1. TRACHEOBRONCHITIS:Review of the Literature and the PHS TBS Outcomes January 19, 2012 Roy C. Maynard, M.D. 1 of 37

2. Tracheobronchitis Definition: Inflammation of the trachea and bronchi Causes: - Viruses (influenza, parainfluenza, RSV, measles, rubella, adenovirus, Echovirus, coxsackie, herpes and others) - Bacteria (haemophilus influenzae, streptococcus pneumoniae, streptococcus, staphylococcus, nocardia, diptheria, mycoplasma and others) - Miscellaneous (asthma, COPD, allergies, cystic fibrosis, ciliary dyskinesia, tracheostomy) 2 of 37

3. Tracheobronchitis Symptoms: - Cough - Sputum - Hemoptysis - Fever - Difficulty breathing - Stridor, wheeze, rhonchi - Chest pain 3 of 37

4. Review of the Literature Bacterial colonization, tracheobronchitis and pneumonia following tracheostomy and long-term intubation in pediatric patients. (Chest 1979;76;420-424). 27 patients with CNS diagnosis and artificial airways 100% had airway colonization TB defined as purulent secretions without clinical or radiographic evidence for pneumonia 16.5 trach cultures/patient/year Bacteria profile changed 50% of the time with pneumonia 24 (89%) had recurrent chronic TB and 68 episodes of pneumonia (2.8 episodes per patient) Antibiotic treatment changed bacteria profile Pseudomonas, serratia, strep pneumoniae, alpha-strep, E coli, staph, anaerobes (2 patients had positive blood cultures) 4 of 37

5. Review of the Literature Suspected Respiratory Tract Infection in the Tracheostomized Child: The Pediatric Pulmonologists Approach. (Chest 1998;113;1549-1554). Goal to determine standard of care for differentiating colonization from infection in trached children (multiple diagnoses) by survey of practitioners in academic setting (34/46 responded) Average 48.5 +/- 77 patients (50% vented) 91% get trach culture if change in trach secretions (regardless clinical status) Most frequent change (green sputum, then foul smelling, then fever) Most frequent indication for Abx Tx (WBCs in sputum, then resp illness, then green or foul smelling secretions) 79% managed over telephone No formal protocol Most centers will not treat with Abx in presence of purulence if patient well Most common Abx Bactrim and Augmentin outweighed nebulized tobi/gent No waiting for culture to prescribe (base on previous), no f/u cultures 5 of 37

6. Review of the Literature Oropharyngeal carriage and lower airway colonization/infection in 45 tracheotomized children. (Thorax 2002;57;1015-1020). 5-year prospective study of 45 children (neuro and airway obstruction) initially intubated then trached in a PICU before transfer to chronic ward Infection treated with Abx for fever>38.5C, leukocytosis, increased CRP, purulent secretions (>106 CFU/ml) Pneumonia only diagnosed if + CXR Compared potential pathogens in mouth with lower airway 6/45 had sterile lower airways (these patients had normal mouth flora) 39/45 (86%) had colonized/infected lower airways post trach Community flora more common following trach (S pneumoniae, M catarrhalis, H influenzae, S aureus, E coli) Hospital flora more common intubated (pseudomonas, acintobacter, klebsiella, S maltophilia) 33% post trach with pseudomonas (no change) but increased S aureus 6 of 37

7. Review of the Literature Surveillance tracheal aspirate cultures do not reliably predict bacteria cultured at the time of an acute respiratory infection in children with tracheostomy tubes. (Chest 2011;DOI 10.1378/ Chest 10-2539). Study designed to characterize practice of obtaining and using info from trach cultures to guide treatment of lower resp tract infections Records retrospectively reviewed from 170 children over 4 years Survey of pediatric pulmonologists and otolarygologists (ENT) 54% of pulmonologists and 15% of ENT obtain routine tracheal aspirates, among physicians who obtain cultures, 80% of ENT and 97% of pulmonologists use info to guide therapy In children with surveillance cultures, common for recovered pathogenic bacteria (when patient ill) to be different than from previous surveillance culture Potentially ineffective antibiotic coverage would have been chosen in 56% of cases if previous trach culture had been used to guide therapy Limited value using previous trach cultures to guide therapy Probably little value obtaining routine trach cultures 7 of 37

8. Review of the Literature A pediatric home health infection control surveillance program: Implementation to outcomes. (Caring 2005, Sept. 26-33). Childrens Homecare of Columbus, Ohio Monitored respiratory infections in home-bound trach dependent children Clinical; fever>99 axillary, new or increased secretions, purulence, cough, SOB, RR, new chest findings Diagnostic criteria; trach culture and or CXR Needed one clinical and one diagnostic or 3 clinical and Abx prescribed 6 to 12 respiratory infections per 1,000 trach days 8 of 37

9. Tracheobronchitis Episodes/1,000 trach days 14 12 10 8 Columbus 6 Columbus 4 2 0 2000 2001 2002 2003 2004 9 of 37

10. What We Know! Microbiological colonization well described May be different from when first hospitalized to steady state Microbiological colonization is dynamic, often changes over time and after antibiotic treatment Should not base treatment on cystic fibrosis model 10 of 37

11. What We Know! Surveillance cultures probably not helpful Role of anaerobes unclear Different prescribing patterns for threshold of tracheobronchitis Oral antibiotics most common treatment in the past Most managed over the phone Little data on frequency of respiratory infections or tracheobronchitis in trached patients at home 11 of 37

12. What We Dont Know! Standard of care in the PHS community: - Telephone or office visit to manage episodes - Prescribing patterns of antibiotics; neb vs. oral vs. IV vs. combination - Duration of treatment - Cultures obtained? - Other interventions implemented? 12 of 37

13. What We Dont Know! Episodes of TB per patient per year Episodes of TB per 1,000 trach days Failed treatment for TB episodes resulting in hospitalization (still in review) Incidence of fever with TB episodes Difference in TB episodes related to: - Suction technique - Vent or no vent - Patient ability to cough or not cough - Diagnosis - Age 13 of 37

14. PHS Tracheobronchitis Study Objective: - Document standard of care in community - Frequency of TB episodes - Most common presenting clinical symptoms - Identify risk factors associated with development of TB in trached home care patients - Episodes of home treatment failure resulting in a respiratory hospitalization 14 of 37

15. PHS Tracheobronchitis Study Study Design: - Prospective surveillance study 12-month duration - Final 225 trached patients (started 238; 13 patients dropped out, ended up with 140 vent, 85 humidity) - Patient ages (0-40 years) - Surveyed monthly by PHS respiratory therapists for Abx treated TB episodes - Tracheobronchitis episode defined as respiratory symptoms and illness in a tracheostomized patient felt to warrant antibiotic treatment by a health care provider 15 of 37

16. Pneumonia New crackles CXR findings Health care provider diagnosed (Still in review of hospital records) 16 of 37

17. Patients Greater/Less Than 18 Years of Age Patients Min Max Mean Std Median Mode All 225 0 40 10.08 9.1086 7.0 0 < 18 years 175 0 17 6.22 5.5043 4.0 0 >= 18 years 50 18 40 23.60 5.6460 22.0 18 17 of 37

18. Age Subcategories Patients Min Max Mean Std Median ModeAll 225 0 40 10.08 9.1086 7.0 0