Impact of Inhaled Tobramycin on Healthcare Utilization and Morbidity in Non-CF Pediatric Tracheostomy Dependent Patients with Pseudomonas Infections

Impact of Inhaled Tobramycin on Healthcare Utilization and Morbidity in Non-CF Pediatric Tracheostomy Dependent Patients with Pseudomonas Infections | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 27 July 2025 V1 Latest version Share on Impact of Inhaled Tobramycin on Healthcare Utilization and Morbidity in Non-CF Pediatric Tracheostomy Dependent Patients with Pseudomonas Infections Authors : Nada ALABDULKARIM 0000-0001-9657-8058 [email protected] , Kaitlyn KUNTZMAN , Raja BALUSU , Jonathan SCHROEDER , Jessica LUNDEEN , and Maria Arroyo Authors Info & Affiliations https://doi.org/10.22541/au.175364283.32962411/v1 Published American Journal of Respiratory and Critical Care Medicine Version of record Peer review timeline 353 views 185 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction: Tracheostomy-dependent pediatric patients face an increased risk of respiratory infections due to bacterial colonization by Pseudomonas aeruginosa (PA). Inhaled antibiotics, such as tobramycin, were developed as targeted treatments to reduce infection rates and the need for systemic antibiotics; however, limited research explores their use in tracheostomy-dependent children, particularly their impact on healthcare utilization and optimal dosing. Methods: We conducted a retrospective cohort study at Children’s National Hospital in Washington, DC, including tracheostomy-dependent patients aged 0 to 21 years from January 1, 2003, to June 30, 2023. Patients with cystic fibrosis (CF), bronchiectasis, or primary ciliary dyskinesia were excluded. The primary outcome measured emergency department visits, regular floor admissions, ICU admissions, and systemic antibiotic use six months before and after initiating inhaled tobramycin. The secondary outcome assessed changes in PA positivity rates. Results: A total of 42 children were included, with a median age of 2 years; 64.3% were male. Neurologic disorders (45.2%) and bronchopulmonary dysplasia (26.2%) were the most common reasons for tracheostomy. Inhaled tobramycin therapy was associated with reduced regular admissions (p = 0.04), ICU admissions (p = 0.006), and systemic antibiotic use (p = 0.05). PA positivity decreased from 40.5% to 30.9% post-treatment (p = 0.001). Conclusion: This study the largest in non-CF, tracheostomy-dependent children demonstrates that inhaled tobramycin significantly reduces hospitalizations, ICU admissions, and antibiotic use. Although 40% of patients received doses between 160 mg and 300 mg every other month, dose variability did not significantly impact clinical outcomes. Impact of Inhaled Tobramycin on Healthcare Utilization and Morbidity in Non-CF Pediatric Tracheostomy Dependent Patients with Pseudomonas Infections Nada ALABDULKARIM¹, MBBS, Kaitlyn KUNTZMAN¹, DO, Raja BALUSU¹, MD, Jonathan SCHROEDER², MD, Jessica LUNDEEN³, PharmD, BCPPS, Maria A. ARROYO, MD MBA ¹ ¹ Pediatric Pulmonary Department, Children’s National Hospital, Washington, DC, USA ² Pediatric Pulmonary Department, Brooke Army Medical Center, Fort Sam Houston, TX, USA ³ Department of Pharmacy Services, Children’s National Hospital, Washington, DC, USA Corresponding Author: Nada Alabdulkarim, MBBS Email: [email protected] Tel: 202-476-7714 Fax: 202-935-9378 Address: 111 Michigan Ave NW, Washington, DC 20010 Conflict of interest: The authors declare no conflicts of interest. Ethical Statement: Approved by the Institutional Review Board at Children’s National Hospital ID MOD00008607. Consent was waived due to the retrospective nature and de-identified data. Author Contributions: All authors contributed equally to the study design, data interpretation, and manuscript preparation. Keywords: Tracheostomy, Pseudomonas aeruginosa, Inhaled Tobramycin, Respiratory Infections Abstract: Introduction: Tracheostomy-dependent pediatric patients face an increased risk of respiratory infections due to bacterial colonization by Pseudomonas aeruginosa (PA). Inhaled antibiotics, such as tobramycin, were developed as targeted treatments to reduce infection rates and the need for systemic antibiotics; however, limited research explores their use in tracheostomy-dependent children, particularly their impact on healthcare utilization and optimal dosing. Methods: We conducted a retrospective cohort study at Children’s National