Tracheostomy Placement and Clinical Outcomes for Children Unable to Liberate From Mechanical Ventilation in the PICU.

Abstract

Objectives: Ventilator liberation is a priority for physicians in the PICU. Need for reintubation is associated with worse clinical outcomes and may culminate in tracheostomy tube placement for long-term invasive mechanical ventilation (IMV). We hypothesized that increasing number of extubation attempts were associated with increased likelihood of new tracheostomy tube placement, increased noninvasive respiratory support (NRS) use, and increased time between extubation and reintubation for children receiving IMV in the PICU.

Design: Retrospective cohort study. We measured the frequency of new tracheostomy tube placement, number of reintubations, and use of NRS before reintubation. We also derived a mixed-effects logistic regression model to identify factors significantly associated with new tracheostomy tube placement.

Setting: Virtual Pediatric Systems Database.

Patients: All encounters younger than 19 years old, endotracheally intubated for greater than or equal to 24 hours, and required reintubation within 7 days of a planned extubation attempt in the PICU between January 1, 2013, and December 31, 2022.

Interventions: None.

Measurements and main results: We identified 14,085 encounters that met inclusion criteria, and 1,255 (8.9%) received a new tracheostomy tube. Increasing number of extubation attempts were significantly associated with increased odds of receiving a new tracheostomy tube (odds ratio, 1.42 [1.32-1.52]; p < 0.01). Mortality increased linearly with each unsuccessful extubation attempt from 8.1% with one attempt to 20.9% with five or more attempts. NRS use before reintubation increased from 45.6% after the first extubation attempt to a peak of 59.2% after the second extubation attempt. The time between extubation to reintubation increased from 0.8 days after the first extubation attempt to 3.5 days after the fourth extubation attempt. Younger age and renal and cardiac diagnoses were associated with lower odds of new tracheostomy tube placement. Respiratory, neurologic, oncologic, and traumatic diagnoses, as well as a longer total duration of IMV were associated with increased odds of new tracheostomy tube placement. Among encounters with two or more extubation attempts, tracheostomy placement was associated with longer IMV duration, longer length of stay, and lower mortality.

Conclusions: We found that increasing numbers of extubation attempts was associated with new tracheostomy tube placement, increased NRS use before reintubation, and increased time between extubation and reintubation in children in the PICU.