Chest
Volume 113, Issue 6, June 1998, Pages 1549-1554
Journal home page for Chest

Clinical Investigations: Inflammation/Infection
Suspected Respiratory Tract Infection in the Tracheostomized Child: The Pediatric Pulmonologist's Approach

https://doi.org/10.1378/chest.113.6.1549Get rights and content

Study objectives

It is difficult to determine, in the child with a long-term tracheostomy, when bacterial airway colonization has progressed to a respiratory infection requiring antibiotic treatment. Our aim was to investigate whether there is a consensus regarding this and related chronic care issues among clinicians treating these patients.

Design and setting

A questionnaire asking about practices regarding use of tracheal aspirate cultures and antibiotics was distributed to 47 pediatric pulmonary centers.

Participants

Individuals representing 34 centers (72%), caring for 10 to 400 patients, responded.

Interventions

None.

Results

At 65% of centers, management is variable, dependent on the patient's underlying condition. The most common indications to obtain a culture were change in secretions (91%) or fever without an obvious source (21 centers). Indications to treat with antibiotics included many leukocytes in secretions (21 centers) or a respiratory illness (18 centers). When treating, 97% prescribe antibiotics empirically, most often enterally; nine centers use inhaled antibiotics. In most centers (79%), management is often done by telephone.

Conclusions

Although pediatric pulmonologists tend to have similar approaches to assessment and management of suspected respiratory tract infections in tracheostomized children, no clear consensus exists, and much of current practice is empirical. To optimize care of these patients, studies should be conducted to develop criteria to objectively differentiate bacterial airway “colonization” from “infection.”

Section snippets

Questionnaire Distribution

A three-page questionnaire was mailed early in 1994, along with a self-addressed, stamped envelope to the directors of the 46 accredited pediatric pulmonology fellowship programs listed in the January 1993 issue of Journal of Pediatrics and/or the October 1993 issue of the American Review of Respiratory Disease.8,9 An accompanying cover letter was sent, describing the survey, and our desire to assess the “standard of care” regarding management of children with tracheostomies at different

Responses

Completed questionnaires were returned by 34 centers (72% response rate), 4 of which desired to remain anonymous. Five questionnaires were completed by nurses or respiratory therapists; the rest were completed by physicians. Not all questionnaires that were returned contained responses to every question; when the number of responders to a question was <34, it is indicated below.

Center and Patient Characteristics

Respondents completing the questionnaire as center representatives (referred to in this “Results” section as

DISCUSSION

The survey results show that pediatric pulmonologists do not generally follow a formal protocol to guide management of possible respiratory tract infections in tracheostomized children; most center representatives (hereafter referred to as “centers”) vary their approach based on the patient's underlying diagnosis. Most centers obtain a tracheal aspirate for culture and sensitivity analysis if there has been a change in usual secretions, even in a well patient; secretions becoming green was

References (14)

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