Hospital in Washington, DC, including tracheostomy-dependent patients aged 0 to 21 years from January 1, 2003, to June 30, 2023. Patients with cystic fibrosis (CF), bronchiectasis, or primary ciliary dyskinesia were excluded. The primary outcome measured emergency department visits, regular floor admissions, ICU admissions, and systemic antibiotic use six months before and after initiating inhaled tobramycin. The secondary outcome assessed changes in PA positivity rates. Results: A total of 42 children were included, with a median age of 2 years; 64.3% were male. Neurologic disorders (45.2%) and bronchopulmonary dysplasia (26.2%) were the most common reasons for tracheostomy. Inhaled tobramycin therapy was associated with reduced regular admissions (p = 0.04), ICU admissions (p = 0.006), and systemic antibiotic use (p = 0.05). PA positivity decreased from 40.5% to 30.9% post-treatment (p = 0.001). Conclusion: This study the largest in non-CF, tracheostomy-dependent children demonstrates that inhaled tobramycin significantly reduces hospitalizations, ICU admissions, and antibiotic use. Although 40% of patients received doses between 160 mg and 300 mg every other month, dose variability did not significantly impact clinical outcomes. Abbreviations : PA: Pseudomonas aeruginosa ; CF: Cystic Fibrosis; BPD: Bronchopulmonary Dysplasia; CNS: Central Nervous System; ICU: Intensive Care Unit; ED: Emergency Department; FiO₂: Fraction of Inspired Oxygen; IRB: Institutional Review Board. Introduction: Tracheostomies are often lifesaving for children with complex respiratory conditions, providing essential airway support. However, their presence introduces new challenges. As foreign bodies, Tracheostomies significantly increase the risk of respiratory tract colonization and infection particularly with gram-negative bacteria like Pseudomonas aeruginosa (PA). This risk rises further when these patients are mechanically ventilated 1 . Studies reports that up to 90% of children start growing PA approximately five months after placing tracheostomy. 2–5 While a direct causal relationship between colonization and recurrent infection remains under investigation, the consequences of respiratory infections in this vulnerable population are clear: increased use of systemic antibiotics, more frequent emergency room visits and hospitalizations, and greater dependence on supplemental oxygen. These factors not only burden families but also strain healthcare resources. 6 Inhaled antibiotics were developed as an alternative to systemic antibiotics out of a need for targeted, high concentration treatment with fewer systemic side effect. 7 Tobramycin was first approved by the FDA in 1975, with subsequent approval of the inhaled formulation in 1997 for patients with cystic fibrosis (CF) aged six years and older with chronic PA infection. Since then, inhaled tobramycin has become a cornerstone of CF management, with studies demonstrating bacterial eradication as early as one to two months after initiation. 8–10 Adult studies recommend starting patients with chronic PA airway colonization on inhaled antibiotics once they develop three or more exacerbations per year. 10,11 The use of inhaled antibiotics in tracheostomized patients has demonstrated variable clinical outcomes. While some studies report reductions in respiratory infection frequency, hospitalization rates, and intravenous antibiotic use, others have shown no statistically significant benefits. 12,13 Inhaled tobramycin use in children with tracheostomies remains an area of clinical and scientific investigation. Due to the lack of guidance in pediatric patients, the dose, duration, and treatment schedule may vary depending on the institution. Efficacy studies are lacking creating an over-reliance on adult-driven data. Commercial insurance authorization, cost, and physician discomfort with off-label use also contribute to inconsistent application in this patient population. 