Factors Impacting Physician Recommendation for Tracheostomy in Pediatric Prolonged Mechanical Ventilation: A National Cross-Sectional Survey.
CCCF ePoster library. Meyer-Macaulay C. Nov 8, 2018; 233426
Dr. Colin Meyer-Macaulay
Dr. Colin Meyer-Macaulay
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Abstract
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Introduction: Recently, a consensus definition for pediatric prolonged mechanical ventilation (PMV) has been proposed, including all children or infants >37 weeks gestational age (GA) ventilated invasively or non-invasively ≥ 3 wks1. Early tracheostomy has been shown to be associated with improved morbidity and mortality  in adults, however little is known about the attitudes of physicians towards tracheostomy for pediatric PMV2.



 



Objectives: Characterize the stated practice of qualified Canadian physicians (pediatric intensivists, neonatologists, respirologists and otolaryngologists to tracheostomy, specifically for pediatric PMV.



 



Methods: We designed a 2 part cross-sectional, web-based survey for REDCap according to established methodology3,4. Part 1 consisted of questions related to demographics while part 2 presented 3 case-based scenarios followed by a series of alterations in a single relevant clinical variable. Case 1 was a neonate with bronchopulmonary dysplasia now at 40 weeks gestational age. Cases 2 and 3 were previously healthy 1 and 10-year-olds with acute respiratory distress syndrome ventilated for 3 weeks. The Chi-square test was used to compare differences in likelihood of recommending tracheostomy at 3 weeks of MV between cases and by subspecialty. The McNemar’s test was used to evaluate whether altering specific clinical variables changed physician willingness to recommend tracheostomy, and its impact on preferred timing (≤ 3 weeks or > 3 weeks of MV).



 



Results: Overall response rate was 165/396 (42%). We received at least 1 response all 16 Canadian tertiary-care academic hospitals performing pediatric tracheostomy. Table 1 shows that 47/121 (38.8%), 23/93 (24.7%) and 40/87 (46.0%) of respondents would recommend tracheostomy at or before 3 weeks of MV for case 1, 2 and 3, at baseline respectively; the difference between case 2 and 3 was statistically significant (p < 0.001).



 



As shown in Figure 1 only two of 16 clinical variables - subglottic stenosis (OR 6.5 95% CI 1.47-59.33), and bilateral vocal paralysis (OR 5.33, 95% CI 1.53-28.56) - significantly increased the likelihood of ever recommending tracheostomy, in case 1, and none in cases 2 and 3. Far more variables were associated with a decreased likelihood of ever recommending tracheostomy for all 3 cases , the strongest of which was with life limiting condition (Case 1, OR 0.06, 95% CI 0.02-0.17, Case 2 OR 0.03 95% CI 0.0-0.1, Case 3 OR 0.05 95% CI 0.01-0.2). The association between variables and preferred timing  of tracheostomy can be seen in figure 2. Again in case 1 a strong association was found between recommendation for earlier tracheostomy and subglottic stenosis (OR 31 95% CI 5.7-1263.43) or bilateral vocal cord paralysis (OR 16, 95% CI 4.08-137.79).



 



Conclusion: A significant majority of physicians appear reluctant to recommend tracheostomy for children requiring PMV. Further,  there were only a small number of factors that increased the likelihood of recommending tracheostomy at ≤ 3 weeks of MV. The information obtained in this survey will help to inform a Canada-wide prospective cohort study to evaluate the effects of early tracheostomy on patient outcomes in paediatric PMV.


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