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.