2,14 Given the high burden of infection and healthcare utilization among tracheostomy-dependent children, there is a critical need for targeted research. We hypothesize that inhaled tobramycin, when used as chronic bacterial suppression therapy, reduces healthcare utilization and morbidity in non-CF, tracheostomy-dependent pediatric patients with PA infections. The objective of this study is to evaluate the impact of inhaled tobramycin on key clinical outcomes including emergency department visits, hospital admissions, and systemic antibiotic use as well as microbiologic outcomes in this high-risk population. Additionally, we aim to explore whether different dosing strategies influence these outcomes. Methods: This study is a retrospective cohort analysis conducted at Children’s National Hospital in Washington, DC, utilizing data obtained from the Electronic Health Record system. Data collection spanned from January 1, 2003, to June 30, 2023. Patients were identified using ICD-10 code Z93.0 and the presence of ’tobramycin, inhaled’ listed under medications. A total of 42 patients met the eligibility criteria and were included in the study (Figure 1). The primary outcome was to assess morbidity in tracheostomy-dependent children who received ’chronic bacterial suppression,’ defined as at least six months of continuous or every-other-month cycled inhaled tobramycin therapy, by evaluating their healthcare utilization. Morbidity was assessed for 6 months prior to starting treatment and for 6 months after treatment initiation. We included tracheostomy dependent patients aged 0 to 21 years. We excluded patients with CF, bronchiectasis, primary ciliary dyskinesia, and those patients who were on inhaled tobramycin for non-pseudomonal infections. Data Collection: Data abstraction involved detailed chart reviews, capturing patient demographics (age, gender, ethnicity, race), comorbid conditions, reason for tracheostomy, inhaled tobramycin dose and cycle (monthly vs. every other month), and respiratory support at baseline and after 6 months of therapy. Additionally, healthcare utilization before and after starting inhaled tobramycin was compared, including the number of systemic antibiotic courses for respiratory infections, positive respiratory cultures, viral panels, emergency room visits, regular floor hospital admissions, and intensive care unit admissions for primary respiratory causes. Data Management: Data was securely managed using randomly generated patient codes without identifiable information to ensure confidentiality. The study received approval from the Institutional Review Board with a waived consent requirement. Statistical Analysis: Descriptive statistics were generated, with categorical variables reported as absolute numbers and percentages, and continuous variables reported using medians with interquartile ranges. McNemar’s Chi-square test was employed to compare proportions of study participants for different categories of respiratory support and FiO2 requirements before and after inhaled tobramycin therapy. For healthcare utilization variables, paired t-tests or Wilcoxon signed-rank tests were used depending on the normality of data distribution. Results: Baseline Characteristics: The cohort, described in Table 1, included 42 pediatric tracheostomy dependent patients who received inhaled tobramycin therapy (Table 1). The median age at the start of inhaled tobramycin was 2 years (IQR 0.84, 6.25), and the majority of the participants were male (64.3%). The racial composition was diverse with 26.2% Caucasian, 21.4% African American, 4.76% Asian and 47.6% were other/unknown. Additionally, 16.7% of the participants were Hispanic. Comorbidities and Reasons for Tracheostomy: A significant proportion of the patient cohort had underlying Central Nervous System (CNS) disorders (52.4%), which was the most common comorbidity observed (Table 1). Neurologic/Genetic conditions were the leading reason for tracheostomy, accounting for 45.2% of cases. Bronchopulmonary Dysplasia (BPD) was another prevalent comorbidity, present in 33.3% of patients, and similarly, BPD was identified as a reason for tracheostomy in 26.2% of the cases. Clinical Outcomes Pre- and Post-inhaled tobramycin Therapy: A significant reduction in healthcare utilization was observed post-inhaled tobramycin therapy. The mean number of respiratory regular floor admissions decreased from 0.57 before inhaled tobramycin to 0.26 after inhaled tobramycin (p = 0.04) (Table 2). Similarly, the mean number of ICU Admissions was reduced from 1.64 before inhaled tobramycin to 0.98 post-inhaled tobramycin (p = 0.006). The use of systemic antibiotics also decreased from 2.23 courses to 1.55 courses (p = 0.05). There was no significant decrease noted in ED presentation. Respiratory Support and FiO2 Requirements: The distribution of respiratory support types and FiO2 requirements before and after inhaled tobramycin