Pediatric Tracheostomy Research Articles

Children with a tracheostomy: Global speech-language therapists' practice.

Speech-language Therapists (SLTs) are specialists in communication, feeding and swallowing as core members of the paediatric tracheostomy multidisciplinary team (MDT). Inconsistent tracheostomy care leads to staff and family frustration and delayed intervention. Little is known about international SLT tracheostomy practices. This global survey explored training, clinical practices, perceived knowledge, skills and roles, and barriers for SLTs working with paediatric tracheostomy. Survey questions consisted of Likert scale and open-ended questions. 92 SLTs completed the survey representing 6 continents and 19 countries. Overall SLTs were confident in their knowledge of communication, and feeding but less confident in weaning, tracheostomy care skills (such as suctioning and cuff deflation) and specialist tracheostomy tube use (such as tracheostomy tubes with a subglottic suction port). Formal competency training was infrequent but most had access to supervision. Understanding of the SLT role by the MDT was perceived as good. Many felt managing one-way speaking valves was part of their role. The majority reported staffing, lack of guidelines and access to resources (one-way speaking valves and flexible endoscopic evaluation of swallowing) as barriers. This expert opinion paper summarises the current evidence-base and international paediatric tracheostomy practice. SLTs were experienced and confident in tracheostomy. The SLT role varies internationally with a lack of formal written policy to guide practice and a variability in access to education.

720 Pediatric tracheostomy workshop for residents

720 Pediatric tracheostomy workshop for residents

Use of virtual reality to remotely train healthcare professionals in paediatric emergency tracheostomy skills: protocol for a multi-centre, non-inferiority educational interventional study with historical controls

BackgroundThe insertion of a tracheostomy is an established technique used to wean patients off ventilatory support, manage secretions in complex conditions, and as a potentially life-saving procedure to bypass upper airway obstruction. Life-threatening complications during aftercare are not uncommon and may be influenced by a lack of education of carers or healthcare providers of children and young people living with a tracheostomy. Education programmes designed and supported by the National Tracheostomy Safety Project are effective, but resources are not available to educate the workforce at scale. With the overarching aim of widening access to paediatric tracheostomy skills training, we present the protocol for the development and evaluation of a novel virtual reality (VR) training tool designed to simulate the emergency management of paediatric tracheostomy complications.Methods and discussionA multi-centre, non-inferiority educational interventional study with historical controls will be used to evaluate the novel VR training package. A group of 69 healthcare staff and students will have one week to use the educational intervention as often as necessary to learn paediatric emergency tracheostomy skills. The primary outcome measure is skill performance in simulation in a pre- and post-intervention structure within subjects. Participant performance will also be assessed using non-inferiority metrics against historical traditional educational control data. Secondary outcomes include knowledge gain, knowledge retention, usability, side effects, and participant satisfaction. To minimise the risk of cybersickness, teleportation was the preferred locomotion method for the user navigation within the VR environment.Trial registrationFull registration of this study was completed at ClinicalTrials.gov. The registration number is NCT06350708 and was accepted on the 4th April 2024.

Indications and Outcomes for Tracheostomies in Pediatric Oncology Patients-A Single Center Study.

Children with cancer face a high risk of complications including prolonged mechanical ventilation requiring tracheostomies. While tracheostomies have been demonstrated to be a generally safe procedure, there remain significant rare complications and a paucity of literature addressing outcomes specifically for pediatric patients with cancer. The objective of this study was to characterize pediatric patients with cancer who underwent tracheostomies and describe their indications and outcomes for length of stay, decannulation, and complications. At a single large volume children's hospital, retrospective medical record analysis was performed in all pediatric patients with cancer who received tracheostomies from 2004 to 2023. Sixty-five patients were identified with a median follow-up time of 763 days (interquartile range 302-1687). Twenty-one (32%) patients had a tracheostomy placed due to complications from mass effect of the tumor, 16 (25%) due to complications from cancer treatment, and 14 (22%) had a tracheostomy placed for nononcologic reasons. Additionally, a distinct subgroup of 14 (22%) patients underwent tracheostomy perioperatively for elective airway management during surgical resection of their tumors. Twenty-nine (45%) were decannulated and 17 (26%) patients had a tracheostomy-associated complication, including tracheitis and tracheocutaneous fistula, and no patients had a tracheostomy-associated mortality. The incidence of tracheostomy-associated complications and decannulation rates in pediatric patients with cancer was comparable with the general pediatric tracheostomy population. This study establishes a reference point for clinicians regarding the anticipated outcomes among pediatric patients with cancer requiring or having undergone a tracheostomy.

