E25
Outcomes of Tracheostomy Following Congenital Heart Surgery: A Contemporary Experience John P. Costello, MD,*† Dominic A. Emerson, MD,* Michael K. Shu, BS,* Syed M. Peer, MD,* David Zurakowski, PhD,‡ Brian K. Reilly, MD,§ Darren Klugman, MD,¶** Richard A. Jonas, MD,* and Dilip S. Nath, MD* Departments of §Otolaryngology, ¶Critical Care Medicine, **Cardiology, *Division of Cardiovascular Surgery, †The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, DC; and ‡Department of Anesthesia and Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Mass, USA ABSTRACT
Introduction. Following congenital heart surgery, pediatric patients may experience persistent respiratory failure that requires tracheostomy placement. Currently, definitive knowledge of the optimal timing for tracheostomy placement in this patient population is lacking. Methods. An 8-year retrospective review of 17 pediatric patients who underwent congenital heart surgery and subsequently required tracheostomy placement was performed. Patients were evaluated with regard to the timing of tracheostomy and mortality. Results. The overall study mortality was 24%. The median duration of intubation prior to tracheostomy was 60 days (interquartile range: 19–90 days); there was no difference in the average time between intubation and tracheostomy for survivors compared with nonsurvivors (51 vs. 73 days, P = .37). No difference was observed in the overall duration of positive pressure ventilation when tracheostomy was performed within 30 days of intubation compared with greater than 30 days following intubation (481 vs. 451 days, P = .88). Overall, 18% of patients were successfully weaned from the ventilator after a median duration of positive pressure ventilation of 212 days. Conclusion. The timing of tracheostomy placement may be an important factor in clinical outcomes for pediatric patients with persistent dependence on mechanical ventilatory support following congenital heart surgery. A larger, multi-institution study may help further elucidate our observed clinical findings in this patient population. Key Words. Tracheostomy; Congenital Heart Surgery; Mechanical Ventilation; Critical Care
Introduction
P
ediatric patients with congenital heart disease often require surgical intervention very early in life. Despite significant advances in surgical and critical care management over time, this population remains at high risk for respiratory failure following operative intervention. Persistent respiratory dysfunction resulting in the inability to wean from mechanical ventilation necessitates the creation of a tracheostomy in approximately 1.3– 2.7% of pediatric patients following congenital heart surgery (CHS).1,2 To date, the majority of published studies regarding the use of tracheostomy in this population have focused on risk factors and short-term outcomes. This study seeks to provide a contemporary experience on the use of tracheostomy following CHS with specific
© 2014 Wiley Periodicals, Inc.
regard to the timing of tracheostomy and its associated outcomes. Methods
An 8-year (January 2005 to December 2012) retrospective review of the medical records of all pediatric patients (less than 18 years of age) who underwent CHS at our institution was conducted. Patients who received a tracheostomy following CHS were identified and selected for further review. Inpatient and outpatient records were analyzed to obtain demographic and outcomes data. Patients were followed for at least 6 months (until July 2013) or up to the time of death. Patients were evaluated for total duration of positive pressure ventilation (PPV) and length of time of endotracheal intubation prior to tracheostomy. Congenit Heart Dis. 2015;10:E25–E29
E26 These parameters were evaluated using two distinct analyses as related to survival and operative mortality: (1) total duration of PPV for patients undergoing tracheostomy within 30 days of intubation vs. more than 30 days following intubation and (2) total number of days intubated prior to tracheostomy. Operative mortality was defined as patient death either prior to hospital discharge or within 30 days of the date of surgery according to the CHS Outcome Measures endorsed by The Society of Thoracic Surgeons.3,4 Statistical analysis was performed using IBM SPSS Statistics (version 21.0, IBM, Armonk, NY, USA). The Student t-test and Fisher’s exact test were utilized in comparing the study variables. Two-tailed values of P < .05 (95% confidence level) were considered statistically significant. This study was approved by the Institutional Review Board at Children’s National Health System.
Costello et al. Table 1.
Demographics and Patient Characteristics
Variable Male gender, number (%) Birth weight (kg) Gestational age (weeks) Prematurity Duration of hospitalization (days) STAT mortality category Type of repair Univentricular Biventricular Age at cardiac surgery (days) Age at tracheostomy (days) Genetic syndromes Time from tracheostomy to death (days) Duration of intubation (days) Duration of PPV (days) Total After tracheostomy† Ongoing*
Overall (n = 17) 11 (65%) 2.93 (1.74–3.45) 36.5 (351⁄7–38) 7 (41%) 146 (82–232) 3 (2–4) 4 (24%) 13 (76%) 73 (8–184) 205 (94–283) 4 (24%) 221 (63–379) 60 (19–90) 307 (161–553) 212 (112–216) 529 (280–718)
Continuous variables are median (interquartile range). *For patients who remained on PPV at the conclusion of follow-up. †For patients who were successfully weaned from PPV. PPV, positive pressure ventilation.
