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Background Tracheostomy procedures are used to establish a surgical airway in patients when non-invasive meth- ods fail to offer adequate support. In pediatric patients, this procedure is relatively rare, and data on patients is scarce, limiting the ability of physicians to contextualize patient outcomes and identify those most at risk. This can be crucial, as research has shown that early tracheostomy in pediatric patients may improve clinical outcomes. The objective of this study is to characterize the comorbidities of pediatric patients undergoing open and percutaneous trache- ostomies and examine their association with in-hospital mortality, as well as to compare patient demographics and comorbidity frequency between the two approaches. The 2016 Kids’ Inpatient Database was used to identify patients younger than 21 with ICD-CM-10 codes for open or percutaneous tracheostomies to determine demographic charac- teristics and identify the most frequent comorbidities in these patient cohorts. Results A weighted total of 5229 cases were analyzed. Congenital cardiopulmonary defects, newborn respiratory diseases, and traumatic lung or brain injury were the most common comorbidities for tracheostomy patients. In open tracheostomies, there was an increased likelihood of in-hospital mortality in patients aged less than one (OR = 2.2; 95% CI, 1.6–3.0) and in patients with atrial septal defects (OR = 1.9; 95% CI, 1.5–2.5), patent ductus arteriosus (OR = 2.5, 95% CI, 2.0–3.3), bronchopulmonary dysplasia (OR = 2.1; 95% CI, 1.6–2.8), and acute kidney injury (OR = 5.6, 95% CI, 4.3–7.2). Trauma-related comorbidities were more common in patients who underwent percutaneous procedures and were not associated with an increased likelihood of mortality. Patient age < 1 was associated with an increased risk of in-hospital mortality in both the open (OR = 2.2; 95% CI, 1.6–3.0) and percutaneous (OR = 2.3, 95% CI (1.3–3.9) approaches. Conclusion There are many indications for pediatric tracheostomy, and patients often present with complicated disease profiles and complicated courses of care. Broadly, we found that congenital cardiopulmonary defects were associated with a higher likelihood of in-hospital patient mortality, especially in younger patients undergoing an open-approach procedure. Patients undergoing a percutaneous-approach procedure were more likely to have trauma-related comorbidities such as pneumothorax or brain hemorrhage that were not associated with in-hospital mortality. Keywords Tracheostomy, Pediatrics, Socioeconomic status, Congenital birth defects, Pediatric surgery *Correspondence: Medical Center, BCD Building 5Th Floor, 830 Harrison Ave, Boston, MA Jessica R. Levi 02118, USA Jessica.firstname.lastname@example.org Boston University School of Medicine, 72 East Concord St, Boston, MA 02118, USA Department of Otolaryngology–Head and Neck Surgery, Boston © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Schemm et al. Annals of Pediatric Surgery (2023) 19:7 Page 2 of 7 younger than 21 years of age . The HCUP has many Background contributing partners . Boston Medical Center and Tracheostomy procedures are used to establish a surgi- Boston University Medical Campus Institutional Review cal airway in patients when non-invasive methods fail to Board did not require approval or exemption, as the KID offer adequate support . In pediatric patients, this pro - is a public database, and research with publicly avail- cedure is relatively rare . Tracheostomies occur in less able data does not meet the definition of human subject than 1.5% of ventilated children, compared with 10–24% research at our institution under 45 CFR 46. Data were of ventilated adults . The procedure is classically per - obtained from the most recent KID, which provides data formed using either an open approach (OT) or a percu- on nationwide inpatient discharges in 2016. taneous approach (PT) as described in Watters et al. . Patients with International Classification of Diseases, Due to its infrequency in pediatric care, data on patient 10th Revision, Procedure Coding System codes cor- profiles are scarce, which could limit the ability of phy - responding to OT and PT procedures were included in sicians to identify pediatric patients most at risk for our analysis. The International Classification of Diseases, tracheostomy, as well as