Accidental tracheostomy decannulation: Risk factors and complications in pediatric patients using the NSQIP-P database

BackgroundAccidental tracheostomy decannulation (ATD) is a life-threatening event in pediatric patients. The factors associated with ATD in children are largely unknown. Utilizing the National Surgical Quality Improvement Pediatric (NSQIP-P) dataset, we sought to identify the incidence of ATD and associated factors. MethodsPatients who underwent surgery at continuously enrolled American College of Surgeons NSQIP-P hospitals from January 1, 2012, to December 31, 2021, were included. Those who underwent a tracheostomy (CPT 31600 or 31601) as a primary or concurrent procedure were analyzed. ATD was defined by the NSQIP-P REINTUB variable. Multivariable logistic regression analysis and propensity score matching were performed to identify independent associations between demographic variables, relevant comorbidities, intraoperative factors, and ATD. Multivariable regression analyses were performed to identify any association between ATD and unplanned reoperation, pneumonia, extended length of stay, and death in 30 days in both pre-matched and matched cohorts. ResultsA total of 5229 patients undergoing tracheostomy were included in the final analysis for the pre-matched cohort. ATD occurred in 93 (1.8 %) patients, with 42 % (n = 39) of these cases occurring within the first two postoperative days. In the matched cohort, female gender (P = 0.002) and structural pulmonary/airway abnormality (P = 0.016) were independently associated with ATD. Additionally, ATD was associated with unplanned reoperation (P < 0.001) and pneumonia (P = 0.024). The pre-matched cohort showed consistent results with the matched cohort. DiscussionAccidental decannulation is a serious complication following pediatric tracheostomy. By identifying patients at higher risk for ATD and the timing of its occurrence, providers can employ measures targeting these patients during their highest risk period. The sequelae associated with ATD further emphasize the importance of preventing this complication.

Technological lifelines: the everyday lived complexities of dependence and care of pediatric long-term tracheostomy

Purpose As the group of technology-dependent children with long-term tracheostomy continues to expand, we aimed to explore parents’ lived experience of everyday life with a child dependent on long-term tracheostomy. Materials and methods Six parents of four children were interviewed and the transcripts analyzed using Giorgi’s descriptive phenomenology. Results All aspects of everyday life, parent-child interaction, and interaction with the surrounding outside world were affected by technology dependency. Parents played an active role by acting both as a protective shield between the outside world and the child and as an enabling bridge to help the child interact with the outside world. The active and involved role of parents is interwoven in all aspects, levels, and directions of interaction and everyday life. The lived experiences can be described in four themes: caution and risk awareness due to technology, meeting the demands of technology dependence, strained and constrained by technology dependence, and conflicted feelings about technology dependence. Conclusions Long-term tracheostomy and technology-dependency affect and shape everyday life. Practical implications from the study suggest that re-design and co-design between all stakeholders involved are needed to support parental well-being, coping and enhance patient safety for this growing population and their parents.

Factors associated with early mortality in pediatric tracheostomy placement: a retrospective cohort study.

