PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019 PhiliPPine Journal of otolaryngology-head and neck Surgery 1716 PhiliPPine Journal of otolaryngology-head and neck Surgery ORIGINAL ARTICLES ABSTRACT Objective: To determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy. Methods: Design: Causal-Comparative (ex post facto) Chart Review Setting: Tertiary National University Hospital Participants: Records of 68 pediatric patients who underwent elective tracheostomy from January 1, 2013 to June 30, 2018 were considered for inclusion. Patients were excluded if invasive mechanical ventilation was not done for at least a day prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. Selected patients were categorized in the early tracheostomy group if the procedure was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. Early post- tracheostomy weaning from mechanical ventilation was defined as less than 7 days from time of tracheostomy. Results: A total of 21 patients were included, 6 in the early tracheostomy group and 15 in the late tracheostomy group. Although early tracheostomy did not show significant association with shortened post-tracheostomy duration of mechanical ventilation (O.R. 6; C.I. 0.276 to 130.322; p = .476), two-sample t-tests showed the early tracheostomy group had a significantly shorter mean duration of mechanical ventilation and hospitalization compared to the late tracheostomy group (13.17 vs. 54.13 days, p = .0012; 21.17 vs. 66.67 days, p = .0032). Conclusion: Although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support, there is a significant difference in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and this may suggest potential benefits of performing tracheostomy earlier in children. Keywords: tracheotomy; pediatric; mechanical ventilation; hospitalization Historically, the common indication for tracheostomy in children was for relief of acute inflammatory airway obstruction, but this changed with the use of vaccines and development Timing of Tracheostomy, Weaning from Mechanical Ventilation and Duration of Hospitalization among a Sample of Pediatric Patients Jose Brian A. Ferrolino, BS, MD1 José Florencio F. Lapeña Jr., MA, MD2 Ryner Jose D. Carrillo, MD, MSc1,3 1Department of Otorhinolaryngology Philippine General Hospital University of the Philippines Manila 2Department of Otorhinolaryngology College of Medicine – Philippine General Hospital University of the Philippines Manila 3Department of Anatomy College of Medicine University of the Philippines Manila Correspondence: Prof. Dr. José Florencio F. Lapeña, Jr. Department of Otorhinolaryngology Ward 10, Philippine General Hospital Taft Avenue, Ermita, Manila 1000 Philippines Phone: (632) 8554 8467 Telefax: (632) 8524 4455 Email: lapenajf@upm.edu.ph, jflapena@up.edu.ph The authors declared that this represents original material that is not being considered for publication or has not been published or accepted for publication elsewhere in full or in part, in print or electronic media; that the manuscript has been read and approved by all the authors, that the requirements for authorship have been met by each authors, and that each author believes that the manuscript represents honest work. Disclosures: The authors signed disclosures that there are no financial or other (including personal) relationships, intellectual passion, political or religious beliefs, and institutional affiliations that might lead to a conflict of interest. Philipp J Otolaryngol Head Neck Surg 2019; 34 (2): 16-19 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc. Creative Commons (CC BY-NC-ND 4.0) Attribution - NonCommercial - NoDerivatives 4.0 International PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019 PhiliPPine Journal of otolaryngology-head and neck Surgery 1716 PhiliPPine Journal of otolaryngology-head and neck Surgery ORIGINAL ARTICLES of modern neonatal intensive care units. These changes allowed increased survival of neonates and preterm babies with complex cardiopulmonary disease, shifting the main indication of tracheostomy to cases of prolonged intubation.1,2 For adults, it is generally recommended that patients who are on mechanical ventilation or expected to be on mechanical ventilation for > 2 weeks undergo tracheostomy.3 For pediatric patients, to the best of our knowledge, it seems there is currently no consensus as to when to perform tracheostomy4,5 although it is claimed that children can tolerate intubation for longer period than adults.6 A current institutional guideline7 recommends a safe period of 30 to 60 days intubation before considering