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.