Numerous factors are associated with an increased likelihood of early mortality following tracheostomy placement. These findings are particularly relevant for planning the timing for tracheostomy among critically ill children and engaging in discussions with caregivers about the heightened risks for mortality and complications of the procedure. • The prevalence of tracheostomies in children has risen significantly due to major advancements in neonatal and pediatric intensive care treatments. • Nonetheless, the mortality rate among children undergoing tracheostomy remains elevated, with approximately one-third of them experiencing mortality during the same hospital admission in which their tracheostomy is carried out. • We hypothesize that certain risk factors may discourage tracheostomy placement, potentially advocating for a more conservative management in carefully selected cases of critically ill children. • In children who underwent tracheostomy placement, the 30-day mortality rate was 10.9%, and the complication rate was 26%. • Prematurity, age < 12 months, American Society of Anesthesiologists class 4, congenital heart disease, heart failure, and ventilatory dependency were associated with a higher likelihood of mortality. These children also exhibited higher rates of postoperative complications. • These findings are particularly relevant for planning the timing for tracheostomy among critically ill children and engaging in discussions with caregivers about the heightened risks for mortality and complications of the procedure.

Significance of Functional Status Scale in decannulation after pediatric tracheostomy: A single-center, retrospective study

Abstract Background: Metrics to successfully predict pediatric decannulation have been ineffective. The Functional Status Scale (FSS) is a validated pediatric scoring system of functional outcomes. The objective of this study was to evaluate if the FSS over time predicts pediatric tracheostomy decannulation. Subjects and Methods: Chart review of patients admitted to the pediatric intensive care unit (PICU) and underwent tracheostomy at a tertiary care children’s hospital from 2010 to 2019. Baseline demographics, comorbidities, tracheostomy indication, decannulation status, and FSS scores were recorded at PICU discharge and 1 and 3 years after tracheostomy. Logistic regression was performed to assess the association of FSS components with decannulation status at 3 years. Results: Fifty-three patients met the inclusion criteria. Forty (75.5%) patients had complete data. There were no decannulations at 1 year. Nine (22.5%) patients were decannulated at 3 years. An abnormal 3-year FSS score in the feeding domain was significantly associated with persistent tracheostomy at 3 years, with an odds ratio of 7.4 (95% confidence interval: 1.5–36.6, P = 0.01). Conclusions: FSS score can predict decannulation in children discharged from the PICU. This information could modify caregiver expectations and guide rehabilitative efforts.

Features Associated With the Presence of Specific Bacterial Strains in Pediatric Tracheostomy.

Tracheostomy bypasses physical barriers that decrease microbial access to the lower airway, which can lead to changes to the lung microbiota. Patients often become chronically colonized with potential pathogens. This study described the incidence and prevalence of specific organisms in a 5-y cohort of children with tracheostomy. This retrospective cohort of children aged 0-18 y with tracheostomy identified associations between microbial species and subject characteristics including reason for tracheostomy, gastrostomy tube (G-tube), fundoplication, and ventilator use using chi-square test or Fisher exact test. Of 113 eligible patients, 79 (57% male) met study inclusion criteria. Reasons for tracheostomy included airway obstruction secondary to craniofacial anomalies in 16 children (20%), upper-airway obstruction in 14 subjects (17.3%), neuromuscular disorder in 19 subjects (24%), bronchopulmonary dysplasia with or without pulmonary hypertension in 17 subjects (21%), and congenital heart disease in 13 subjects (16%). Most (69%) used a ventilator for at least 6 h/d; 63% had a G-tube; 41% also had a Nissen fundoplication. Of the 20% with upper-airway obstruction, one third were ventilator dependent, unlike other diagnoses where 57% used a ventilator. Staphylococcus aureus (52/113), Pseudomonas aeruginosa (43/113), and Stenotrophomonas species (39/113) were the most frequently identified bacterial species. Most microbes identified were not associated with subjects underlying diagnoses, ventilator use, or feeding type. However, there was a significant association between upper-airway obstruction and group B Streptococcus species and G-tube with P. aeruginosa. This retrospective single-site descriptive cohort analysis of pediatric subjects with long-term tracheostomy identified trends in microbial prevalence. The presence of specific bacterial strains was more likely to follow individual subject trajectories than sequential appearance of species. P. aeruginosa was associated with G-tube and Streptococcus species with upper-airway obstruction. Ventilator dependence was not associated with specific microbial profiles.