comorbidities that may com- 10th Revision, Clinical Modification (ICD-10-CM) codes plicate hospital care or infer mortality risk. Pediatric for these procedures, as well as diagnoses of concurrent patients with tracheostomies have a threefold greater medical problems in these patients, were used to collect morbidity and mortality compared to adult patients . data . To demonstrate national estimates, we applied Research has shown that early tracheostomy in children discharge weights provided in the KID to each discharge on mechanical ventilation may improve medical out- data value. Stratifying variables used to produce dis- comes . Given the benefit of early tracheostomy and charge weights were geographic region, urban/rural loca- the level of care and preparation required for this proce- tion, teaching status, bed size, ownership, and children’s dure, identifying pediatric patients at risk is of high clini- hospital . Statistical analysis in this study was per- cal importance. formed using SPSS Statistics (v 26; IBM corp). Pediatric tracheostomy patients regularly present with After separating patients who had undergone OT or complicated disease profiles and prolonged hospitali - PT from the overall KID cohort, the most prevalent ICD- zations, often requiring long-term, complex care after 10-CM diagnosis codes among these patients were identi- discharge . Caregivers must be well-prepared and well- fied to examine the prevalence of different comorbidities. resourced for routine care of their child’s tracheostomy This was repeated in a separate cohort containing OT tube and identification of medical emergencies . How - and PT patients who died during their hospitalization. ever, in a survey of 220 tracheostomy caregivers, McCor- Odds ratios (ORs) and 95% confidence intervals (CIs) mick et al. found that only 48% felt “very prepared” to were used to determine associations between individual treat their patient at the time of discharge, 11% did not comorbidities and likelihood of patient death during receive emergency training, and 14% sought emergent hospitalization. care within one week of discharge . The financial, Binary logistic regression models were used to assess emotional, and physical burdens of post-tracheostomy if patient age or gender was associated with in-hospital childcare can be detrimental to caregivers, and a better mortality. ORs and CIs were used to describe associa- understanding of patient risk factors, comorbidities, and tions between these patient characteristics and clinical complications may help providers better support patient outcomes. The statistical significance of variables within families . the regression models was determined with a Wald chi- This study uses a national database to characterize square test (p < 0.05). the most common comorbidities within pediatric tra- cheostomy patients and explores their association with Results in-hospital mortality, as well as compare patient demo- Patient demographics graphics and common comorbidities between OT and There were 6,266,285 weighted pediatric hospitalizations PT patients. It also examines overall in-hospital mortal- in the 2016 KID. We identified 4004 OT procedures and ity rates for pediatric tracheostomy patients and explores 1225 PT procedures. Prevalence rates within the data- associations between age, gender, and mortality. base population for OT and PT were 2.56 and 0.78 per 100,000 patients, respectively. The mean and median ages Methods of patients undergoing OT and PT were 7.4 and 3.0 years Our study examined nationwide pediatric hospitaliza- and 11.7 and 16.0 years, respectively. tions in 2016 with the Kids’ Inpatient Database (KID), Forty-two percent of OT patients were under 1 year Healthcare Cost and Utilization Project (HCUP), Agency old, and 50.4% of 1-year-old patients were neonates, for Healthcare Research and Quality, which provides defined by the KID as patients admitted within 28 days national estimates of hospital inpatient stay for patients S chemm et al. Annals of Pediatric Surgery (2023) 19:7 Page 3 of 7 Fig. 1 Percentage share of procedure type by patient age, OT, and PT Table 1 Patient sex and percentage share of procedure cohort, Table 2 Multivariate OR analysis comparing patient age and sex OT and PT approaches with in-hospital mortality for OT and PT Open (n = 4004) Percutaneous (n = 1225) Open Percutaneous N, share of patient N, share of