Results
A total of 17 patients underwent tracheostomy placement following CHS in the 8-year study period, during which there were 3295 CHS procedures performed (tracheostomy incidence: 0.5%, 17/3295). Of note, over the last 4 years, our center has been near the top nationally with regard to case mix index for cardiac surgery among Pediatric Health Information Service (PHIS) hospitals. The median age at the time of CHS was 73 days (interquartile range [IQR]: 8–184 days). The median duration of intubation was 60 days (IQR: 19–90 days). The median age at the time of tracheostomy placement was 205 days (IQR: 94–283 days). Two patients (12%) were not intubated prior to tracheostomy. The most common indication for tracheostomy within our cohort was prolonged PPV requirement due to persistent respiratory failure (n = 13), followed by tracheal stenosis (n = 2), excess secretions (n = 1), and bilateral vocal cord paralysis (n = 1). The overall median duration of hospitalization in this population was 146 days (IQR: 82–232 days). Three patients (18%) were successfully weaned from PPV; of these weaned patients, the median duration of PPV was 212 days (IQR: 112–216 days), and one of these three patients was successfully decannulated (Table 1). There was one operative mortality. Three other patients died during the follow-up period. Overall, four of 17 patients (24%) died. There was no correlation between the duration of PPV and the timing of tracheostomy placement. Congenit Heart Dis. 2015;10:E25–E29
Figure 1. Comparison of the duration of PPV with timing of tracheostomy. The two patients who were not intubated prior to tracheostomy were not included in this analysis.
In particular, comparing patients who underwent tracheostomy placement within 30 days of intubation with those who underwent placement 30 days or greater after intubation yielded no mean difference in duration of PPV between the two groups (481 ± 441 vs. 451 ± 325 days, P = .88) (Figure 1). When evaluating patient operative mortality with duration of intubation prior to tracheostomy, survivors were found to have a shorter average duration of intubation (51 days) compared with nonsurvivors (73 days), although this difference was not significant (P = .37) (Figure 2). All four patients who died were intubated for greater than 30 days prior to tracheostomy, whereas only 46% of
Outcomes of Tracheostomy Following CHS
Figure 2. Comparison of the duration of intubation before tracheostomy with patient outcome. The two patients who were not intubated prior to tracheostomy were not included in this analysis.
survivors were intubated for more than 30 days; however, this comparison did not reach a statistical significance (P = .10, Fisher’s exact test). The median length of time from tracheostomy placement to death in the four nonsurvivors was 221 days (IQR: 63–379 days). Discussion
The need for tracheostomy following CHS remains infrequent.1,2 Though uncommon, patients requiring tracheostomy have high rates of all-cause morbidity and mortality.1,5 In the present study, patients with longer duration of mechanical ventilation prior to tracheostomy placement appear to have increased mortality, although this finding did not achieve a statistical significance. Within the adult population, the subject of tracheostomy timing has been a topic of great debate. A large meta-analysis consisting of 1044 critically ill adult patients did not demonstrate any significant difference between patients undergoing early (0–8 days) or late (13–28 days) tracheostomy.6 However, other authors have demonstrated conflicting results.7 When specifically considering the adult cardiac surgery population, data suggest that early tracheostomy appears to be beneficial.8 In the CHS population, this debate has been similar but has been based on a smaller amount of reported data compared with the adult literature. The demographics, baseline characteristics, and physiology of our study population are certainly markedly different than these adult populations, but the underlying hypotheses for the benefit of
E27 early tracheostomy intervention are largely the same. It is believed that early tracheostomy leads to a decreased need for sedation, which in turn allows for a more rapid wean from ventilatory support and improved hemodynamics, as well as shorter intensive care unit stays and improved pulmonary toilet.8 While the present study was not powered to evaluate the effects of these factors on the outcomes of our CHS population, we believe they play an important role in the clinical course of CHS patients. Previous work by multiple authors has identified several preoperative risk factors that are related to the need for tracheostomy within the CHS population, including underlying chromosomal abnormalities (the most common risk factor present in 48% of patients requiring tracheostomy), prematurity, younger age, low birth weight (
Outcomes of Tracheostomy Following Congenital Heart Surgery: A Contemporary Experience John P. Costello, MD,*† Dominic A. Emerson, MD,* Michael K. Shu, BS,* Syed M. Peer, MD,* David Zurakowski, PhD,‡ Brian K. Reilly, MD,§ Darren Klugman, MD,¶** Richard A. Jonas, MD,* and Dilip S. Nath, MD* Departments of §Otolaryngology, ¶Critical Care Medicine, **Cardiology, *Division of Cardiovascular Surgery, †The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, DC; and ‡Department of Anesthesia and Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Mass, USA ABSTRACT
