Disparities in Delirium across the Continuum of Care and Associations with Social Determinants of Health.

Disparities exist in the identification, treatment, and management of delirium. These disparities can be most holistically and comprehensively understood by using a social-ecological model-which acknowledges multilevel impacts including individual, interpersonal, organizational, community, and policy-level factors-as well as a social determinant of health framework, that considers nonmedical factors that influence health outcomes. This narrative review leverages both frameworks to identify and discuss existing literature pertaining to the intersection of these social risk factors and delirium, focusing specifically on disparities due to racial and/or ethnic identity, language ability, and socioeconomic differences. We also look at disparities and the potential role of these social risk factors throughout the continuum of care, including prehospitalization, hospitalization, and posthospitalization factors. Understanding and analyzing the role of these inequities is critical to ensuring better health outcomes for patients at risk of and/or with delirium.

Improving Tracheostomy Care in Resource-Limited Settings.

OBJECTIVES: Tracheostomy care in leading pediatric hospitals is both multidisciplinary and comprehensive, including generalized care protocols and thorough family training programs. This level of care is more difficult in resource-limited settings lacking developed healthcare infrastructure and tracheostomy education among nursing and resident staff. The objective of this study was to improve pediatric tracheostomy care in resource-limited settings. METHODS: In collaboration with a team of otolaryngologists, respiratory therapists, tracheostomy nurses, medical illustrators, and global health educators, image-based tracheostomy education materials and low-cost tracheostomy care kits were developed for use in resource-limited settings. In addition, a pilot study was conducted, implementing the image-based tracheostomy pamphlet, manual suctioning device and low-cost ambulatory supply kit ("Go-Bags"), within a low-fidelity simulated training course for nurses and residents in Kigali, Rwanda. RESULTS: An image-based language and literacy-independent tracheostomy care manual was created and published on OPENPediatrics, an open-access online database of clinician-reviewed learning content. Participants of the training program pilot study reported the course to be of high educational and practical value, and described improved confidence in their ability to perform tracheostomy care procedures. CONCLUSIONS: Outpatient tracheostomy care may be improved upon by implementing image-based tracheostomy care manuals, locally-sourced tracheostomy care kits, and tailored educational material into a low-fidelity simulated tracheostomy care course. These materials were effective in improving technical skills and confidence among nurses and residents. These tools are expected to improve knowledge and skills with outpatient tracheostomy care, and ultimately, to reduce tracheostomy-related complications.

Prevalence of voice disturbances in pediatric airway patients: Are we missing anything?

OBJECTIVE: To report on the prevalence of voice disturbances in pediatric airway patients. METHODS: Consecutive patients seen in a specialized Center for Airway Disorders at a tertiary children's hospital from February 2017 to September 2017 were included. Patients' families were invited to complete a pediatric voice health handicap index (pVHI) questionnaire. Patients underwent evaluation including flexible laryngoscopy and/or direct laryngoscopy and bronchoscopy. RESULTS: 146 patients were included. Of these children, 73 patients (50.3%) presented with swallowing difficulty and 44 patients (30.3%) presented with respiratory complaints. Only 9 patients (6.2%) reported hoarseness initially. The median age at referral was 2.7 years of age (interquartile range: 1.4-4.3). The mean total pVHI score was 9.5 (± 12.9). Sixty-seven patients (45.9%) had abnormal pVHI findings of score > 4. Six patients (4.1%) had pVHI > 40. The mean pVHI score was 26.0 (± 21.1) among 12 patients with a history of tracheostomy, 12.0 (± 14.3) among 30 patients with laryngeal cleft, and 9.0 (± 9.9) among 19 patients with laryngomalacia. CONCLUSION: Voice disturbances are not uncommon in pediatric patients evaluated for airway disorders. Although patients may present with primary concerns for breathing or swallowing difficulties, many of these patients may need further work-up and treatment for dysphonia.

Medialization Laryngoplasty in Pediatric Patients With Unilateral Vocal Fold Immobility: A Case Series.