Pediatric Tracheostomy Education Program Structures, Barriers, and Support: A Nationwide Survey of Children's Hospitals.

Safe discharge for children with tracheostomies requires caregivers to be competent in tracheostomy management, including emergency interventions. Inpatient pediatric units are tasked with preparing families for discharge, yet variations exist in the standards of tracheostomy education across institutions. To address this gap, we aimed to describe the inpatient tracheostomy education programs in children's hospitals across the United States. This is a cross-sectional study conducted between May and July 2022. We distributed an online survey to a purposeful sample of representatives from participating children's hospitals. The 42-item survey evaluated various aspects of tracheostomy education, including teaching strategies, timing of education, operational support, and overall program structure. Descriptive statistics were generated, and researchers reviewed open-ended items to identify themes. Thirty-seven institutions participated, 26 of which were free-standing children's hospitals. All programs surveyed conducted bedside checkoffs, required a rooming-in period, and provided tracheostomy cardiopulmonary resuscitation and low-fidelity simulation for emergency teaching. Programs varied in the order of education and the type of support received. Many programs lacked a postdischarge follow-up structure and the majority evaluated program effectiveness with readmission rates. Lack of private-duty nursing was the primary barrier to discharge, followed by family availability and reluctance to participate in education. The program structure and support variations suggest that more investigation is needed in discharge education and postdischarge follow-up for children with tracheostomies. A national guideline for tracheostomy education and identification of standardized quality metrics for program evaluation would benefit current and emerging programs.

The impact of maturation sutures on false passage formation in pediatric tracheostomy

IntroductionFalse passage (FP) after tracheostomy is an infrequent but potentially life-threatening complication. The practice of tracheal stomal maturation at the time of tracheostomy is variable amongst surgeons in pediatric patients, and it remains unknown whether or not maturation sutures decrease the risk of FP. Our objective was to evaluate the impact of maturation sutures on the incidence of FP after pediatric tracheostomy. Materials and methodsA retrospective review of children who underwent tracheostomy (2001–2024) was performed. Records were reviewed for demographics and procedural details including use of maturation sutures. Outcomes included incidence of FP, time to FP and associated complications resulting from FP. ResultsOne-hundred and twenty-five children met study criteria [median (IQR) age 0.5 (0.2–3.2) years]. Fifty-five children (44.0 %) received maturation sutures, with 31 (56.4 %) of these being four-point sutures, 10 (18.2 %) being two-point sutures (70 % of which were placed inferiorly), and 14 (25.5 %) being unrecorded. Four out of 125 (3.2 %) patients developed FP at a median (IQR) of 12.8 (4.6–13.5) days following tracheostomy insertion, and they all occurred within the first two tracheostomy changes. None of the patients who developed FP had maturation sutures. Of the four children who developed FP, three (75 %) had no further complications, and one (25 %) developed subcutaneous emphysema and pneumomediastinum. No deaths associated with FP were identified. ConclusionThis large single institution study evaluating the relationship between maturation sutures and FP in children undergoing tracheostomy suggests that maturation sutures may help prevent FP; however, ongoing work is required to validate these findings and guide clinical practice. Level of evidence3.

Incidence of Pediatric to Adult Transition Among Tracheotomy Patients.