Introduction. Following congenital heart surgery, pediatric patients may experience persistent respiratory failure that requires tracheostomy placement. Currently, definitive knowledge of the optimal timing for tracheostomy placement in this patient population is lacking. Methods. An 8-year retrospective review of 17 pediatric patients who underwent congenital heart surgery and subsequently required tracheostomy placement was performed. Patients were evaluated with regard to the timing of tracheostomy and mortality. Results. The overall study mortality was 24%. The median duration of intubation prior to tracheostomy was 60 days (interquartile range: 19–90 days); there was no difference in the average time between intubation and tracheostomy for survivors compared with nonsurvivors (51 vs. 73 days, P = .37). No difference was observed in the overall duration of positive pressure ventilation when tracheostomy was performed within 30 days of intubation compared with greater than 30 days following intubation (481 vs. 451 days, P = .88). Overall, 18% of patients were successfully weaned from the ventilator after a median duration of positive pressure ventilation of 212 days. Conclusion. The timing of tracheostomy placement may be an important factor in clinical outcomes for pediatric patients with persistent dependence on mechanical ventilatory support following congenital heart surgery. A larger, multi-institution study may help further elucidate our observed clinical findings in this patient population. Key Words. Tracheostomy; Congenital Heart Surgery; Mechanical Ventilation; Critical Care
Introduction
P
ediatric patients with congenital heart disease often require surgical intervention very early in life. Despite significant advances in surgical and critical care management over time, this population remains at high risk for respiratory failure following operative intervention. Persistent respiratory dysfunction resulting in the inability to wean from mechanical ventilation necessitates the creation of a tracheostomy in approximately 1.3– 2.7% of pediatric patients following congenital heart surgery (CHS).1,2 To date, the majority of published studies regarding the use of tracheostomy in this population have focused on risk factors and short-term outcomes. This study seeks to provide a contemporary experience on the use of tracheostomy following CHS with specific
© 2014 Wiley Periodicals, Inc.
regard to the timing of tracheostomy and its associated outcomes. Methods
An 8-year (January 2005 to December 2012) retrospective review of the medical records of all pediatric patients (less than 18 years of age) who underwent CHS at our institution was conducted. Patients who received a tracheostomy following CHS were identified and selected for further review. Inpatient and outpatient records were analyzed to obtain demographic and outcomes data. Patients were followed for at least 6 months (until July 2013) or up to the time of death. Patients were evaluated for total duration of positive pressure ventilation (PPV) and length of time of endotracheal intubation prior to tracheostomy. Congenit Heart Dis. 2015;10:E25–E29
E26 These parameters were evaluated using two distinct analyses as related to survival and operative mortality: (1) total duration of PPV for patients undergoing tracheostomy within 30 days of intubation vs. more than 30 days following intubation and (2) total number of days intubated prior to tracheostomy. Operative mortality was defined as patient death either prior to hospital discharge or within 30 days of the date of surgery according to the CHS Outcome Measures endorsed by The Society of Thoracic Surgeons.3,4 Statistical analysis was performed using IBM SPSS Statistics (version 21.0, IBM, Armonk, NY, USA). The Student t-test and Fisher’s exact test were utilized in comparing the study variables. Two-tailed values of P < .05 (95% confidence level) were considered statistically significant. This study was approved by the Institutional Review Board at Children’s National Health System.
Costello et al. Table 1.
Demographics and Patient Characteristics
Variable Male gender, number (%) Birth weight (kg) Gestational age (weeks) Prematurity Duration of hospitalization (days) STAT mortality category Type of repair Univentricular Biventricular Age at cardiac surgery (days) Age at tracheostomy (days) Genetic syndromes Time from tracheostomy to death (days) Duration of intubation (days) Duration of PPV (days) Total After tracheostomy† Ongoing*
Overall (n = 17) 11 (65%) 2.93 (1.74–3.45) 36.5 (351⁄7–38) 7 (41%) 146 (82–232) 3 (2–4) 4 (24%) 13 (76%) 73 (8–184) 205 (94–283) 4 (24%) 221 (63–379) 60 (19–90) 307 (161–553) 212 (112–216) 529 (280–718)
Continuous variables are median (interquartile range). *For patients who remained on PPV at the conclusion of follow-up. †For patients who were successfully weaned from PPV. PPV, positive pressure ventilation.
