Tracheobronchitis: Review of Literature and PHS TBS Outcomes
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Tracheobronchitis: Review of Literature and PHS TBS Outcomes

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Dr. Roy Maynard discusses the results of the trachebronchitis study conducted by PHS

Dr. Roy Maynard discusses the results of the trachebronchitis study conducted by PHS

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Tracheobronchitis: Review of Literature and PHS TBS Outcomes Tracheobronchitis: Review of Literature and PHS TBS Outcomes Presentation Transcript

  • TRACHEOBRONCHITIS:Review of the Literature and the PHS TBS Outcomes January 19, 2012 Roy C. Maynard, M.D. 1 of 37
  • 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
  • Tracheobronchitis• Symptoms: - Cough - Sputum - Hemoptysis - Fever - Difficulty breathing - Stridor, wheeze, rhonchi - Chest pain 3 of 37
  • 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
  • Review of the Literature• Suspected Respiratory Tract Infection in the Tracheostomized Child: The Pediatric Pulmonologist’s 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 – (WBC’s 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
  • 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
  • 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
  • Review of the Literature• A pediatric home health infection control surveillance program: Implementation to outcomes. (Caring 2005, Sept. 26-33). – Children’s 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
  • Tracheobronchitis Episodes/1,000 trach days 14 12 10 8 Columbus 6 Columbus 4 2 0 2000 2001 2002 2003 2004 9 of 37
  • 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
  • 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
  • What We Don’t 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
  • What We Don’t 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
  • 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
  • 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
  • Pneumonia• New crackles• CXR findings• Health care provider diagnosed• (Still in review of hospital records) 16 of 37
  • 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
  • Age Subcategories Patients Min Max Mean Std Median ModeAll 225 0 40 10.08 9.1086 7.0 0<2 42 0 1 0.33 0.4771 0.0 02-5 55 2 5 3.16 1.1016 3.0 26-9 26 6 9 7.19 1.1668 7.0 610-12 15 10 12 10.93 0.9612 11.0 1013-17 37 13 17 14.84 1.4436 15.0 1318-24 34 18 24 20.50 2.1356 21.0 1825-40 16 25 40 30.19 5.1019 28.0 26 18 of 37
  • Diagnosis Categories At Least One Tracheobronchitis No Tracheobronchitis Episodes Episode N Row % Col % N Row % Col %All Diagnosis Categories 91 40.4 100.0 134 59.6 100.0Unknown 4 100.0 4.4 . . .Brain Injury or CNS 33 34.4 36.3 63 65.6 47.0Hypotonia or Neuromuscular 10 47.6 11.0 11 52.4 8.2Airway Obstruction 11 45.8 12.1 13 54.2 9.7Primary Lung Disorder 5 23.8 5.5 16 76.2 11.9Congenital Heart Disease 1 14.3 1.1 6 85.7 4.5Congenital Syndrome 19 48.7 20.9 20 51.3 14.9Inborn Error of Metabolism 5 71.4 5.5 2 28.6 1.5Other 3 50.0 3.3 3 50.0 2.2 19 of 37
  • Vent vs. Humidity N % All 225 100.00 Vent 140 56.00 Humid 85 33.33 Vent/Humid 0 5.33 No Record 0 1.33 No Record/Humid 0 3.11 No Record/Humid/Vent 0 0.89 20 of 37
  • Symptoms of Tracheobronchitis 100 90 80 I secretions d secretions 70 breath sounds 60 O2 sat 50 heart rate cough 40 fever 30 tachypnea 20 dyspnea 10 chest pain 0 Symptoms 21 of 37
  • Interventions100 90 80 70 inc nebs 60 inc O2 50 inc BDs 40 trach culture 30 end tidal CO2 20 antibiotics 10 0 interventions
  • Antibiotic Administration Trach Culture Trach Culture All Not Sent Sent N N % N % All 287 199 69.34 88 30.66 Combo 171 102 59.65 69 40.35 Neb 65 58 89.23 7 10.77 Oral 48 39 81.25 9 18.75 IV 3 . . 3 100.00 23 of 37
  • Antibiotic Treatment50454035 neb/oral30 neb oral25 neb/IV/oral20 oral/IV neb/IV15 IV10 5 0 Antibiotic Administration Routes 24 of 37