elective tracheostomy in pediatric patients more than 1 year old. However, this prolongs hospital stay of patients, extends use of hospital resources, and increases expenses. This study aims to determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy. METHODS This causal-comparative chart review considered for inclusion records of all pediatric patients (age < 18) admitted in the Philippine General Hospital who were referred for tracheostomy to the Department of Otorhinolaryngology and underwent the surgical procedure between January 1, 2013 and June 30, 2018. The study was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2018-310-01). Informed consent was waived by the board. Data of tracheostomies performed on pediatric patients were reviewed from the departmental operating room (OR) census, then in-patient records were retrieved from the hospital records section and the following variables were obtained: age, sex, indication for tracheostomy, date of hospital admission, date of intubation, date of tracheostomy, date of weaning from mechanical ventilation and date of hospital discharge. Patients were excluded if they were not on mechanical ventilation for at least a day prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. Duration of mechanical ventilation was counted in days starting from the date of intubation up to the date of weaning. Duration of hospitalization was counted in days starting from the date of admission up to the date of hospital discharge. The patients were categorized in the early tracheostomy group if the tracheostomy was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. This definition was based on a previous study.8 Post-tracheostomy duration of mechanical ventilation was determined, with weaning from mechanical ventilation considered early if within < 7 days from the time of tracheostomy, and late if > 7 days from the time of tracheostomy. Tests for association between early tracheostomy and shortened post-tracheostomy duration of mechanical ventilation among patients 3 years old or younger, and those above 3 years old (based on pediatric airway development) was performed. The deidentified data were recorded by the principal investigator in MS Excel for Mac v.16.20 (2018, Microsoft Corp., Redmond, WA) and analyzed by a statistician using STATA Release 14 (2015, StataCorp LP, College Station, TX) software. Descriptive summary measures (mean, standard deviation, range) were used and inferential statistics included a two-sample T-test for two means to compare the average difference of patients in the two treatment arms that were considered as independent samples. A p-value of less than .05 was considered statistically significant. Odds ratios were computed to test for association between early tracheostomy and post-tracheostomy duration of mechanical ventilation. RESULTS Records of a total of 68 pediatric patients who underwent tracheostomy between January 1, 2013 and June 30, 2018 were considered for inclusion. Excluded were 47 patients: 34 who underwent emergency tracheostomy and 13 who had incomplete records. The records of 21 patients (13 male, 8 female) were finally included in the study. Age range was 2 months to 12 years old with a mean age of 5 years. There were 6 in the early tracheostomy group and 15 in the late tracheostomy group, with a M/F ratio of 4:2 and 9:6 in the early and late tracheostomy group respectively. The indication for tracheostomy in most (n=19) was prolonged intubation while a minority (n=2) were due to airway obstruction. The minimum time before tracheostomy was 2 days while the maximum time was 93 days. The average pre-tracheostomy MV duration was 10.33 days in the early tracheostomy group and 46.13 days in the late tracheostomy group. Table 1 presents the total duration of mechanical ventilation in the two tracheostomy groups. In the early tracheostomy group the mean duration of mechanical ventilation was 13.17 days while in the late tracheostomy group it was 54.13 days. There was a significant difference between the duration of mechanical ventilation in the early tracheostomy group compared to the late tracheostomy group (p = .0012) Table 2 presents the hospital duration in the two groups. The mean hospital duration in the early tracheostomy group was 21.17 days while in the late tracheostomy group it was 66.67 days. Comparing the two means showed a significant difference (p = .0032) PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019 PhiliPPine Journal of otolaryngology-head and neck Surgery 1918 PhiliPPine Journal of otolaryngology-head and neck Surgery ORIGINAL ARTICLES However, the