patient cohort (%) Variable OR (95% CI) P-value OR (95% CI) P-value cohort (%) Age Sex < 1 2.22 (1.63–3.02) .000 2.26 (1.32–3.85) .003 Male 2429 (60.7) 817 (66.9) Neonates 1.67 (1.23–2.23) .001 1.51 (0.74–3.09) .262 Female 1572 (39.3) 408 (33.1) 1–5 0.79 (0.47–1.31) .351 0.44 (0.13–1.51) .193 3 patients in this cohort did not have listed information on sex 6–10 0.68 (0.35–1.30) .242 0.51 (0.09–2.98) .452 11–15 1.07 (0.64–1.77) .804 0.85 (0.30–2.39) .759 a a 16–20 – – – – of birth (Fig. 1). Patients younger than one accounted for Sex 24% of those undergoing PT, and 58% of patients were a a Male – – – – between the ages of 15–20 (Fig. 1). Male patients made Female 0.79 (.472–1.31) .558 1.80 (1.11–2.92) .018 up the majority of our patient cohort, representing 60% Reference value of OT procedures and 66% of PT procedures (Table 1). Patient mortality CI = 1.07–2.81) also had an increased likelihood of in- Table 2 shows the relationship between in-hospital mor- hospital mortality (Table 2). tality and patient age and sex, using OR analysis. Three Additionally, we examined which comorbidities were hundred eleven (7.8%) patients undergoing OT died dur- most common among patients undergoing OT and PT ing their hospitalization. There was an increased likeli - procedures, as well as whether they were associated hood of in-hospital mortality in patients younger than with an increased or decreased likelihood of in-hospital 1 year old (OR = 2.22; 95% CI = 1.63–3.02). In the cohort mortality. These findings are shown in Tables 3 and 4, of patients younger than one, neonatal age was further respectively. associated with an increased likelihood of mortality com- pared to those older than 28 days of life (OR = 1.67; 95% CI = 1.23–2.26) (Table 2). Discussion Seventy-four PT patients (6.0%) died during their hos- Given the infrequency of tracheostomies in younger pitalization. Patients younger than 1 year old (OR = 2.26; patients, a large database was useful in examining 95% CI = 1.32–3.85) had an increased likelihood of in- demographic trends and comorbidities. To our knowl- hospital mortality. Female PT patients (OR = 1.739; 95% edge, no studies exist that so broadly examine patient Schemm et al. Annals of Pediatric Surgery (2023) 19:7 Page 4 of 7 Table 3 Prevalence of comorbidities in OT patients and their association with in-hospital mortality using OR analysis Diagnoses Share of patient Share of patients with OR (95% CI) cohort (%) in-hospital mortality (%) Atrial septal defect (Q21.1) 813 (20.30) 99 (31.83) 1.94 (1.51–2.51) Atelectasis (J98.11) 789 (19.71) 50 (16.08) 0.77 (0.56–1.05) Acute tracheitis without obstruction (J04.10) 707 (17.66) 43 (13.83) 0.73 (0.52–1.02) Bronchopulmonary dysplasia originating in the perinatal period (P27.1) 591 (14.76) 79 (25.40) 2.12 (1.61–2.77) Patent ductus arteriosus (Q25.0) 573 (14.31) 87 (27.97) 2.56 (1.97–3.34) Acute post-hemorrhagic anemia (D62) 524 (13.09) 31 (9.97) 0.71 (0.49–1.05) Respiratory failure of newborn (P28.5) 502 (12.54) 74 (23.79) 2.38 (1.80–3.15) Anemia of prematurity (P61.2) 472 (11.79) 53 (17.04) 1.60 (1.17–2.19) Acute kidney failure, unspecified (N17.9) 405 (10.11) 103 (33.12) 5.56 (4.27–7.24) Pleural effusion, not elsewhere classified (J90) 319 (7.97) 30 (9.65) 1.26 (0.84–1.87) Pulmonary hypertension, unspecified (I27.20) 319 (7.97) 46 (14.79) 3.09 (2.27–4.22) Respiratory distress syndrome of newborn (P22.0) 297 (7.42) 44 (14.15) 2.24 (1.59–3.19) Persistent fetal circulation (P29.3) 256 (6.39) 59 (18.97) 4.15 (3.02–5.71) Ventricular septal defect (Q21.0) 247 (6.17) 36 (11.58) 1.90 (1.31–2.76) Transient neonatal thrombocytopenia (P61.0) 226 (5.64) 33 (10.61) 2.15 (1.46–3.18) Traumatic pneumothorax, initial encounter (S27.0XXA) 186 (4.65) 1 (0.01) 0.06 (0.01–0.44) Congenital hypoplasia and dysplasia of the lung (Q33.6) 136 (3.40) 28 (9.00) 3.28 (2.13–5.06) Bloodstream infection due to a central venous catheter ( T80.211A) 105 (2.62) 31 (9.97) 5.29 (3.42–8.19) Corresponding ICD-10-CM code for listed diagnosis Table 4 Prevalence of comorbidities in PT patients and their association with in-hospital mortality using OR analysis Diagnoses Share of patient Share of patients with OR (95% CI) cohort (%) in-hospital mortality (%) Acute post-hemorrhagic anemia (D62) 308 (25.14) 14 (18.92) 0.68 (0.38–1.25) Atelectasis (J98.11) 228 (18.61) 13 (17.57) 0.92 (0.50–1.72) Pneumonitis due to inhalation of food and vomit (J69.0) 