therapy did not show significant changes (p > 0.05). The majority of patients remained in the same respiratory support category (Table 3). Microbial Outcomes: The positivity rate for PA significantly decreased after inhaled tobramycin therapy, with 30.95% of patients testing positive post-inhaled tobramycin compared to 40.48% pre-inhaled tobramycin (p = 0.001) (Table 2), (Figure 1). Other bacterial and viral pathogens did not show significant changes in positivity rates. Impact of Inhaled tobramycin Dose and Cycle on Outcomes: Patients were categorized into four groups based on inhaled tobramycin dosage and frequency: 150 mg or less monthly, 150 mg or less every other month, 160-300 mg monthly, and 160-300 mg every other month. There were no statistically significant differences in the type of respiratory support or FiO2 requirements across these groups post-inhaled tobramycin therapy (Table 4). Additionally, the number of respiratory ED visits, respiratory floor admissions, ICU admissions, and required systemic antibiotics did not differ significantly across the dose groups (Table 4). Discussion: Inhaled antibiotics are increasingly recognized for their role in breaking the cycle of inflammation and reducing the need for systemic antibiotics among tracheostomized patients. 15 This study represents the largest cohort to date of pediatric, tracheostomy-dependent, non-CF patients with PA infections assessed for the impact of prophylactic inhaled tobramycin therapy. Our findings indicate a significant reduction in PA infections, healthcare utilization, including hospitalizations, ICU admissions, and systemic antibiotic use. According to several analyses, Pseudomonas aeruginosa (PA) is the most frequently isolated bacterium in tracheostomized individuals, with prevalence estimates as high as 50%.² ¹⁴ ¹⁵ These patients are at increased risk for biofilm formation, which allows bacteria to survive long-term by shielding them from environmental stressors and immune responses, thereby complicating treatment.¹⁶ ¹⁷ The role of inhaled antibiotics in eradicating biofilms has been extensively studied in children with cystic fibrosis (CF). A meta-analysis comparing inhaled antibiotics to placebos in CF patients demonstrated reductions in exacerbations, modest improvements in lung function, and enhanced quality of life. However, studies in non-CF populations remain limited and less comprehensive. ¹⁸ The most common reason for readmissions among tracheostomy patients is bacterial tracheitis. 3 Children who are persistently colonized with Gram-negative bacteria, such as PA experience longer intensive care unit stays, and more hospitalizations. In Previous analyses, inhaled antibiotics have been shown to significantly reduce respiratory infections, systemic antibiotic use, hospitalization rates, bacterial colonization, and duration of stay in intensive care units. 13 16 While our study primarily focused on inhaled tobramycin therapy due to its widespread use in our institution and its established safety profile, the above mentioned analyses have investigated other antibiotics, such as gentamicin and colistin. Differences in antibiotic selection, patient characteristics, and observation periods may account for some of the observed variations in outcomes across studies. For instance, a smaller case series involving six patients, with a shorter observation period, reported no significant reduction in the use of broad-spectrum antibiotics or respiratory infections. 12 When reviewing the impact of inhaled tobramycin on the frequency of other organisms in our cohort, we observed that it remained constant. The second most frequently isolated pathogens were Staphylococcus aureus (9.52% of cases), Klebsiella pneumoniae, and Stenotrophomonas maltophilia (each at 4.7%), consistent with findings from other studies. 13,15,17,18 The current literature continues to explore viral–bacterial interactions during acute respiratory infections. 4 In line with this, we investigated the potential impact of inhaled tobramycin therapy on viral positivity. Rhinovirus/enterovirus remained the most frequently detected viral pathogens both before and after therapy, with a positivity rate of 16.67%. However, this finding was not statistically significant. Certain comorbidities, including neurological conditions such as hypoxic-ischemic encephalopathy, neuromuscular disorders, and CNS infections, significantly increase the risk of tracheostomy placement due to associated respiratory complications, such as upper airway obstruction, recurrent pneumonia, and prolonged mechanical ventilation. 