To estimate the incidence and identify predictors of pediatric tracheostomy patients who transition into adulthood with a tracheostomy. We conducted a retrospective analysis of pediatric tracheostomy patients treated at a single tertiary care pediatric hospital between 2009 and 2022. Patient demographics, comorbidities, tracheostomy outcomes, including decannulation and mortality rates, and the status of those alive with a tracheostomy at adulthood were compared. Of the 663 children who underwent a tracheostomy, 103 (15.5%) would have surpassed 18 years by September 1, 2023. Detailed breakdown: 26 (25%) were alive with a tracheostomy, 35 (34%) had been decannulated, 25 (24%) had passed away, and 17 (16.5%) were lost to follow-up. Patients who retained their tracheostomies into adulthood were more likely to be older at tracheostomy placement (mean age 14.3 vs. 1.7 years, p < 0.001), Hispanic (43.7% vs. 30.5%, p = 0.003), not ventilated at initial discharge (41% vs. 24%, p < 0.001), and have severe neurocognitive disabilities (72% vs. 53%, p < 0.001). Logistic regression identified older age at tracheostomy placement (OR = 1.35, 95% CI [1.24-1.48]) and severe neurocognitive disability (OR = 6.20, 95% CI [2.13-18.09]) as significant predictors of maintaining a tracheostomy into adulthood. Older age at tracheostomy placement and severe neurocognitive disabilities significantly predict the transition of pediatric tracheostomy patients to adult care with their tracheostomies. These findings highlight the need for specialized transition programs tailored to the needs of this unique population. IV Laryngoscope, 2024.

Bronchopulmonary dysplasia and ventilation-associated outcomes after pediatric tracheostomy.

The objective of this study is to determine the time to ventilator liberation and decannulation after tracheostomy placement in children with bronchopulmonary dysplasia (BPD) and pulmonary hypertension. A prospective cohort study included all children (<18 years old) who underwent tracheostomy between 2015 and 2021 with or without a diagnosis of BPD. The primary outcomes were time to ventilator liberation, tracheostomy decannulation, or death with tracheostomy in place. A total of 303 children met inclusion with a median (interquartile range [IQR]) age at tracheostomy of 6.9 (IQR: 4.0-49.5) months. A diagnosis of BPD was made for 42% (N = 127) and this group was younger (5.1 vs. 24.5 months, p < .001) and more often had pulmonary hypertension (68% vs. 24%, p < .001). Children with BPD spent a median of 2.9 years (IQR: 1.6-4.0) on ventilation compared to 1.9 years (IQR: 0.9-3.7) for children without BPD (p = .009). The time to decannulation was greater among children with BPD (3.4 vs. 1.8 years, p < .001). However, unadjusted estimates of ventilator liberation (hazard ratio [HR]: 1.05, 95% confidence interval [95% CI]: 0.77-1.44) and decannulation (HR: 1.11, 95% CI: 0.74-1.66) over time were not prolonged by BPD. Pulmonary hypertension was associated with shorter time to death (adjusted HR [aHR] = 1.99, 95% CI: 1.17-3.38, p = .01), while BPD was associated with longer time to death (aHR: 0.38, 95% CI: 0.22-0.67, p = .001). BPD is associated with increased ventilation and duration of tracheostomy but over time many children with BPD will wean off the ventilator and be decannulated. Pulmonary hypertension and not BPD is associated with increased time to death after tracheostomy.

Subglottic Stenosis After Pediatric Tracheostomy.

To determine the incidence of subglottic stenosis (SGS) in children after tracheostomy and identify risk factors for development. Retrospective cohort. All patients (<18 years) undergoing tracheostomy at a tertiary children's hospital between 2015 and 2020 were included. Patients with a direct laryngoscopy (DL) concurrent with tracheostomy and a subsequent DL were included. Medical records, including operative reports, were reviewed to identify subglottic stenosis and associated risk factors. A total of 140 patients were included with mean age at tracheostomy of 2.4 years (standard deviation [SD]: 4.3) (median: 0.5 years, interquartile range [IQR]: 0.3-1.5 years) and gestational age of 33.8 weeks (SD: 5.9) (median: 36 weeks, IQR: 28-39 weeks). At initial DL, 24% (N = 34) had subglottic injury and 26% (N = 37) developed SGS. The incidence of SGS after tracheostomy was 11.5 cases per 100 patients per year. At tracheostomy, lower birth weight (1.8 vs. 2.3 kg, p = 0.005), shorter gestational age (31.8 vs. 34.6 weeks, p = 0.01), younger age (0.8 vs. 2.9 years, p = 0.01), lower weight (5.8 vs. 14.7 kg, p = 0.01), and subglottic injury (44% vs. 21%, p = 0.01) were associated with the development of SGS. Multivariable logistic regression analysis associated birth weight (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.31-0.75, p = 0.001) and early subglottic injury (OR: 3.22, 95% CI: 1.31-7.88, p = 0.01) with SGS development. The incidence of SGS after pediatric tracheostomy is estimated at 11.5 cases per 100 patients per year. Low birth weight and subglottic injury at the time of tracheostomy were associated with SGS in this vulnerable population of children. 3 Laryngoscope, 135:402-408, 2025.