Results
A total of 17 patients underwent tracheostomy placement following CHS in the 8-year study period, during which there were 3295 CHS procedures performed (tracheostomy incidence: 0.5%, 17/3295). Of note, over the last 4 years, our center has been near the top nationally with regard to case mix index for cardiac surgery among Pediatric Health Information Service (PHIS) hospitals. The median age at the time of CHS was 73 days (interquartile range [IQR]: 8–184 days). The median duration of intubation was 60 days (IQR: 19–90 days). The median age at the time of tracheostomy placement was 205 days (IQR: 94–283 days). Two patients (12%) were not intubated prior to tracheostomy. The most common indication for tracheostomy within our cohort was prolonged PPV requirement due to persistent respiratory failure (n = 13), followed by tracheal stenosis (n = 2), excess secretions (n = 1), and bilateral vocal cord paralysis (n = 1). The overall median duration of hospitalization in this population was 146 days (IQR: 82–232 days). Three patients (18%) were successfully weaned from PPV; of these weaned patients, the median duration of PPV was 212 days (IQR: 112–216 days), and one of these three patients was successfully decannulated (Table 1). There was one operative mortality. Three other patients died during the follow-up period. Overall, four of 17 patients (24%) died. There was no correlation between the duration of PPV and the timing of tracheostomy placement. Congenit Heart Dis. 2015;10:E25–E29
Figure 1. Comparison of the duration of PPV with timing of tracheostomy. The two patients who were not intubated prior to tracheostomy were not included in this analysis.
In particular, comparing patients who underwent tracheostomy placement within 30 days of intubation with those who underwent placement 30 days or greater after intubation yielded no mean difference in duration of PPV between the two groups (481 ± 441 vs. 451 ± 325 days, P = .88) (Figure 1). When evaluating patient operative mortality with duration of intubation prior to tracheostomy, survivors were found to have a shorter average duration of intubation (51 days) compared with nonsurvivors (73 days), although this difference was not significant (P = .37) (Figure 2). All four patients who died were intubated for greater than 30 days prior to tracheostomy, whereas only 46% of
Outcomes of Tracheostomy Following CHS
Figure 2. Comparison of the duration of intubation before tracheostomy with patient outcome. The two patients who were not intubated prior to tracheostomy were not included in this analysis.
survivors were intubated for more than 30 days; however, this comparison did not reach a statistical significance (P = .10, Fisher’s exact test). The median length of time from tracheostomy placement to death in the four nonsurvivors was 221 days (IQR: 63–379 days). Discussion
The need for tracheostomy following CHS remains infrequent.1,2 Though uncommon, patients requiring tracheostomy have high rates of all-cause morbidity and mortality.1,5 In the present study, patients with longer duration of mechanical ventilation prior to tracheostomy placement appear to have increased mortality, although this finding did not achieve a statistical significance. Within the adult population, the subject of tracheostomy timing has been a topic of great debate. A large meta-analysis consisting of 1044 critically ill adult patients did not demonstrate any significant difference between patients undergoing early (0–8 days) or late (13–28 days) tracheostomy.6 However, other authors have demonstrated conflicting results.7 When specifically considering the adult cardiac surgery population, data suggest that early tracheostomy appears to be beneficial.8 In the CHS population, this debate has been similar but has been based on a smaller amount of reported data compared with the adult literature. The demographics, baseline characteristics, and physiology of our study population are certainly markedly different than these adult populations, but the underlying hypotheses for the benefit of
E27 early tracheostomy intervention are largely the same. It is believed that early tracheostomy leads to a decreased need for sedation, which in turn allows for a more rapid wean from ventilatory support and improved hemodynamics, as well as shorter intensive care unit stays and improved pulmonary toilet.8 While the present study was not powered to evaluate the effects of these factors on the outcomes of our CHS population, we believe they play an important role in the clinical course of CHS patients. Previous work by multiple authors has identified several preoperative risk factors that are related to the need for tracheostomy within the CHS population, including underlying chromosomal abnormalities (the most common risk factor present in 48% of patients requiring tracheostomy), prematurity, younger age, low birth weight (
