Neonatologists at The Children’s Hospital of Philadelphia frequently face the intricate decision of whether to place a tracheostomy in a preterm infant with severe lung disease and when to do it. A lack of relevant literature about this procedure makes it a challenging consideration.
A recent study in the Journal of Pediatrics led by a CHOP neonatologist gives more guidance on this problem by evaluating the developmental outcomes of infants born before 30 weeks’ gestation who underwent tracheostomy. With these data in hand, clinicians contemplating a tracheostomy for a preterm infant can supplement clinical status and medical history to help parents comprehend potential long-term outcomes.
Premature infants’ lungs, especially the air sacs, are not fully developed. While many premature infants must use a mechanical ventilator and extra oxygen for breathing, a minority ultimately undergo tracheostomy placement. A tracheostomy is the insertion of an artificial airway into the windpipe through a surgical incision to provide a safe, long-term way to ventilate a child.
When Sara B. DeMauro, MD, MSCE, an attending neonatologist and medical director of Neonatal Follow-up Programs at CHOP, and co-investigators looked at a dataset collected at 16 sites from 2001 to 2011 by the NICHD Neonatal Research Network, they identified 304 preterm infants with tracheostomies to include in a retrospective cohort study.
“This is the first time anybody has ever performed a comprehensive evaluation of the developmental outcomes of these children at 18-22 months,” Dr. DeMauro said.
The researchers demonstrated that even when they performed adjusted analyses controlling for many of the factors known to be predictive of poor developmental outcomes in preterm infants, those with tracheostomies still had significantly increased odds of adverse outcomes. These outcomes consisted of neurologic impairment, developmental delay, or visual or hearing impairment.
Dr. DeMauro pointed out that while this study suggests that tracheostomy is a marker for a risk of adverse developmental outcomes in this vulnerable population, it does not indicate that tracheostomy causes these problems.
“Based on their entire medical histories, these children are predisposed to having poor developmental outcomes,” Dr. DeMauro said. “This is almost a way to measure that. If they’re so sick that they need a tracheostomy, then they’re so sick that they’re at very high risk for having an adverse outcome.”
This clinical conundrum has another nuance: If a preterm infant needs a tracheostomy, when should the procedure be performed?
Again, Dr. DeMauro and colleagues found a paucity of literature to guide that decision. So they assessed the impact of timing by comparing outcomes of infants who underwent tracheostomy before and after 120 days of life. Their study suggests a possible association between earlier (<120 days) tracheostomy and better neurodevelopmental outcomes.
While more studies must be done to determine if earlier decisions about tracheostomy placement are advantageous, Dr. DeMauro described how it is possible that a “sooner than later” approach could have benefits in the NICU.
“Before their tracheostomy is placed, infants aren’t allowed to move around too much because they could dislodge their tube. Therefore, they can’t engage in developmentally appropriate play and are often heavily sedated,” Dr. DeMauro said. “As soon as they have a tracheostomy that is in place and healed, you get them out of bed, you play with them, and you take them off sedation.”
Further data also is needed on the outcomes of tracheostomy in preterm infants who have lung disease compared to those who also have airway disease. Delving into these complexities will help clinicians have more complete information when they speak with families about pursuing tracheostomy placement, Dr. DeMauro said.
“This study is an important first step in understanding what the range of outcomes for these children tends to be,” she said. “When these data are combined with a child’s individual clinical situation and any additional risk factors for poor outcomes, it allows you to make a much more informed decision about whether a tracheostomy is a good choice.”
Grants from the National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development for the Neonatal Research Network supported this study.