\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[polish,greek,english]{babel}



\usepackage{float}








\begin{document}

\title{Bronchopulmonary Dysplasia and Ventilation-Associated Outcomes After
Pediatric Tracheostomy}



\author[1]{Romaine Johnson}%
\author[1]{Dylan Beams}%
\author[1]{Arushii Nadar}%
\author[2]{Folashade A. Afolabi}%
\author[2]{Andrew Gelfand}%
\author[1]{Rebecca Brooks}%
\author[1]{Stephen R. Chorney}%
\author[1]{Yann-Fuu Kou}%
\affil[1]{The University of Texas Southwestern Medical Center}%
\affil[2]{The University of Texas Southwestern Medical Center Department of Pediatrics}%


\vspace{-1em}



  
  \date{May 16, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
\emph{Objectives}: To determine the time to ventilator liberation and
decannulation after tracheostomy placement in children with
bronchopulmonary dysplasia (BPD) and pulmonary hypertension.
\emph{Methods:} A prospective cohort study included all children
(\textless{}18 years old) who underwent tracheostomy between 2015 and
2021 with or without a diagnosis of BPD. The primary outcome measures
were times to mechanical ventilator liberation, tracheostomy
decannulation, or death with tracheostomy in place. Patient
demographics, associated comorbidities, and outcomes were compared
between groups. \emph{Results:} A total of 318 children met inclusion
with a median (interquartile, IQR) age at tracheostomy of 6.9 (IQR: 4.1
-- 49.2) months and 54\% (N=170) were male. A diagnosis of BPD was made
for 43\% (N=136) and this group was younger at tracheostomy placement
(5.2 vs. 24.5 months, \emph{P}\textless{}.001) and more often had
pulmonary hypertension (65\% vs. 24\%, \emph{P}\textless{}.001) than
children without BPD. Children with BPD spent a median of 2.92 years
(IQR: 1.60 -- 4.03) on mechanical ventilation compared to 1.84 years
(IQR: 0.84 -- 3.60) for children without BPD ( \emph{P}=.003).
Unadjusted estimation of time to decannulation was longer for children
with BPD (HR=0.92, 95\% CI: 0.62 -- 1.38). The adjusted survival
analysis for time to mortality included pulmonary hypertension as a
variable of significance (aHR= 2.5, 95\% CI: 1.43 -- 4.40).
\emph{Conclusion}: The presence of BPD is associated with an increased
duration of mechanical ventilation and time to tracheostomy
decannulation. Pulmonary hypertension is associated with an increased
mortality risk among this vulnerable population of children.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease
of prematurity with an estimated 10,000 to 15,000 infants diagnosed with
BPD annually in the United States. Despite changes in diagnostic
criteria, most studies suggest that both the incidence and prevalence
have remained stable.\textsuperscript{1,2} Patients diagnosed with BPD
necessitate increased healthcare resources and often require long-term
respiratory support. Additionally, comorbid medical conditions such as
pulmonary hypertension and other sequelae of prematurity can influence
their need for further care.\textsuperscript{3-9}

Tracheostomy placement is often considered for children with
BPD.\textsuperscript{10,11} These patients require prolonged
hospitalization and long-term intensive care given their medical
complexity.\textsuperscript{12-16} Research on tracheostomy outcomes for
children with BPD has yielded varied findings on morbidity and
mortality, perhaps due to the influence of
comorbidities.\textsuperscript{17-20} The relationship between patient
characteristics, rates of tracheostomy, hospital readmissions, and
mortality have been described for children with
BPD.\textsuperscript{21,22} The increasing use of tracheostomy in this
population has resulted in single-instution series on duration of
ventilator support and tracheostomy
dependence.\textsuperscript{17,18,20,23} However, there have been
limited prospective studies looking at long-term ventilator and
tracheostomy outcomes among children with BPD.

The Children's Health Airway Management Program (CHAMP) prospectively
follows all children who had tracheostomy placement at Children's
Medical Center Dallas. Children are enrolled in a registry until
decannulation, death, or reaching 21 years of age. This dataset has been
used previously to publish work related to perioperative outcomes,
socioeconomic and racial disparities, as well as tracheostomy caregiver
quality of life.\textsuperscript{24-27} CHAMP is therefore well-suited
to explore longterm outcomes after tracheostomy surgery in children with
BPD. The primary objective of this study is to examine the relationship
between the presence of BPD and pulmonary hypertension with a patient's
time to ventilator liberation as well as eventual decannulation. Based
on prior data,\textsuperscript{28} we hypothesized that children
diagnosed with BPD and resultant secondary pulmonary hypertension would
have an increased duration of mechanical ventilation and thus a
prolonged time to tracheostomy decannulation.

\textbf{Methods}

A prospective cohort study included all children \textless{}18 years old
who underwent tracheostomy placement between January 1, 2015 and
December 31, 2021 at Children's Medical Center Dallas. This tertiary
care children's hospital located in Dallas, Texas has a Level I
pediatric trauma center and a Level IV neonatal intensive care unit
(NICU). Patients who underwent tracheostomy at another facility or were
older than 18 years at the time of tracheostomy were excluded. This
study was approved by the UT Southwestern Medical Center Institutional
Review Board (STU 2019-1103).