19,20 Similarly, in our study, CNS disorders were the most common comorbidity, affecting 52.4% of the cohort and being the leading reason for tracheostomy placement. No previous study has examined changes in respiratory support following inhaled antibiotic therapy. In our study, we did not observe significant changes in respiratory support levels or FiO2 requirements after initiating inhaled tobramycin treatment. This suggests that while inhaled tobramycin effectively reduces bacterial burden and infection frequency, it may not directly influence respiratory mechanics or the need for respiratory support in tracheostomy-dependent patients. Few studies have discussed inhaled tobramycin dosing and systemic absorption in non-CF patients. About 40% of our cohort received doses between 160 mg and 300 mg every other month. This dosing variability was reported in other studies, where regimens ranged from 80 mg twice daily to 300 mg once daily. 13,17 Despite these variations, there is no clear consensus on the optimal dose or frequency of inhaled tobramycin therapy for non-CF pseudomonal infections. Notably, in our study, dosing did not significantly impact clinical outcomes, including respiratory support and healthcare utilization. These findings raise the possibility that lower doses of inhaled tobramycin may be just as effective as higher doses in non-CF patients, given the lack of significant differences in clinical outcomes. This highlights the need to explore more standardized, potentially lower-dose regimens. In trials testing the systemic absorption of inhaled tobramycin, most tracheostomy-dependent patients had undetectable trough values, indicating minimal systemic absorption. However, individuals with chronic kidney disease, those with tracheostomies, and younger patients deemed prone to have detectable trough levels, which were managed through dose adjustments. 21,22 Nonetheless, the retrospective design of our study limited the availability of data on adverse effects, as these were not routinely collected. Children with tracheostomies face significant healthcare expenses, with approximately 70% of their hospital readmissions resulting from respiratory failure or infections 23 . In 2016, hospital stays involving tracheostomies with ventilator use ranked among the most expensive non-birth-related admissions 24 . Research indicates that each additional hospital day for a child with a tracheostomy adds over $1,000 to the cost, and when ICU care is required, a nine-day hospital stay can cost nearly $60,000 23 . Given these financial and health challenges, preventing respiratory infections in this vulnerable population is crucial to reducing hospitalizations. Alternatively, inhaled antibiotics can offer a potentially cost-effective strategy for infection prevention. A 28-day supply of generic tobramycin inhalation solution (300 mg/5 mL) costs approximately $463 for 30 ampules 25 . While this treatment involves an upfront expense, it may significantly lower hospitalization rates, reducing financial strain and improving long-term health outcomes for children with tracheostomies. Conclusion and limitations: In conclusion, this study the largest of its kind in non-CF, tracheostomy-dependent children demonstrates that chronic bacterial suppression with inhaled tobramycin significantly reduces PA infection rates, hospitalizations, ICU admissions, and systemic antibiotic use. We focused on tobramycin due to its widespread use at our institution and its well-established safety profile. Lower doses appeared to be as effective as higher ones, offering a promising opportunity to optimize treatment while minimizing drug exposure. Despite these encouraging results, the study has some limitations, and external validity may be limited by the single-center and institutional practices. More studies are needed to assess the impact of inhaled tobramycin “chronic bacterial suppression therapy” on bacterial resistance, PA colony-forming units, hospital length of stay, systemic absorption, and potential adverse effects such as ototoxicity and nephrotoxicity. 1. 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Retrieved January 27, 2025. https://www.drugs.com/price-guide/tobramycin Figure 1: Patient Selection Flowchart Table 1: Baseline Patient Characteristics: Age at start of inhaled Tobramycin in years a 4.57 (5.58) 2.00 (0.84, 6.25) Gender (N = 42) Count (%) Male 27 (64.30 %) Female 15 (35.70 %) Race Count (%) African American 9 (21.4 %) Caucasian 11 (26.2 %) Asian 2 (4.76 %) Other/unknown 20 (47.6 %) Ethnicity Count (%) Hispanic 7 (16.70 %) Non-Hispanic 34 (81.0 %) Unknown 1 (2.38 %) Comorbidities Count (%) Bronchopulmonary Dysplasia (BPD) 14 (33.3 %) Central Nervous System (CNS) 22 (52.4 %) Neuromuscular System (NMS) 5 (11.9 %) Cardiovascular System (CVS) 14 (33.3 %) Airway obstruction/ abnormal anatomy 15 (35.7 %) Indication for Tracheostomy Count (%) BPD 11 (26.2 %) Neurologic/Genetic 19 (45.2 %) Anatomic/ airway obstruction 9 (21.4 %) Other/unknown 3 (7.14 %) Table 2: Comparison of PA Positivity Rate and Healthcare Utilization Before and After Inhaled tobramycin Therapy: Number of Respiratory ED Visits a 42, 0.67 (1.05) 42, 0.45 (0.80) 0.26 Number of Respiratory Floor Admissions a 42, 0.57 (1.21) 42, 0.26 (0.59) 0.04* Number of ICU Admissions a 42, 1.64 (1.34) 42, 0.98 (1.05) 0.006* Number of Systemic Antibiotics a 40, 2.23 (1.61) 40, 1.55 (1.48) 0.05 Pseudomonas Aeruginosa Presence Before Inhaled Tobramycin Pseudomonas Aeruginosa Presence After Inhaled Tobramycin Yes No p-value Yes 13 (30.95 %) 17 (40.48 %) 0.001* No 2 (4.76 %) 10 (23.81 %) a: Variable is not normally distributed. Table 3: Comparison of Patients’ Respiratory Support Before and After Inhaled Tobramycin Therapy (N for matched pairs = 42): Respiratory Support (Before Inhaled Tobramycin) HME without Oxygen HME with Oxygen Mechanical ventilation without oxygen Mechanical ventilation with oxygen p-value HME without Oxygen 5 (11.90 %) 0 1 (2.38 %) 1 (2.38 %) 1.00 HME with Oxygen 4 (9.52 %) 5 (11.90 %) 1 (2.38 %) 2 (4.76 %) Mechanical ventilation without oxygen 0 0 3 (7.14 %) 0 Mechanical ventilation with oxygen 1 (2.38 %) 1 (2.38 %) 0 18 (42.86 %) FiO2 Requirement (Before Inhaled Tobramycin) FiO2 requirement (After Inhaled tobramycin) 30% p-value 30% 5 (11.90 %) 6 (14.29 %) Abbreviations: HME = heat moisture exchanger, FiO₂ = fraction of inspired oxygen Table 4: Impact of Inhaled Tobramycin Therapy on Respiratory Support and Healthcare Utilization Based on Different Dosing Groups HME without Oxygen 1 (14.29 %) 7 (50.00 %) 0 2 (11.76 %) 0.08 HME with Oxygen 3 (42.86 %) 1 (7.14 %) 1 (25.00 %) 1 (5.88 %) Mechanical ventilation without oxygen 0 1 (7.14 %) 0 4 (23.53 %) Mechanical ventilation with oxygen 3 (42.86 %) 5 (35.71 %) 3 (75.00 %) 10 (58.82 %) FiO2 Requirement 30% 3 (42.86 %) 4 (28.57 %) 0 (0 %) 2 (11.76 %) Number of Respiratory ED Visits a Mean (SD) 7, 0.14 (0.38) 14, 0.36 (0.63) 4, 0.50 (1.00) 17, 0.65 (1.00) 0.59 Number of Respiratory Floor Admissions a Mean (SD) 7, 0.29 (0.76) 14, 0.43 (0.65) 4, 0 (0) 17, 0.18 (0.53) 0.31 Number of ICU Admissions a Mean (SD) 7, 1.00 (0.58) 14, 1.21 (1.31) 4, 0.75 (0.50) 17, 0.82 (1.07) 0.72 Number of Systemic Antibiotics a Mean (SD) 7, 2.29 (2.43) 12, 2.08 (1.31) 4, 0.75 (0.50) 17, 1.06 (1.03) 0.13 a: Variable is not normally distributed. Abbreviations: HME = heat moisture exchanger; FiO₂ = Fraction of Inspired Oxygen; ICU: intensive care unit; ED: emergency department Information & Authors Information Version history V1 Version 1 27 July 2025 Peer review timeline Published American Journal of Respiratory and Critical Care Medicine Version of Record 1 May 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords inhaled tobramycin pseudomonas aeruginosa respiratory infections tracheostomy Authors Affiliations Nada ALABDULKARIM 0000-0001-9657-8058 [email protected] Children's National Hospital View all articles by this author Kaitlyn KUNTZMAN Children's National Hospital View all articles by this author Raja BALUSU Children's National Hospital View all articles by this author Jonathan SCHROEDER Brooke Army Medical Center Medical Library View all articles by this author Jessica LUNDEEN Children's National Hospital View all articles by this author Maria Arroyo Children's National Hospital View all articles by this author Metrics & Citations Metrics Article Usage 353 views 185 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Nada ALABDULKARIM, Kaitlyn KUNTZMAN, Raja BALUSU, et al. Impact of Inhaled Tobramycin on Healthcare Utilization and Morbidity in Non-CF Pediatric Tracheostomy Dependent Patients with Pseudomonas Infections. Authorea . 27 July 2025. 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