196 (16) 9 (12.16) 0.71 (0.35–1.46) Atrial septal defect (Q21.1) 146 (11.92) 19 (25.68) 2.79 (1.60–4.84) Traumatic pneumothorax, initial encounter (S27.0XXA) 130 (10.61) 4 (5.41) 0.46 (0.17–1.29) Glasgow coma scale score 3–8 (R40.243) 125 (10.2) 4 (5.41) 0.49 (0.17–1.36) Acute kidney failure, unspecified (N17.9) 122 (9.96) 11 (14.86) 1.63 (0.84–3.20) Other fracture of the base of the skull, initial encounter for closed fracture 121 (9.88) 4 (5.41) 0.50 (0.18–1.41) (S02.19XA) Acute tracheitis without obstruction (J04.10) 118 (9.63) 9 (12.16) 1.32 (0.64–2.73) Bilateral contusion of lung (S27.322A) 112 (9.14) 6 (8.11) 0.87 (0.37–2.05) Cerebral edema (G93.6) 111 (9.06) 13 (17.57) 2.29 (1.22–4.31) Subarachnoid hemorrhage w/loss of consciousness (S06.6X9A) 104 (8.49) 1 (1.35) 0.13 (0.02–1.01) Traumatic subdural hemorrhage w/loss of consciousness (S06.5X9A) 103 (8.41) 1 (1.35) 0.14 (0.02–1.02) Pleural effusion, not elsewhere classified (J90) 98 (8.00) 3 (4.05) 0.47 (0.15–1.52) Anoxic brain damage, not elsewhere classified (G93.1) 93 (7.59) 7 (9.46) 1.29 (0.57–2.90) Patent ductus arteriosus (Q25.0) 85 (6.94) 13 (17.57) 3.31 (1.73–6.31) Bronchopulmonary dysplasia originating in the perinatal period (P27.1) 78 (6.37) 11 (14.86) 2.88 (1.45–5.72) Unilateral contusion of the lung (S27.321A) 69 (5.63) 1 (1.35) 0.21 (0.03–1.59) Ventricular septal defect (Q21.0) 56 (4.57) 11 (14.86) 4.29 (2.11–8.69) Corresponding ICD-10-CM code for listed diagnosis S chemm et al. Annals of Pediatric Surgery (2023) 19:7 Page 5 of 7 comorbidities and their associations with in-hospital utilizing KIDs from 2000 to 2012 . Although tech- mortality for both OT and PT in pediatric patients, as nique has not changed much over the previous two well as compare patient demographics and comorbidities decades, there have been significant evolutions in indi - for these procedures. Our results show OT as the more cations, complications, and technological advances commonly chosen approach in younger patients, with PT , although this does not seem to have led to a sig- becoming more prevalent in ages 15–20. Though PT has nificant decline in in-hospital mortality. One possible gained substantial evidence in adult populations for its explanation is the increase in indications for trache- safety, efficacy, and cost-effectiveness compared to OT in ostomy in pediatric patients due to better survival of recent years [13, 14], comparative data between the two premature infants and those suffering from severe con - procedures is sparse in pediatric populations. genital anomalies, creating a patient cohort that may Historically, PT was not often utilized in airway man- have a higher baseline risk for mortality than the cohort agement of pediatric patients because the small, mobile of 20 years ago . Our analysis also found associa- characteristics of the trachea were thought to make this tions between patient age, gender, and procedure mor- approach dangerous . There has also been concern tality that have been noted in prior literature , with that bronchoscopic guidance during the procedure could the additional finding of neonatal age further increas - compromise ventilation . A 2019 retrospective study ing the likelihood of in-hospital mortality. Tables 2 comparing the two approaches in pediatric patients and 3 show congenital heart defects, acute respiratory showed PT to be a feasible approach in children, with pathologies, and traumatic lung or brain injury were endoscopic guidance recommended for the control of the most common comorbidities, with congenital car- intra-procedural complications. This same study showed diopulmonary defects having the greatest association no differences in intra-operative complications between with in-hospital mortality. OT and PT, with long-term complications being more Previous literature has noted increased mortality in common in OT patients, indicating PT can be a suitable tracheostomy patients with congenital heart disease option in the airway management of some children . but has not examined mortality rates for each specific However, data on the safety and efficacy of PT in patients defect . Although ventricular septal defects are the aged 0–5 years old is sparse, and studies with longer most common congenital heart defect in the general follow-ups and higher patient counts may be needed to pediatric population , we identified atrial septal determine the lowest