Methods
This was a single center retrospective study of patients with
tracheostomy who were followed at Riley Hospital for Children at Indiana
University Health from January 2012- December 2019. Eighty-two patients
were identified through review of internal tracheostomy and chronic
ventilator patient lists. Patients were included in the study if they
were tracheostomy dependent anytime between 2012-2019 and received
pulmonary outpatient care at Riley Hospital for Children. Patients were
excluded if they had a diagnosis of cystic fibrosis, primary ciliary
dyskinesia or malignancy, lived primarily at a long term care facility
or if they did not have any sick calls for respiratory illness.
For each patient, we reviewed all outpatient clinic visits, phone
messages recorded in the electronic medical record, emergency room (ER)
visits, and respiratory hospitalizations at Riley Hospital for Children
or other hospitals within the Indiana University Health system. We
gathered demographic data including sex, age and race. Tracheostomy
information including date of placement, date of initial hospital
discharge, date of ventilator liberation, and date of decannulation.
Respiratory cultures were collected via tracheal aspirate, blind
bronchoalveolar lavage (BAL) or bronchoscopic BAL were recorded. Blind
BAL samples are obtained by introducing a lavage catheter into the
artificial airway. The catheter is advanced into the distal airway until
gentle resistance is met. 0.5 mL/kg of 0.9% NaCl is then instilled
through the catheter and aspirated into the same syringe. Most of the
cultures were collected while the patient was admitted for illness.
Routine surveillance cultures are not part of the standard of care at
our institution.
Outpatient treatment of respiratory tract infections involved increasing
frequency and/or intensity of routine AWC measures. Such measures
included chest physiotherapy via manual percussion or high-frequency
chest wall compression vests, cough assist and nebulized inhalation of
albuterol and 3% sodium chloride. Treatment may also include enteral or
inhaled antibiotics in addition to increasing AWC, which are usually
selected based on patient symptoms and clinician judgement. We defined a
treatment episode as a recommendation to increase AWC and/or begin an
antibiotic in the outpatient setting (i.e. via phone or during a clinic
visit) for treatment of an LRTI. LRTI was physician defined and included
diagnoses of tracheitis, tracheobronchitis or pneumonia and/or symptoms
of cough, increased work of breathing, fever, or change in tracheostomy
secretions. Details of each treatment episode were recorded including
date of treatment, patient symptoms and whether increased AWC only or
antibiotics and increased AWC were recommended by the practitioner.
Additional treatment episodes within a 28 day period were not included
if the encounter resulted in the same intervention. Additional episodes
were included if the treatment method changed.