289 - Timing of Tracheostomy in Patients with Severe Bronchopulmonary Dysplasia: A Retrospective Analysis and Multidisciplinary Survey

Timing of tracheostomy in patients with severe bronchopulmonary dysplasia (BPD) is widely variable across institutions. Potential benefits associated with earlier tracheostomy include improved growth and tolerance of developmental cares, yet ideal timing must also consider the possibility of weaning from ventilation and available resources to provide care.

Objective: To examine the timing of tracheostomy discussions and placement for severe BPD patients over a 4-year period, and to conduct a multidisciplinary survey to understand the provider considerations when determining timing of tracheostomy.

Design/Methods: We conducted a retrospective analysis of tracheostomy placement in severe BPD patients at the Boston Children’s Hospital (BCH) NICU between July 2016 to September 2020. A web-based 10 item survey was administered in November 2022 to multi-disciplinary healthcare providers at both quaternary (BCH) and referring NICUs.

Results: The study included 28 patients with a median age of 41 weeks post-menstrual age (PMA) at initial tracheostomy discussion with the family. The median age at tracheostomy placement in patients on non-invasive respiratory support (9/28) was 48 weeks PMA and on invasive support (17/28) was 44 weeks PMA. Ninety-seven providers (31%) responded to the survey. The majority (54%) reported that the optimal timing for tracheostomy discussion with the family was between 36 to 40 weeks PMA. Optimal timing for tracheostomy placement in patients on non-invasive respiratory support was 44 weeks PMA in 49% of the responses. For infants still requiring invasive ventilation, providers from the quarternary NICU reported 40 weeks (56%) as the optimal timing for tracheostomy placement compared to 44 weeks (47%) preferred by tertiary NICU providers. Concerns reported for earlier tracheostomy placement were the possibility of weaning and not requiring a tracheostomy (47%) and the risk destabilization during surgery (49%). The barriers to optimal tracheostomy timing identified were family reluctance (88%), logistical delays (52%), and referral medical team reluctance (48%).

Conclusion(s): Optimal tracheostomy timing remains a complex and important issue for severe BPD patients. We report a single center experience and identify a difference in provider reported optimal tracheostomy timing with referral NICUs favoring a later PMA in patients on invasive respiratory support compared to quaternary NICU providers. Standardized guidelines, parental partnership and education may help provide a consistent approach to optimize timing.