associations between early tracheostomy and shortened post-tracheostomy duration of mechanical ventilation across the population [O.R. 6 (0.276 to 130.322); P = .476], for patients 3 years old and below [O.R. 2.4 (0.079 to 72.896); P = .798], and those above 3 years old [O.R. 3.6 (0.13 to 99.424); P = .928] were not statistically significant. (Tables 3, 4, 5) DISCUSSION Our study showed that there was a statistically significant difference in the total duration of mechanical ventilation and hospitalization among early versus late tracheostomy groups of tracheotomized pediatric patients in our institution. In adult patients, tracheostomy is usually performed within two weeks of mechanical ventilation3 with some recommending adult tracheostomy at < 10 days4,9 or even as early as 72 hours on mechanical ventilation.10 In contrast, there is still seems to be no definite criteria with regards the timing of tracheostomy in pediatric patients.4,5 A survey of 28 pediatric intensive care units in the UK showed variation in answers with regards to the duration of invasive ventilation before considering tracheostomy: four units suggested less than 14 days of mechanical ventilation while other units suggested > 14 days or > 28 days with some respondents even considering more than 90 days.11 Wakeham et al.12 reported a variation of pre-tracheostomy ventilation ranging from 4.3 days to 30.4 days. Further analysis revealed that an infectious or cardiac diagnosis and 2 or more reintubations are associated with longer time to tracheostomy. Our current institutional guidelines suggest 30 to 60 days before considering tracheostomy in patients more than one year old.7 In our current study, the range of pre-tracheostomy ventilation was 2 to 93 days. The cut-off of 14 days to delineate between early and late tracheostomy was extrapolated from adult studies cited by Holloway et al.8 In their study of 73 pediatric patients, they determined that the total hospital length of stay was 4 weeks shorter in the early tracheostomy group. A similar study of 111 pediatric patients by Lee et al.5 showed a significantly shorter duration of MV, and length of ICU and hospital stay in the early tracheostomy group. In this study, a cut-off of 14 days was also used to classify patients into early and late tracheostomy groups.4 Lin et al.1 also concluded that earlier tracheostomy can shorten total MV Table 1. Comparison of Early and Late Tracheostomy with Duration of Mechanical Ventilation N Mean (Day) Std. Err. Std. Dev. p-value95% Conf. Interval Early Late Diff 6 15 13.17 54.13 -40.97 1.89 7.24 11.69 4.62 28.05 .0012 8.32 - 18.02 38.60 - 69.67 -65.43 - -16.50 t = -3.50 Degrees of freedom = 19 Table 2. Comparison of Early and Late Tracheostomy with Hospital Duration N Mean (Day) Std. Err. Std. Dev. p-value95% Conf. Interval Early Late Diff 6 15 21.17 66.67 -45.5 4.40 8.24 13.50 10.78 31.92 .0032 9.86 - 32.48 48.99 - 84.34 -73.76 - -17.24 t = -3.37 Degrees of freedom = 19 Table 3. Early tracheostomy vs Early weaning from post-tracheostomy mechanical ventilation Weaning from MV after tracheostomy for < or = 7 days Weaning from MV after tracheostomy for > 7 days Tracheostomy after intubation for <14 days Tracheostomy after intubation for >= 14 days 6 10 0 (0.5) 5 Odds ratio: 6 (0.276 to 130.322) P value .476 Table 4. Early tracheostomy vs Early weaning from post-tracheostomy mechanical ventilation for pediatric patients less than or equal to 3 years old Weaning from MV after tracheostomy for 7 days Tracheostomy after intubation for <14 days Tracheostomy after intubation for >= 14 days 3 5 0 (0.5) 2 Odds ratio: 2.4 (0.079 to 72.896) P value .798 Table 5. Early tracheostomy vs Early weaning from post-tracheostomy mechanical ventilation for pediatric patients greater than 3 years old Weaning from MV after tracheostomy for 7 days Tracheostomy after intubation for <14 days Tracheostomy after intubation for >= 14 days 3 5 0 (0.5) 3 Odds ratio: 3.6 (0.13 to 99.424) P value: .928 PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 2 July – december 2019 PhiliPPine Journal of otolaryngology-head and neck Surgery 1918 PhiliPPine Journal of otolaryngology-head and neck Surgery ORIGINAL ARTICLES ACKNOWLEDGEMENTS We thank Angelica Anne E. Latorre, MPH, MSPH(candidate) of the University of the Philippines Manila - College of Public Health for her assistance with statistical analysis. REFERENCES 1. Lin CY, Ting TT, Hsiao TY, Hsu WC. Pediatric Tracheostomy: A comparison of outcomes and lengths of hospitalization between different indications. Int J Pediatr Otorhinolaryngol. 