  • Number of Antibiotic Episodes and Antibiotic Episode Days by Route Antibiotic Episode Days % of Episodes Episodes Min Max Mean Std Median Mode All Routes 287 100.00 2 70 14.74 9.3343 11.0 11 Combo 171 59.58 3 70 16.87 10.686 14.0 11 Neb 65 22.65 2 42 12.29 6.2192 11.0 11 Oral 48 16.72 5 27 10.77 4.6915 10.0 10 IV 3 1.05 8 11 10.00 1.7321 11.0 11 25 of 37
  • Episodes by Trach Days All Patients Patients Total Min Max Mean Std Median ModeTrach Days 225 69515 3.0000 365.00 308.96 102.06 365.00 365.00Antibiotic Episodes 225 287 0.0000 8.0000 1.2756 1.5014 1.0000 0.0000Total Episode Days 225 4231 0.0000 144.00 18.804 25.272 10.000 0.0000Episodes per Trach Day 225 1 0.0000 0.0294 0.0043 0.0054 0.0027 0.0000Episode Days per Trach Day 225 15 0.0000 0.7097 0.0655 0.1003 0.0301 0.0000 26 of 37
  • Tracheobronchitis Episodes/1,000 trach days 14 12 10 8 Columbus Columbus 6 PHS 4 2 0 2000 2001 2002 2003 2004 2010 27 of 37
  • Hospital Stays Associated with Antibiotic Episode Total Days in Hospital Hospital Stays Total Hospital Patients Days Min Max Mean Std Median Mode All 225 323 0 41 1.44 5.2624 0.0 0.0 0 188 0 0 0 0.00 0.0000 0.0 0.0 1 32 190 2 35 5.94 5.8802 4.0 3.0 2 3 61 9 40 20.33 17.098 12.0 . 3 2 72 31 41 36.00 7.0711 36.0 . 28 of 37
  • Sterile Suction Technique by Tracheobronchitis Episode The FREQ Procedure Table of bRST by abEpisodes bRST(Binary Routine Suction Techniques) abEpisodes Frequency Expected Percent Row Pct At least one Tracheobronchitis Col Pct No Tracheobronchitis Episodes Episode Total Sterile 90 131 221 89.382 131.62 40.00 58.22 98.22 40.72 59.28 98.90 97.76 Non-Sterile 1 3 4 1.6178 2.3822 0.44 1.33 1.78 25.00 75.00 1.10 2.24 Total 91 134 225 40.44 59.56 100.00 29 of 37
  • What Did We Learn?• Of the 225 patients enrolled in the study, 175 (77.7%) were less than 18 years of age and 50 (23.3%) were older than 18 years of age• 287 episodes of tracheobronchitis in 225 patients (1.27 episodes per patient/year)• 4.1 episodes/1,000 trach days• 40% of patients did not have an episode of tracheobronchitis• 60% of patients had one or more episodes 30 of 37
  • What Did We Learn?• Episodes of tracheobronchitis trended to be common the younger the patient• Episodes of tracheobronchitis trended to be more common in ventilator-dependent patients (p=0.0525)• Higher risk for tracheobronchitis associated with CNS injury or disease, primary lung disorder and congenital heart disease 31 of 37
  • What Did We Learn?• Trach cultures are obtained only 30% of the time• Most common symptoms are increased and discolored secretions, change in breath sounds and oxygen saturations• Fever is noted 50% of the time, and 76% of fevers are less than 102 32 of 37
  • What Did We Learn?• Other Interventions: – 75% receive increased neb treatments – 52% receive additional oxygen – 35% receive additional bronchiodrainage – 17% have end-tidal CO2 checked• Effective cough had no effect on incidence of tracheobronchitis 33 of 37
  • What Did We Learn?• 23% of episodes treated with nebulized antibiotics (Abx) alone• 60% receive combination antibiotic therapy• 17% receive oral Abx only – 32% were fluoroquinilones – 20% were cephalosporins – 17% were penicillins – 14% were macrolides• Mean duration of antibiotic therapy was 18.8 days, median 10 days 34 of 37
  • What Did We Learn?• 84% initially managed with telephone• 37% had office visit or ED visit• 18.6% of patients ended up with a hospitalization• 8 patients (8/42 or 19% of hospitalized patients) had 2 or more hospitalizations• 81% of enrolled patients had no hospitalization for respiratory illness• Mean duration of hospitalization for patients with a single episode was 8.2 days but mode was 3 days 35 of 37
  • Conclusions• PHS has established a benchmark for the incidence and standard of care for episodes of tracheobronchitis in tracheostomized home care patients• Still need to review hospitalizations for justification and incidence of pneumonia• Possible presentation at the Chest conference in Atlanta this year• Publication in Chest or Pediatric Pulmonology 36 of 37
  • Q&A Questions?Thank you for attending! 37 of 37