C. C. Style1, M. A. Verla1, T. C. Lee1, S. C. Fallon1, H. Srirani1, C. J. Fernandes2, S. G. Keswani1, A. M. Vogel1, O. O. Olutoye1 1Baylor College Of Medicine, Texas Childrens Hospital,Department Of Surgery, Divison Of Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine, Texas Children’s Hospital,Department Of Pediatrics, Newborn Secton,Houston, TX, USA
Introduction: Numerous advances in pre- and postnatal management of critically-ill CDH patients have improved long term survival and outcomes, but a small percentage of patients continue to require tracheostomy. The purpose of this study was to define the characteristics and associated risk factors for tracheostomy in the CDH population.
Methods: An IRB approved retrospective review of all infants evaluated for CDH at a single institution from March 2004 to April 2018 was performed. Data analyzed included maternal and fetal demographics, prenatal imaging data, and postnatal clinical outcomes. Primary outcomes assessed were indication for and duration of tracheostomy, requirement for ECMO and survival. Statistical analysis included chi-square analysis, student’s t test, and stepwise logistic regression. A p-value of <0.05 was considered significant.
Results:Of 273 CDH patients treated, 10% (26) underwent a tracheostomy prior to 2 years of life (median age of 4 [3 – 8] months). Of these 26 patients, 65% (17) had a left-sided CDH and 76% (19) were male. Indications for tracheostomy were persistent pulmonary hypertension in the setting of severe pulmonary hypoplasia (31%, 8), tracheomalacia (27%, 7), bronchopulmonary dysplasia (27%, 7), upper airway obstruction/structural defect (11%, 3), and vocal cord paralysis (4%, n=1). Only two patients underwent tracheostomy after their initial inpatient hospitalization; both were eventual recipients of lung transplants. Prenatally, although lungs volumes were similar to the non-tracheostomy cohort, percent liver herniation was significantly higher in the tracheostomy group (27% ± 18, p<0.01). Additionally, 79%(p=0.009) had an associated structural, genetic, and/or cardiac anomaly, which was a strong predictor of tracheostomy (OR 4.991,CI:1.25 – 20.3) in this cohort. At birth, prematurity and low birthweight also significantly correlated to need for tracheostomy (p<0.05, table 1). Incidence of ECMO was similar to the non-tracheostomy cohort (39% vs 31%, p=0.44) as was the overall survival (62% vs 74%, p=0.171). Non-survivors with a tracheostomy were, however, significantly older at time of death. Of the surviving tracheostomy patients (n=16), median length of hospital stay was prolonged 259 [187, 299] days (p<0.05) with a median time from tracheostomy to discharge of 98 [78, 172] days. Length of outpatient follow-up was 3 [0.5 – 9] years during which time 38% of survivors were decannulated (a range of 28 days to 3.5 years after tracheostomy).
Conclusion:CDH patients born prematurely and/or those with associated anomalies are at increased risk for tracheostomy. This is associated with prolonged hospitalization and median tracheostomy time of 1.5 years.
