We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Characteristics of Extremely Low Gestational Age Newborns Undergoing Tracheotomy A Secondary Analysis of the Trial of Late Surfactant Randomized Clinical Trial ONLINE FIRST

Katherine C. Wai, BS1; Roberta L. Keller, MD2; Leslie A. Lusk, MD2; Roberta A. Ballard, MD2; Dylan K. Chan, MD, PhD3 ; for the Trial of Late Surfactant (TOLSURF) Study Group
[+] Author Affiliations
1Medical Student, School of Medicine, University of California–San Francisco (UCSF)
2Department of Pediatrics, Division of Neonatology, UCSF
3Department of Otolaryngology–Head and Neck Surgery, UCSF
JAMA Otolaryngol Head Neck Surg. Published online September 01, 2016. doi:10.1001/jamaoto.2016.2428
Text Size: A A A
Published online

Importance  Tracheotomy is sometimes performed in extremely low gestational age newborns requiring prolonged ventilation. Studies suggest better neurodevelopmental outcomes in preterm newborns undergoing earlier tracheotomy (<120 days); however, guidelines for who should undergo tracheotomy and when to perform tracheotomy are unclear regarding infants receiving long-term positive-pressure support.

Objective  To determine the characteristics associated with tracheotomy in high-risk, extremely low gestational age newborns.

Design, Setting, and Participants  This secondary analysis of infants enrolled in the double-blind, randomized clinical trial known as the Trial of Late Surfactant (TOLSURF) was conducted from January 10, 2010, to September 3, 2013, in neonatal intensive care units. Participants included 511 premature infants (≤28 weeks’ gestational age) who were intubated and mechanically ventilated anytime between 7 and 14 days of life. Infants were randomized to receive late surfactant plus inhaled nitric oxide or inhaled nitric oxide alone. All data were collected prospectively. A mixed-effects model, with patient-level random effects included to account for individual homogeneity, was used to compare mean airway pressure (MAP) during the first 120 days in infants who did not undergo tracheotomy vs those who underwent tracheotomy. The present analysis was conducted from July 1, 2015, to March 29, 2016.

Exposures  Mean airway pressure, comorbidities of prematurity, airway stenosis, and airway malacia.

Main Outcomes and Measures  Tracheotomy.

Results  Of the 511 infants enrolled in TOLSURF, the mean (SD) gestational age was 25 (1.2) weeks, with a birth weight of 701 (165) g. Fifteen infants (2.9%) underwent tracheotomy. Among those undergoing tracheotomy, 7 infants (46.7%) had airway stenosis or malacia, none of whom died. Of the 8 infants who underwent tracheotomy without airway stenosis or malacia, 4 (50%) died. Mean age at tracheotomy was 126 days (95% CI, 108-144 days). In general, MAP increased over time in the group undergoing tracheotomy (+0.09 cm H2O/wk; 95% CI, 0.06-0.11 cm H2O/wk) but decreased in those who did not undergo tracheotomy (−0.20 cm H2O/wk; 95% CI, 0.19-0.21 cm H2O/wk; P < .001 for interaction).

Conclusions and Relevance  In this cohort of high-risk, extremely low gestational age newborns, trends in MAP can be a clinical indicator for infants requiring long-term positive-pressure ventilation who are at highest risk for receiving tracheotomy. Knowledge of this information may identify infants who would benefit from earlier consideration for tracheotomy.

Trial Registration  clinicaltrials.gov Identifier: NCT01022580

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?


Place holder to copy figure label and caption
Figure 1.
Mean Values of Mean Airway Pressure by Day

Comparison of infants receiving positive-pressure ventilation without tracheotomy vs those with tracheotomy in the first 120 days of life.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Mixed-Effects Model for Mean Airway Pressure During 120 Days of Life in the No Tracheotomy and Tracheotomy Groups

Individual patient trends are depicted in addition to overall trend (heavy lines) generated from the mixed-effects model. Thin gray lines correspond to infants who did not undergo tracheotomy; thin green lines correspond to infants who underwent tracheotomy.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.
Mean Airway Pressure in Infants Receiving Tracheotomy

Proportion of infants who received tracheotomy based on recorded mean airway pressure at 90 days.

Graphic Jump Location




Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections