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Incidence, Management and Outcome of Tracheobronchitis in a Tracheostomized

Home Care Population

Roy Maynard1,2, M.D., Josh Larson1, MS, RHIA, RRT-NPS,

Derek Hustvet1, BS, RRT-NPS William Wheeler2, M.D.

1. Pediatric Home Service, Roseville, MN 2. Children’s Respiratory & Critical Care Specialists, P.A., Minneapolis, MN

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Purpose • A paucity of information exists on the

actual incidence, management and outcome of tracheobronchitis in tracheostomized patients in home care.

– Standard of care in our community – Symptoms and interventions – Episodes of tracheobronchitis and pneumonia – Frequency of respiratory hospitalization – Identify risk factors

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Methods Prospective observational study conducted in a predominantly pediatric population of tracheostomized patients followed through a pediatric home care company (Pediatric Home Service, Roseville, Minnesota).

Parents/patients gave informed consent to participate and release hospital records.

Patient-assigned respiratory therapists surveyed patients/caregivers monthly 10/1/2010 through 9/30/2011.

Hospital records reviewed on 44/48 (92%) of patients.

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Methods

• Tracheobronchitis was defined as a new or altered chronic antibiotic prescription to treat acute respiratory symptoms.

• Pneumonia diagnosed by review of hospital admission records documenting new infiltrates on CXR.

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Methods

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Methods • Statistics: A study specific data reporting tool was

developed to facilitate data collection from a patient registry and patient chart abstraction. A HIPAA compliant dataset was created for analysis. Categorical variables (e.g. age group, route of antibiotic administration, diagnosis group) were reported as proportion of patients and patient visits; continuous variables (e.g. patient age, number of days in hospital; number of antibiotic episodes, number of trach days) were reported as means and standard deviations. Bivariate associations were tested with chi-square (e.g. diagnosis group and tracheobronchitis episode; a p-value ≤ 0.05, two-tailed was used to determine statistical significance. SAS v9.3 (SAS Institute, Cary, NC, USA) was used for all data management and analysis.

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Methods • Demographics

– 225 patients enrolled (initially 238, 13 excluded due to inability to obtain reliable information), 7 patients expired during the study

– Cumulative tracheostomy days counted – 175 patients <18 years of age – 50 patients >18 years of age – 95 females/130 males – Vent=140 patients, H&H=85 patients

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Age Group by Sex

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Vent vs Humidity by Age Group

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Diagnostic Categories

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RESULTS

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Incidence of Tracheobronchitis Symptoms

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Incidence of Tracheobronchitis

• 69,515 tracheostomy days/225 patients • 287 tracheobronchitis episodes/225 patients • 1.28 tracheobronchitis episodes/patient/year • 4.1 tracheobronchitis episodes/1,000 trach days • 60% of patients had one or more episodes of

tracheobronchitis • 40% of patients had no episodes of

tracheobronchitis

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Management

• 89% of episodes initially managed by telephone

• 52% only required phone management

• 43% ultimately had an office visit and/or emergency room visit

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Management: Interventions

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Management: Antibiotic Treatment

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Management: Antibiotic Treatment

0%

5%

10%

15%

20%

25%

30%

35%

fluoroquinilones cephalosporins penicillins macrolides

Mean duration of antibiotic therapy was 18.8 days, median 10 days

Antibiotic Prescriptions

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Outcomes • Hospitalizations

– 48 respiratory hospitalizations among 38 patients

– Hospital records reviewed on 44 out of 48 respiratory hospitalizations (92%)

– 17% of patients had at least one hospitalization

– 83% of patients had no respiratory hospitalizations

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Length of Hospitalization

# of Hospital Stays Patients

Total Days in Hospital

Total Hospital Days Min Max Mean Median Mode

All 38 366 2 41 9.63 5.0 4.0

1 30 181 2 35 6.03 4.0 3.0

2 6 113 4 40 18.83 16.5

3 2 72 31 41 36.00 36.0

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Outcomes • 37.5% (18/48) of hospitalizations had been treated with

antibiotics prior to admission

• 44% (21/48) of hospitalizations had a diagnosis of pneumonia

• 19% (9/48) of hospitalized patients had documented respiratory viral infection (5 RSV, 2 influenza A, 1 adenovirus, 1 humanmetapneumovirus)

• 8/287 (2.8%) of tracheobronchitis episodes treated with antibiotics as outpatients diagnosed in hospital with non-viral pneumonia (progression of tracheobronchitis to pneumonia)

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Risk Factors for Tracheobronchitis and Hospitalization

*statistically significant p-value ≤ 0.05

Vent status was the only significant predictor of antibiotic episodes. Patients who do not have a vent are 0.411 times less likely to have an antibiotic episode.

In the multivariate analysis only one variable, age, was found to be a significant predictor of hospitalizations. The results indicate that older individuals are 0.26 times less likely to be hospitalized than younger patients.

Factor Odds Ratio Tracheobronchitis

Odds Ratio Hospitalization

Sex: Female 1.43 (0.810; 2.540) p-value=0.2163

1.29 (0.20 2.201) p-value = 0.4924

HV: Vent 0.411 (0.227; 0.744) p-value = 0.0033*

0.51 (0.232; 1.140) p-value = 0.1017

Dx: CNS 2.09 (1.092; 3.999) p-value = 0.1548

2.45 (0.957; 6.266) p-value = 0.2993

Dx: Lung 1.81 (0.818; 4.016) p-value = 0.5418

2.65 (0.950; 7.414) p-value = 0.2227

Age: <12 0.56 (0.299; 1.028) p-value = 0.0613

0.26 (0.103; 0.667) p-value = 0.0056*

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Conclusions • Incidence of Tracheobronchitis

– 4.1 episodes per 1000/trach days – 60% of patients had one or more episodes

• Incidence of Respiratory Hospitalization – 17% of patients had at least one respiratory hospitalization – 20% of inpatients had documented viral infections – Nearly half of hospitalized patients diagnosed with pneumonia – Most hospitalizations are brief (mode 3 days)

• Risk Factors for tracheobronchitis and/or respiratory hospitalization include age and ventilator dependency

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Acknowledgements

• Clinical Staff at Pediatric Home Service

• Families and patients that agreed to participate in the study

• Administrative assistant Marlene Brekke

• DataIQ for statistical support

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Incidence, Management and Outcome of Tracheobronchitis in a Tracheostomized Home Care

Population