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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




                                      1 of 24
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

                     2 of 24
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.



                          3 of 24
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.



                   4 of 24
Methods




  5 of 24
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.


                           6 of 24
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


                         7 of 24
Age Group by Sex




      8 of 24
Vent vs Humidity by Age Group




             9 of 24
Diagnostic Categories




        10 of 24
RESULTS




  11 of 24
Incidence of Tracheobronchitis
          Symptoms




             12 of 24
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


                      13 of 24
Management
• 89% of episodes initially managed by
  telephone
• 52% only required phone management
• 43% ultimately had an office visit and/or
  emergency room visit




                    14 of 24
Management: Interventions




          15 of 24
Management: Antibiotic Treatment




              16 of 24
Management: Antibiotic Treatment
                              Antibiotic Prescriptions
              Mean duration of antibiotic therapy was 18.8 days, median 10 days

35%

30%

25%

20%

15%

10%

5%

0%
      fluoroquinilones   cephalosporins       penicillins      macrolides



                                      17 of 24
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



                       18 of 24
Length of Hospitalization
                                        Total Days in Hospital

# of                   Total
Hospital               Hospital
Stays       Patients   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




                                  19 of 24
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)



                             20 of 24
Risk Factors for Tracheobronchitis
                and Hospitalization
   Factor                                      Odds Ratio                             Odds Ratio Hospitalization
                                            Tracheobronchitis
   Sex: Female                              1.43 (0.810; 2.540)                               1.29 (0.20 2.201)
                                              p-value=0.2163                                  p-value = 0.4924
   HV: Vent                                 0.411 (0.227; 0.744)                            0.51 (0.232; 1.140)
                                             p-value = 0.0033*                               p-value = 0.1017
   Dx: CNS                                  2.09 (1.092; 3.999)                             2.45 (0.957; 6.266)
                                             p-value = 0.1548                                p-value = 0.2993
   Dx: Lung                                 1.81 (0.818; 4.016)                             2.65 (0.950; 7.414)
                                             p-value = 0.5418                                p-value = 0.2227
   Age: <12                                 0.56 (0.299; 1.028)                             0.26 (0.103; 0.667)
                                             p-value = 0.0613                                p-value = 0.0056*

*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.


                                                           21 of 24
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


                               22 of 24
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




                    23 of 24
Incidence, Management and
Outcome of Tracheobronchitis in
 a Tracheostomized Home Care
          Population




             24 of 24

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

  • 1. 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 1 of 24
  • 2. 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 2 of 24
  • 3. 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. 3 of 24
  • 4. 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. 4 of 24
  • 5. Methods 5 of 24
  • 6. 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. 6 of 24
  • 7. 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 7 of 24
  • 8. Age Group by Sex 8 of 24
  • 9. Vent vs Humidity by Age Group 9 of 24
  • 11. RESULTS 11 of 24
  • 12. Incidence of Tracheobronchitis Symptoms 12 of 24
  • 13. 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 13 of 24
  • 14. Management • 89% of episodes initially managed by telephone • 52% only required phone management • 43% ultimately had an office visit and/or emergency room visit 14 of 24
  • 17. Management: Antibiotic Treatment Antibiotic Prescriptions Mean duration of antibiotic therapy was 18.8 days, median 10 days 35% 30% 25% 20% 15% 10% 5% 0% fluoroquinilones cephalosporins penicillins macrolides 17 of 24
  • 18. 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 18 of 24
  • 19. Length of Hospitalization Total Days in Hospital # of Total Hospital Hospital Stays Patients 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 19 of 24
  • 20. 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) 20 of 24
  • 21. Risk Factors for Tracheobronchitis and Hospitalization Factor Odds Ratio Odds Ratio Hospitalization Tracheobronchitis Sex: Female 1.43 (0.810; 2.540) 1.29 (0.20 2.201) p-value=0.2163 p-value = 0.4924 HV: Vent 0.411 (0.227; 0.744) 0.51 (0.232; 1.140) p-value = 0.0033* p-value = 0.1017 Dx: CNS 2.09 (1.092; 3.999) 2.45 (0.957; 6.266) p-value = 0.1548 p-value = 0.2993 Dx: Lung 1.81 (0.818; 4.016) 2.65 (0.950; 7.414) p-value = 0.5418 p-value = 0.2227 Age: <12 0.56 (0.299; 1.028) 0.26 (0.103; 0.667) p-value = 0.0613 p-value = 0.0056* *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. 21 of 24
  • 22. 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 22 of 24
  • 23. 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 23 of 24
  • 24. Incidence, Management and Outcome of Tracheobronchitis in a Tracheostomized Home Care Population 24 of 24