age for its safe performance . defect as the most prevalent within pediatric tracheos- PT patients were of a higher median age than OT, tomy patients. A 2018 study showed that patients with largely due to the increased prevalence of PT in patients atrial septal defects were also more likely to have bron- aged 15–20. One possible explanation for this finding is chopulmonary dysplasia, a comorbidity also found to the increased risk of trauma-related injury within this be associated with in-hospital mortality . We found age cohort, particularly in male patients . Table 3 bronchopulmonary dysplasia and atrial septal defects shows brain hemorrhages, skull fractures, and coma were were both twice as likely to be found in the younger relatively common comorbidities in PT patients, with a cohort of OT patients, indicating that neonate patients prevalence of 8–10% depending on the diagnosis code with combined cardiac and pulmonary defects may be examined. Acute post-hemorrhagic anemia, potentially at the highest risk for in-hospital mortality following a sign of rapid blood loss, occurred in approximately tracheostomy procedures. 25% of PT patients. Research in the adult population Acute kidney injury (AKI) was also associated with has shown PT to be a successful intervention in patients a higher likelihood of in-hospital mortality. We found with brain  and spinal cord injury . Additionally, a no prior study examining the connection between 2013 study on critically injured trauma patients found PT AKI and mortality among tracheostomy patients. In a to have a lower risk of surgical site infection when com- study conducted by Youseff et al., predisposing factors pared to OT . Currently, no evidence or guidelines to AKI included mechanical ventilation, particularly broadly favors one surgical approach versus the other, so in newborn populations whose comorbidities include our findings align with current literature showing pro - respiratory distress syndrome . A separate study cedure choice is often the result of surgeon preference examining pediatric patients with postoperative AKI . They were analyzed separately to define prevalence, found these patients had an increased rate of tracheos- demographics, and comorbidities more precisely in each tomy and a longer duration of postoperative ventilation approach, given the lack of current studies comparing the . It follows that tracheostomy patients who develop techniques in pediatric patients. AKI during their hospitalization may represent those Our analysis revealed in-hospital mortality rates with more severe respiratory distress, increasing mor- that are consistent with previous values from studies tality risk. Schemm et al. Annals of Pediatric Surgery (2023) 19:7 Page 6 of 7 Follow-up Conclusions When compared to other research examining demo- Our analysis showed that comorbidities for pediatric graphic trends and comorbidities within pediatric tracheostomy patients are commonly related to con- tracheostomies, our large sample size increases the genital cardiopulmonary defects and traumatic injury. external validity and generalizability of our findings. Broadly, we found that congenital cardiopulmonary To our knowledge, our study is the first to use an inpa - defects were associated with a higher likelihood of in- tient database to broadly examine the prevalence of hospital patient mortality. Our analysis also shows specific comorbidities among pediatric tracheostomy younger, male patients may also be at higher risk for patients and determine their association with in-hospi- post-procedural mortality. While trauma-related inju- tal mortality. These findings may assist clinicians with ries are more common in patients undergoing percu- risk stratification in a complicated patient population taneous tracheostomy, they are not associated with and inform clinical assessments of patient prognosis increased in-hospital mortality. Qualitative research based on which comorbidities are present. Although investigating post-procedural complications and car- indications for pediatric tracheostomy have increased egiver experience with at-home tracheostomy care may in recent decades , procedure risk remains high provide additional context for these findings and offer both intra- and postoperatively. Continued research further information to guide inpatient care for this to explore safety improvement strategies decrease