Introduction
An increasing number of critically ill children are surviving to
hospital discharge and tracheostomy placement has become more
widespread, often serving as a bridge from hospital to home. In addition
to tracheostomy, these children often have other comorbidities requiring
technology assistance including ventilators, gastrostomy tubes, vagal
nerve stimulators and cerebrospinal fluid shunts 1.
Despite the benefits of tracheostomy, rehospitalization is common, often
due to respiratory illness, major surgery, technology malfunction,
seizure or feeding difficulty 1. Hospitalizations for
children with tracheostomy account for over $2.6 billion each year2. In 2019, the readmission rate for children on home
mechanical ventilation was 2.16 hospitalizations per patient in the
first year following discharge and average readmission cost was $73,144
per patient 3. The length of stay was increased in
those with complex co-morbidities and in those who were younger at time
of admission 2,4. Respiratory diagnoses are still the
most frequent indications for admission 2, accounting
for more than 2000 admissions and $100 million in hospital costs in
2009 4.
Considering this high healthcare burden on families and resource
utilization, every effort is made to treat respiratory infections safely
at home. Even though there is a growing number of children with
tracheostomy, there is little published evidence regarding their chronic
care including identification and management of respiratory tract
infections 5. Since there are no guidelines for home
treatment of respiratory tract infections, choice of therapy varies by
institution and is practitioner driven.
The most common outpatient interventions include antibiotics (oral or
inhaled) and increasing frequency of airway clearance (AWC). In the
outpatient setting, it is often unclear if a patient would benefit from
antibiotics, and benefits must be weighed against risk associated with
antibiotics such as cost, drug-related side effects, and antibiotic
resistance. Due to the lack of natural upper airway humidification and
thicker secretions of patients with tracheostomy, providers may
recommend an increase in AWC therapies in an attempt to improve mucus
clearance and prevent or remedy infection.
Currently, there are no studies that evaluate the incidence of
hospitalization after outpatient treatment for lower respiratory tract
infections (LRTI) in children with tracheostomy. The objective of this
study was to identify whether there was a difference in risk of
hospitalization for LRTI within 28 days of treatment comparing
antibiotic prescription to increasing AWC alone. Our hypothesis was that
those treated with antibiotics were less likely to be hospitalized
following treatment.