mercy Kansas City developed the Infant Tracheostomy and Home Ventilator Program in 2005. This neonatology-led program, headed by Winston Manimtim, MD, Neonatologist and Medical Director, is the only program in the U.S. serving as a medical home for these patients in a multidisciplinary setting with other key subspecialists, including pulmonologists, gastroenterologists and otolaryngologists.
The program has collected the data necessary to systematically examine several key factors related to outcomes in this specific patient population, contributing important research to this field. Their most recent retrospective study on tracheostomy and decannulation included:
- 204 infants who met the inclusion criteria from 2005 through 2015 with tracheostomy at <1 year of age and follow-up in the Home Ventilator Clinic. No patients were excluded from the study.
- Primary indications for tracheostomy were abnormalities related to: upper airway (13.7%); lower airway (16.7%); combined airway and lungs (BPD) (40.2%); cardiac (7.3%); neurologic (6.9%); and others (15.2%).
- 93% of infants were G-tube dependent for their nutritional support at discharge; the proportion of infants who were able to feed orally (7%) had tracheostomy only and did not need assisted ventilation at discharge. No patients were discharged with nasogastric tube.
- Mean age at hospital discharge for all infants was 6.5 months and median age was 7 months.5
Highlights Document Age at Tracheostomy, Decannulation
The team’s goal was to describe the respiratory, growth and survival outcomes of these patients. Results were published in the high-impact medical journal Pediatric Research.
- The mean age at tracheostomy was 4.5 months with a median age of 3 months.
- Median age of decannulation was 32 months.
- The time from tracheostomy placement to complete discontinuation of mechanical ventilation was 15.4 months; and from tracheostomy to decannulation was 33.8 months.
- Mortality rate was 21% and median age of death was 18 months.
- Preterm infants with acquired airway and lung disease (BPD) and born at <28 weeks’ gestation had a significantly higher survival rate compared to term infants with various tracheostomy indications.
- The z-scores for weight and weight for length improved from the time of discharge (mean chronological age 6.5 months) to first year and remained consistent through 3 years of age.5
Findings Offer Guidance for Counseling and Care
With 204 infants in this cohort, it was one of the largest studies of its kind, a significant strength of this research. These infants had regular and consistent outpatient follow-up care from a dedicated team throughout the first 3-4 years of age, thanks to the Children’s Mercy Infant Tracheostomy and Home Ventilator Program. This large number allows for more extensive statistical modeling that can help guide families and care providers on important prognostic factors, outcomes and follow-up care plans throughout the first few critical years of life.5
Specific to the Children’s Mercy cohort, the team found through regression analysis that the premature infants had a much higher rate of survival compared to term infants with tracheostomy, as well as a higher rate of decannulation. The authors postulated that the improved overall survival outcomes in these very high-risk infants are the result of providing a dedicated multidisciplinary approach that ensures timely, regular and consistent delivery of both primary and subspecialty care, along with optimizing nutritional support to enhance pro-growth state, incorporating developmental surveillance in every clinic visit, and addressing caregivers’ psychosocial issues.
The team’s goal is that these insights will assist other clinicians as they provide families with counseling based on this data, helping them manage expectations for tracheostomy and home ventilator support, and aiding them in making better informed decisions on behalf of this vulnerable population.
Learn More About the Children's Mercy Infant Tracheostomy and Home Ventilator Program
Winston Manimtim, MD, Neonatologist; Medical Director, Infant Tracheostomy Care and Home Ventilator Program
Gangaram Akangire, MD, Neonatologist
For consults, admissions or transport call: 1 (800) GO MERCY / 1 (800) 466-3729.
Muller RG, Mamidala MP, Smith SH, Smith A, Sheyn A. Incidence, Epidemiology, and Outcomes of Pediatric Tracheostomy in the United States from 2000 to 2012. Otolaryngol. Head Neck Surg. 160, 332–338 (2019).
Overman AE, et al. Tracheostomy for Infants Requiring Prolonged Mechanical Ventilation: 10 Years’ Experience. Pediatrics 131, e1491–e1496 (2013).
Ehrenkranz RA, et al. Validation of the National Institutes of Health Consensus Definition of Bronchopulmonary Dysplasia. Pediatrics 116, 1353–1360 (2005).
Salley J, Kou YF, Shah GB, Mitchell RB, Johnson RF. Survival Analysis and Decannulation Outcomes of Infants with Tracheotomies. Laryngoscope 130, 2319–2324 (2020).
Akangire G, Taylor JB, McAnany S, Noel-MacDonnell J, Lachica C, Sampath V, Manimtim W. Respiratory, Growth, and Survival Outcomes of Infants with Tracheostomy and Ventilator Dependence. Pediatr Res. 2020 Oct. 3:1-9. doi:10.1038/s41390-020-01183-x. Online ahead of print.
Children’s Mercy Kansas City is ranked as one of “America's Best Children's Hospitals” in all 10 specialties rated by U.S. News & World Report and has received MagnetTM recognition for excellence in nursing services four consecutive times. With 366 licensed beds and a medical staff of more than 750 pediatric subspecialists, we care for children from all 50 states and from around the world. In addition, our leadership in pediatric genomic medicine and individualized pediatric therapeutics is driving research and innovation in neonatology, nephrology, endocrinology, gastroenterology, neurology, heart, cancer and other subspecialties to transform outcomes for children. Children’s Mercy also is nationally recognized for innovation in psychosocial care and creating a family-centered environment focused on the unique needs of hospitalized children and their families. Our love for children powers everything we do, inspiring our research, innovations and our everyday care. Because love has no limits. And with it, neither do we.