OBJECTIVES:: The aims of this study were to describe the impact of laryngoplasty in pediatric unilateral vocal fold immobility (UVFI) and to determine the impact of etiology and technique on voice and swallowing. METHODS:: A retrospective review was conducted of all children with UVFI undergoing medialization laryngoplasty at a pediatric hospital (2010-2017). Data including demographics, etiology, subjective voice quality, and swallowing function were collected. RESULTS:: The median age at first surgery among 25 patients with UVFI was 11 years (range, 1.2-25 years). The causes of UVFI were iatrogenic (76%), congenital (16%), and idiopathic (8%). A total of 38 laryngoplasties (24 injections, 11 Silastic implants, 3 Gore-Tex) were performed. Postoperatively, 78% of patients reported improvements in voice and 81% in swallowing. The median duration of voice improvement was 1.0 years (range, 0.1-10 years), with no significant difference by etiology or laryngoplasty technique. Patients who were ⩾10 years of age at surgery reported voice improvement significantly more often than patients <10 years of age at surgery (94% vs 61%, P = .04). CONCLUSIONS:: UVFI has a significant impact on health and quality of life. In this study we found that laryngoplasty is an effective way to address both voice and swallowing in pediatric UVFI. A greater proportion of children with improved voice quality were older at injection. Surprisingly, there was no difference in duration of voice improvement between permanent and absorbable materials. Although this duration would be considered acceptable for many injectable materials, the limited duration in permanent implantation techniques may represent the challenges of managing UVFI in the growing larynx of the pediatric population. Injection laryngoplasty with absorbable materials may serve as an adequate method of addressing UVFI in this population.

Voice Abnormalities and Laryngeal Pathology in Preterm Children.

INTRODUCTION: The prevalence of voice abnormalities in children born prematurely has been reported to be as high as 58%. Few studies have examined these abnormalities with laryngoscopic or videostroboscopic findings and characterized their laryngeal pathologies. OBJECTIVE: To review voice abnormalities in patients with a history of prematurity and characterize the etiology of their voice problems. A secondary objective is to see if there is a correlation between the findings and the patient's intubation and surgical history. METHODS: A retrospective chart review was conducted of all preterm patients seen in voice clinic at a tertiary pediatric hospital. Demographic data, diagnoses, and office laryngoscopies were reviewed as well as any speech therapy evaluations and/or medical and surgical treatments. RESULTS: Fifty-seven patients were included. Mean age at presentation was 5.1 (±4.3) years. Mean gestational age was 27.8 (±3.7) weeks. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) perceptual evaluations included a mean overall dysphonia severity of 46.6 (±24.2). Patients who had undergone prolonged intubation (⩾28 days) in the NICU or had prolonged NICU stays (>12 weeks) had significantly higher overall dysphonia severity scores. Thirty-three patients with vocal fold hypo- or immobility had significantly greater voice deviance in breathiness, loudness, and overall severity compared to those without vocal fold immobility. Of all patients, 35% were recommended surgical intervention and 49% voice therapy. CONCLUSION: Intubation greater than 28 days and prolonged NICU stays are associated with more severe dysphonia in premature patients. There should be a low threshold for clinical evaluation of dysphonia in this unique patient population.

Paradoxical vocal fold motion in children presenting with exercise induced dyspnea.

INTRODUCTION: Although dyspnea with exercise in the pediatric population can be multifactorial, the diagnosis of paradoxical vocal fold motion disorder (PVFMD) in this group is not well characterized. The objective of this study is to review the multiple causes of dyspnea with exercise in children, including the prevalence of PVFMD within this study population. METHODS: A retrospective review was conducted of patients seen at a tertiary pediatric hospital for exercise-induced dyspnea suspected to be related to PVFMD between January 2007 and July 2015. Inclusion criteria included assessment in a specialty exercise clinic and evaluation by a pediatric otolaryngologist and pulmonologist. Pre- and post-exercise pulmonary function tests and laryngoscopic examinations were performed. Data including co-morbidities, presenting symptoms, prior diagnoses and treatments, final diagnoses, prescribed treatments and outcomes were collected and analyzed. RESULTS: 294 patients were evaluated at our institution during the study period. 4 patients were excluded for insufficient data, which left 290 for analysis. 75 were male, 215 female. All patients underwent treadmill testing with monitoring to simulate strenuous exercise. Average patient age was 14.6 years; average BMI was 21.53. The most common sports to elicit symptoms were running and soccer. Patients most frequently complained of stridor or wheezing in addition to dyspnea. Throat tightness was also a common complaint. After evaluation, 86 patients were given the primary diagnosis of exercise-induced PVFMD. 54 patients were diagnosed with physiologic dyspnea and 30 with exercise-induced asthma. CONCLUSION: Pediatric patients presenting with exercise-induced dyspnea can have multiple etiologies for their symptoms including PVFMD. Other causes of dyspnea with exercise should not be underestimated.