Chest
Volume 113, Issue 1, January 1998, Pages 77-85
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Clinical Investigations
Impact of Tracheotomy on Colonization and Infection of Lower Airways in Children Requiring Long-term Ventilation: A Prospective Observational Cohort Study

https://doi.org/10.1378/chest.113.1.77Get rights and content

Study objectives

Determination of the following: (1) colonization and infection rates in children requiring long-term ventilation initially via a transtracheal tube and subsequently via a tracheotomy; (2) the number of infection episodes per 1,000 ventilation days, during both types of artificial airways; and (3) routes of colonization/infection of the lower airways, ie, whether the pathogenesis was endogenous (via the oropharynx) or exogenous (via the transtracheal tube or tracheotomy).

Design

Observational, cohort, prospective study over years.

Setting

Pediatric ICU (PICU), Royal Liverpool Children's National Health Service Trust of Alder Hey, a tertiary referral center

Patients

Twenty-two children requiring long-term mechanical ventilation initially transtracheally and subsequently via a tracheotomy.

Intervention: Nil.

Results

The lower airways were colonized in 71% of children during transtracheal ventilation; posttracheotomy, this was 95% (p=0.03). Children developed significantly fewer infections following colonization with a microorganism posttracheotomy (8/15 pretracheotomy vs 6/21 posttracheotomy; p=0.013). Throughout the study, there were a total of 17 episodes of infection, all of which were preceded by colonization. Haemophilus influenzae, Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa were the same four causative pathogens during mechanical ventilation both transtracheally and via tracheotomy. Forty-nine episodes of colonization were observed, 15 pretracheotomy and 34 posttracheotomy; of these, 12 (80%) and 19 episodes (56%), respectively, were primary endogenous, ie, present in the oropharynx on hospital admission and subsequently at tracheotomy. Only one colonization episode (7%) of exogenous pathogenesis was observed during transtracheal intubation, while 12 (35%) (p=0.02) occurred after tracheotomy. An equal number of secondary endogenous colonization episodes (two and three, ie, acquired in the oropharynx after PICU admission and after tracheotomy, respectively, were recorded.

Conclusions

(1) Despite a high level of hygiene, exogenous colonization without subsequent infection was common. (2) Although all patients were colonized, the infection rate was lower after tracheotomy. This may be due to enhanced immunity (medically stable) and improved tracheobronchial toilet. (3) Microorganisms in children with tracheotomy differ from those in adults.

Section snippets

Materials and Methods

This investigation was a 2½ year prospective observational cohort study from September 1, 1993, until February 28, 1996, in children requiring long-term mechanical ventilation, initially transtracheally and subsequently via tracheotomy, in the PICU.

Results

Before the tracheotomy, all patients had been intubated with orotracheal or nasotracheal tubes, and mechanically ventilated for a median of 22.5 days (range, 1 to 50 days; 95% CI, 7 to 31 days) (Table 1). Following tracheotomy, mechanical ventilation continued for a median of 16.5 days (range, 1 to 220 days; 95% CI, 2 to 45 days). Mechanical ventilation was expected to be permanent in two patients (patients 18 and 20 in Table 2). In four of the patients (patients 3, 13, 15, and 22), infection

Discussion

The significant increase in colonization rates from 7 to 35% once the children received a tracheotomy is thought to be due to altered anatomy (including the presence of a skin lesion), positional change of the trachea, exposure of the tracheal mucosa to the atmosphere, mucous stasis, a change in pH of the mucus,17 the presence of a foreign body (the tracheotomy tube), and repeated manipulation of the trachea during suctioning.

Although the colonization rate of the lower airway approached 100%,

Acknowledgments

We are very grateful to the medical and nursing staff of the PICU and to the microbiology department for their cooperation, to Nia Catahan for her skillful preparation of the tables and figures, and to Mr. J. Rogers and Dr. M.S. Niederman for carefully reviewing the manuscript.

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