in- complex patient population. Studies utilizing individual hospital mortality and post-procedural complications case reports instead of a large patient database, with the would prove beneficial, as there exists high variability ability to examine the full course of patient care, may in tracheostomy care protocols in the literature . provide clearer answers as to how these comorbidities Establishment of a standardized post-procedural care impact the recovery of respiratory function in pediatric protocol and exploring the barriers caregivers may patients. face in caring for tracheostomy tubes at home may help decrease or provide context to post-operative Abbreviations complications. CI Confidence interval OR Odds ratio OT Open tracheostomy PT Percutaneous tracheostomy Study limitations KID Kids’ Inpatient Database While we were able to find associations between patient HCUP Healthcare Cost and Utilization Project ICD-10-CM I nternational Classification of Diseases, 10th Revision, Clinical demographics, comorbidities, and in-hospital mortality, Modification the ultimate cause of patient death is not available within AKI Acute kidney injury the KID, which limits our ability to investigate direct Acknowledgements connections between these data elements and patient Not applicable. mortality. Furthermore, while comparing outcomes based on pro- Authors’ contributions JS developed the study hypothesis and design and had a primary role in the cedure approach would be a reasonable goal of this study, study organization, statistical analysis, manuscript drafting, and interpreta- selection bias regarding the decision to perform OT or tion of data. DOD had significant input on the study design and substantial PT limits the veracity of any possible conclusions, as cur- assistance in the organization and statistical analysis of data and manuscript editing. DH contributed substantial assistance in the organization and inter- rent literature shows that procedure choice is often based pretation of data, as well as the writing of the manuscript. ER had substantial on provider preference . Additionally, detailed infor- contributions to the organization and interpretation of data, review of litera- mation on the course of care is not available within the ture, and editing of the manuscript. KD contributed substantial assistance to the organization and writing of the manuscript, as well as review of literature. KID, limiting us from directly linking patient comorbidi- SF had substantial contributions to the organization of data, manuscript edit- ties to the chosen approach. ing, and literature review. JL helped develop the study hypothesis and design, The limitations of the KID also prevent us from identi - had a major role in data presentation and interpretation, and contributed significantly to manuscript writing and editing. All authors read and approved fying the precise indication for any procedure, as well as the final manuscript, agreeing to be accountable for all aspects of the work. the severity of the patient’s condition. Categorizing out- comes by indication, rather than the comorbidities listed Funding No sources of funding to report. for each patient, would allow us to align preoperative condition more precisely with postoperative outcomes. It Availability of data and materials would also allow us to more precisely examine variations The datasets generated and/or analyzed during the current study are available in the Kids’ Inpatient Database repository, 2016 edition, available publicly at in outcomes within certain comorbidities, such as exam- https:// www. hcup- us. ahrq. gov/ kidov erview. jsp. ining whether the severity of a congenital heart defect was associated with greater in-hospital mortality. S chemm et al. Annals of Pediatric Surgery (2023) 19:7 Page 7 of 7 17. Sleet DA, Ballesteros MF, Borse NN. A review of unintentional injuries in Declarations adolescents. Annu Rev Public Health. 2010;31(1):195–212. https:// doi. org/ 10. 1146/ annur ev. publh ealth. 012809. 103616. Ethics approval and consent to participate 18. Kuechler JN, Abusamha A, Ziemann S, Tronnier VM, Gliemroth J. 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Annals of Pediatric Surgery – Springer Journals
Published: Feb 1, 2023
Keywords: Tracheostomy; Pediatrics; Socioeconomic status; Congenital birth defects; Pediatric surgery
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