2017 Oct; 101: 75 – 80. PubMed PMID: 28964315 2. Ozmen S, Ozmen OA, Unal OF. Pediatric tracheostomies: A 37-year experience in 282 children. Int J Pediatr Otorhinolaryngol. 2009 Jul; 73(7): 959 – 961. PubMed PMID: 19395057 3. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective randomized study comparing early percutaneous dilational tracheostomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004 Dec; 32(12): 2566. PubMed PMID: 15286545. 4. Adly A, Youssef TA, El-Begermy MM, Younis HM. Timing of Tracheostomy in patients with prolonged endotracheal intubation: a systematic review. Eur Arch Otorhinolaryngol. 2017 Mar; 275(3): 679 - 690. PubMed PMID: 29255970. 5. Lee JH, Koo CH, Yee SY, Kim EH, Song IK, Kim HS, et al. Effect of early vs late tracheostomy on clinical outcomes in critically ill pediatric patients. Acta Anesthesiol Scand. 2016 Oct; 60(9): 1281 - 1288. PubMed PMID: 27377041. 6. Ertugrul I, Kesici S, Bayrakci B, Unal OF. Tracheostomy in Pediatric Intensive Care Unit: When and Where? Iran J Pediatr. 2016 Feb; 26(1): e2283. PubMed PMID: 26848369; PubMed Central PMCID: PMC4733285. 7. University of the Philippines; Philippine General Hospital, Department of Otorhinolaryngology. Clinical Practice Guidelines: Tracheostomy and Decannulation. Manila: University of the Philippines Department of Otorhinolaryngology; 2003.p53–60. 8. Holloway AJ, Spaeder MC, Basu S. Association of timing of tracheostomy on clinical outcomes in PICU patients. Pediatr Crit Care Med. 2015 Mar; 16(3): e52 - e58. PubMed PMID: 25581633. 9. Veenith T, Ganeshamoorthy S, Standley T, Carter J, Young P. Intensive Care Unit Tracheostomy: a snapshot of UK practice. Int Arch Med. 2008 Oct; 1(1):21. PubMed PMID: 18950520; PubMed Central PMCID: PMC2583967. 10. Durbin CG Jr, Perkins MP, Moores LK. Should tracheostomy be performed as early as 72 hours in patients requiring prolonged mechanical ventilation? Respir Care. 2010 Jan; 55(1):76 – 87. PubMed PMID: 20040126. 11. Wood D, McShane P, Davis P. Tracheostomy in children admitted to pediatric intensive care. Arch Dis Child. 2012 Oct;97(10): 866 - 869. PubMed PMID: 22814521. 12. Wakeham MK, Kuhn EM, Lee KJ, McCrory MC, Scanlon MC. Use of tracheostomy in the PICU among patients requiring prolonged mechanical ventilation. Intensive Care Med. 2014 Jun; 40(6):863 – 870. PubMed PMID: 24789618. and hospital duration although the study set their cut-off at < 30 days for early tracheostomy. There was no association between early tracheostomy and the post-tracheostomy duration of mechanical ventilation across the pediatric population in our study as shown in table 3-5. This suggests that overall duration of mechanical ventilation (pre-tracheostomy + post-tracheostomy) and hospital stay may be decreased by shortening the pre-tracheostomy period, i.e., performing an early tracheostomy. The possible relationship of early tracheostomy to early weaning is easy to posit. Bypassing the upper airway with a tracheostomy decreases the work of breathing, which may in turn aid a patient with neurological or muscular disease or one experiencing difficulty in weaning.6 Subsequently, earlier weaning can increase patient comfort, facilitate earlier ambulation and mobilization, improve tracheal toilette, oral feeding and rehabilitation and overall better quality of life for the patient5,6,11 while earlier hospital discharge can possibly reduce nosocomial infection.6 Our study has several limitations. First, the small sample size prevented determination of correlations between variables. Other possibly confounding or intervening variables were not accounted for, from which possible biases could arise. These include differences in underlying diseases and morbidities (such as concomitant neurological disease or cardiovascular disease) that may have influenced the timing of tracheostomy. Another limitation is the bias from selection inclusion (inherent to our study design), where measurement of pre- tracheostomy time contributes to the outcome measurement of overall mechanical ventilation and hospital time. A prospective multi-center study with a larger sample size is recommended to obtain better correlations. Such variables as early and long-term follow-up, early and late complications, concomitant diseases and decannulation rates that can better establish the optimum time for tracheostomy in individual pediatric patients, should be analyzed. In conclusion, our study found significant differences in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and may suggest these benefits of performing tracheostomy early in children, although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support.