Research by CHLA Pediatric Hospitalist Seeks to Sharpen Clinical Guidelines for Children with Respiratory Infections Related to Tracheostomy
Children with tracheostomy are at high risk for infections of the airway and lungs, which can lead to frequent hospitalization, overuse of antibiotics, and other problems. Christopher J. Russell, MD, MS, Associate Professor of Clinical Pediatrics at CHLA, investigates better ways to improve health outcomes for this understudied patient population.
As a pediatric hospitalist, Christopher J. Russell, MD, MS, of Children's Hospital Los Angeles (CHLA), cares for children with complex medical problems, including patients who have had tracheostomies—tubes inserted through openings in the neck and into the windpipe to enable breathing. While tracheostomies can be temporary, they may remain in place for several years or permanently for many children with traumatic injuries or serious health conditions that impair breathing.
Unfortunately, while necessary to support respiration, the mere presence of tracheostomy tubes raise the risk of health complications. "The airway is not sterile, so once you put a foreign body into the neck, you're more likely to grow a virus or bacterial infection," said Russell. In fact, such infections are the most common reason for hospitalization in children with tracheostomy. "Children with medical complexity and tracheostomy make up a small proportion of the hospital population but approximately 40 percent of hospital charges."
Bacterial lung infections such as pneumonia account for more than 4,600 hospitalizations and approximately $300 million in U.S. hospital charges. However, since the issues surrounding these types of respiratory infections have not been extensively researched and are not fully understood, explained Russell, physicians do not have clear guidelines to diagnose and treat them, or better yet, prevent them. Developing evidence-based guidelines and improving care for these patients has been one of Russell's primary research goals for several years.
The most common type of infection for children with tracheostomy is Pseudomonas aeruginosa (Pa), which is present in up to 90 percent of patients. However, few studies have examined the association between Pa infection and clinical outcomes in children with tracheostomy. Russell recently completed a retrospective cohort study of 210 children under 18 years old to identify the factors associated with chronic Pa infection in the first two years after tracheotomy.
The study, "Development of Chronic Pseudomonas aeruginosa-Positive Respiratory Cultures in Children with Tracheostomy" was published in the journal Lung, in 2019. Co-authors with Russell were Tamara D. Simon, MD, and Michael N. Neely, MD.
The research, which built upon Russell's previous investigation, found that cultures grown from samples of children prior to planned tracheotomy could show the presence of Pa, and that Pa-positive patients were at higher risk of developing chronic Pa infection after tracheostomy. This suggests future research directions, said Russell, to examine pre-tracheotomy Pa eradication or suppression protocols that could reduce the number of chronic infection and the associated hospitalization, potential overtreatment, and costs.
Russell will continue study of respiratory infection risk among young tracheostomy patients as a principal investigator through a recently awarded grant from the Gerber Foundation. The grant will fund a three-year, multicenter study involving five sites: CHLA, Seattle Children's Hospital, Children's National Hospital in Washington, D.C., Cincinnati Children’s Hospital, and Johns Hopkins All Children's Hospital in St. Petersburg, Fl.
"With the grant from the Gerber Foundation, we can do a prospective study to get more granular data to see full clinical trajectory of these children from admission forward," he said.
Russell has also received a pilot funding award from the Southern California Clinical and Translational Science Institute (SC CTSI), starting July 2020, to evaluate a new rapid diagnostic test for Pa that returns results in one to two hours, rather than the two to three days. Russell will lead a study to determine if the new, faster test could help doctors treat lung infections effectively without overuse of antibiotics.
Russell sharpened his clinical research focus and skills as a scholar in the KL2 Mentored Career Development Program, a program of the SC CTSI designed to advance the careers of rising principal investigators. Among his mentors were Drs. Neely and Simon, Christopher J.L. Newth, MD, as well as Wendy Mack, PhD, director of the SC CTSI's BERD core that provides expert consulting in biostatistics plans, research design and epidemiology.
"There's no question the KL2 program accelerated my development as a clinical researcher," said Russell. "It gave me the background I needed in research methodology and provided the protected time and mentorship to enable me to progress to the next level." Russell was recently promoted to Associate Professor of Clinical Pediatrics at Keck School of Medicine of USC.
The SC CTSI also provides a broad array of clinical services, pilot funding, and expert consulting to help clinical and translational investigators across the entire USC and CHLA research community, several of which Russell accessed in his Pa-infection study. They included the REDCap (Research Electronic Data Capture) data management system—a free, secure, web-based application where users can rapidly develop databases and surveys for research studies.