Emergent challenges in paediatric tracheostomy care: Insights from a case report

Emergent challenges in paediatric tracheostomy care: Insights from a case report

Preventing pediatric accidental decannulation events: A quality improvement initiative

ObjectiveTo describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3. MethodsA retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented: using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases. ResultsPrior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases). ConclusionThis data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.

Equitable Care for Children With a Tracheostomy: Addressing Challenges and Seeking Systemic Solutions.

Children with medical complexity (CMC) often face significant barriers to accessing care, obtaining appropriate insurance coverage for medical devices, technology, supplies, home nursingand social services. These challenges, when viewed through the lens of social determinants of health, highlight concerns about healthcare inequity. These inequities can impact CMC by limiting access to follow-up appointments, leading to disproportionate use of emergency department services, restricting support services, reducing the quality of medical productsand increasing the likelihood of adverse events. Addressing these concerns requires comprehensive policy changes at both state and federal levels. Achieving successful collaborations between states and federal agencies is particularly challenging and may take months or even years to accomplish. Through an exploratory qualitative approach, this study facilitates a nuanced inquiry into the experiences and systemic challenges encountered by medical professionals and primary caregivers managing CMC who require a paediatric tracheostomy. Qualitative interviews were conducted with 17 health professionals and primary caregivers residing in the United States. A thematic analysis was used to analyse the transcribed interview data. Using exploratory thematic analysis, we identified challenges and opportunities for improvement regarding (a) access to health insurance, (b) procurement of essential medical supplies, (c) logistical constraintsand (d) identifying interim solutions. Building on our findings, we discuss how socioecological factors impact health and quality of life of CMC and families. Additionally, we address the growing gap in quality of care through a comprehensive approach that considers patient needs, regulatory frameworksand affordability. Medical practitioners and healthcare professionals were actively involved in the development, productionand implementation of the research project. These individuals were given the opportunity to review their statements and review the manuscript before publishing. While caregivers did not engage in member checking, each provided their consent before data collection.

Impact of ciprofloxacin/dexamethasone on pediatric tracheostomy outcomes

Objective(s)To investigate the effectiveness of ciprofloxacin/dexamethasone in reducing granulation tissue post-tracheostomy in pediatric patients. MethodsThis cohort study examined pediatric patients with a tracheostomy at a single academic institution from 2016 to 2020. Exclusion criteria included: deceased within 1 year (n = 38), >16 years of age (n = 21), decannulated within 1 year (n = 15), lost to follow-up within 1 year (n = 6), and revision tracheostomy (n = 2). Logistic regression or Wilcoxon rank-sum (α = 0.05) were used to compare demographic and clinical characteristics between patients who did and did not receive ciprofloxacin/dexamethasone within 1 year of their tracheostomy. ResultsIn this cohort, (n = 126, median age 5.2 months, 54.0 % male), 62.7 % received ciprofloxacin/dexamethasone within 1 year, with 27.8 % taking the nebulized form. Granulation tissue occurred in 81.0 % of cases, predominantly peristomal (69.8 %) and suprastomal (34.9 %). Notable complications included accidental decannulation (13.6 %), suprastomal collapse (11.2 %), and bleeding (7.2 %). Although granulation tissue was more common in ciprofloxacin/dexamethasone users (92.4 %) versus non-users (61.7 %) (OR: 7.55, 95 % CI: 2.73–20.9, p < 0.001), patients exhibited less frequent granulation tissue events after initiation (z = 3.88, p < 0.001). No significant differences in antibiotic resistance (p = 1.0) or endocrinology complications (p = 0.1) were found between those with and without ciprofloxacin/dexamethasone. ConclusionsWe found a statistically significant reduction of granulation tissue incidence with ciprofloxacin/dexamethasone use and no significant differences in antibiotic resistance or endocrinology complications were noted. Future investigation is warranted to explore timing of ciprofloxacin/dexamethasone administration for granulation tissue and its role in managing and preventing tracheostomy complications.

Utility of chest x-ray for tracheostomy tube placement in pediatric patients.

To evaluate the utility of ordering chest x-rays after pediatric tracheostomy tube placement in identifying acute, post-operative complications and how it impacts clinical decision-making. In this retrospective cohort study, we identified tracheostomies performed in 139 pediatric patients through CPT codes over a 5-year period from 2013 to 2018. Manual chart review was performed for demographic and clinical characteristics, pre-procedure and post-procedure chest x-ray interpretations, and the presence of complications. Each complication was reviewed to see if action was taken due to post-procedure chest x-ray findings. Multivariable logistic regression was performed to determine associations with changes in pre-procedure versus post-procedure chest x-rays. In a cohort of 139 pediatric patients with pre-procedure and post-procedure chest x-rays, 40 (28.8%) of patients had new significant post-procedure chest x-ray findings compared to pre-procedure chest x-ray findings. Of these 40 instances of changes in pre-procedure versus post-procedure chest x-ray findings, only eight resulted in action being taken due to the observed findings. Among these eight instances of action being taken, only one instance involved in invasive action being taken with a bronchoscopy. With multivariable regression analysis, patient age, race, gender, and the presences of genetic syndromes, were not found to be significant risk factors in predicting changes in pre-procedure versus post-procedure chest x-ray. In our study, post-procedure chest x-ray after tracheostomy tube placement did not significantly impact clinical decision making. It may be worth reconsidering the value in routine chest x-rays after tracheostomy tube placement in pediatric patients.

Validation of a Novel Mobile Application for Assessing Pediatric Tracheostomy Emergency Simulations.

Pediatric tracheostomy is associated with high morbidity and mortality, yet clinician knowledge and quality of tracheostomy care may vary widely. In situ simulation is effective at detecting and mitigating related latent safety threats, but evaluation via retrospective video review has disadvantages (eg, delayed analysis, and potential data loss). We evaluated whether a novel mobile application is accurate and reliable for assessment of in situ tracheostomy emergency simulations. A novel mobile application was developed for assessment of tracheostomy emergency in situ simulation team performance. After 1.25 hours of training, 6 raters scored 10 tracheostomy emergency simulation videos for the occurrence and timing of 12 critical steps. To assess accuracy, rater scores were compared to a reference standard to determine agreement for occurrence or absence of critical steps and a timestamp within ±5 seconds. Interrater reliability was determined through Cohen's and Fleiss' kappa and intraclass correlation coefficient. Raters had 86.0% agreement with the reference standard when considering step occurrence and timing, and 92.8% agreement when considering only occurrence. The average timestamp difference from the reference standard was 1.3 ± 18.5 seconds. Overall interrater reliability was almost perfect for both step occurrence (Fleiss' kappa of 0.81) and timing of step (intraclass correlation coefficient of 0.99). Using our novel mobile application, raters with minimal training accurately and reliably assessed videos of tracheostomy emergency simulations and identified areas for future refinement. With refinements, this innovative mobile application is an effective tool for real-time data capture of time-critical steps in in situ tracheostomy emergency simulations.