The CHAMP prospective tracheostomy registry was developed as a quality
improvement initiative to track longitudinal outcomes of children after
tracheostomy. CHAMP maintains the registry with monthly data cleaning
performed to update each patient's current status. Children with
tracheostomies are entered on the day of their tracheostomy and followed
until reaching 21 years old, tracheostomy decannulation, or death. The
registry is stored in the hospital electronic medical record system. All
visits to the healthcare system are subsequently captured (e.g.,
outpatient clinic, inpatient admission, emergency department visits,
etc.). For this study, data were collected and managed using REDCap
electronic data capture tools hosted at UT Southwestern Medical
Center.\textsuperscript{29} Data entry personnel were blinded to the
primary hypothesis of the study.

The cohort was divided into BPD and non-BPD patients. The diagnostic
definition of BPD continues to lack uniformity. However, children
classified as having BPD were generally premature infants who required
respiratory support for more than 28 days after birth. The primary
outcome measures were times to mechanical ventilator liberation,
tracheostomy decannulation, or death with tracheostomy still in place.
Censoring occured if the patient was lost-to-follow or aged out of the
system at 21 years old.

The following demographic variables were collected: age at tracheostomy
placement (months), sex (male or female), race (Native American or
Pacific Islander, Asian, African American or Black {[}hereto referred to
as Black{]}), ethnicity (Hispanic or non-Hispanic), primary payer
(Medicaid, private, other), and the caregiver's preferred language
(English, Spanish, other). Both race and preferred language are
self-selected by the caregiver.

Comorbidities recorded, which were based on the \emph{International
Classification of Diseases, 9\textsuperscript{th} Revision} (ICD-9)
and\emph{International Classification of Diseases, 10th Revision-
Clinical Modification} (ICD-10-CM) codes included: BPD, preterm birth
(\textless{} 37 weeks gestatational age), congenital malformations,
newborn complications, maternal complications, bacterial sepsis of
newborn, birth hypoxia, respiratory distress syndrome, sepsis, cardiac
conditions, chronic respiratory failure, trauma, pulmonary hypertension,
and tracheobronchomalacia.

The Social Capital Atlas and Opportunity Atlas
(https://opportunityinsights.org/) datasets were used to measure the
cohort's socioeconomic status (SES). The specific measures from the
Social Capital Atlas were economic connectedness (EC) and support ratio,
while the fraction of single parents and median household income were
obtained from the Opportunity Atlas. EC measures low-SES individuals'
connection to high-SES individuals within their ZIP code. It is
calculated by taking the average share of high-SES friends among low-SES
individuals in each ZIP code. The support ratio measures the density of
social networks within a ZIP code. It is calculated by taking the
proportion of within-ZIP code friendships where the pair share a third
mutual friend within the same ZIP code. The fraction of single parents
by county is defined as the percentage of households with children under
18 that a single parent heads. The median household income was also
determined at the county level. These measures can help glean insights
into the risk of economic hardship or challenges to caring for a child
with a tracheostomy.\textsuperscript{30-32}

The child's last known status was recorded as of their latest follow up
date. This included: alive with a tracheostomy, decannulated, died with
a tracheotomy in place, or lost to follow-up. Lost to follow-up was
defined as not being seen by any provider in the system in 24 months.
Further, the neurocognitive ability of the child (average, mild/moderate
impairment, and severe impairment) was documented. Severe impairment
refers to children with global developmental delay.

All statistics were performed with Stata Statistical Software
(StataCorp. 2023. \emph{Stata Statistical Software: Release 18} .
College Station, TX: StataCorp LLC.) The distribution of continuous data
was determined with quantile plots and the Shapiro-Wilk test for
normality. Due to the skewness of the data, continuous variables are
presented as median with interquartile ranges (IQR) (25th - 75th
percentile). Categorical data are presented as counts with percentages.
Kruskal-Wallis's test for continuous variables was used and the Pearson
chi-square test for categorical variables to determine differences
between the two groups. A parametric regression survival analysis with
Weibull distribution was created to model the hazard ratios of the three
outcomes and adjust for confounding. In addition to BPD, the model
included variables with a \emph{P} \textless{}.25 in the univariate
analysis. Variables where the \emph{P} \textgreater{}.05 were
sequentially dropped until the final model was formed. Survival analysis
results are presented as hazard ratios (HR) with 95\% confidence
intervals (CIs). The model was checked for fit using visual inspection
of goodness of fit plots.

A power analysis was performed using a two-sample log-rank test to
determine the required sample size for our study. Based on previous
research, an anticipated hazard ratio of 1.7 was considered, which
indicates a 70\% higher risk of decannulation at any given time in the
BPD group compared to the non-BPD group. The significance level (alpha)
was set to 0.05, and the power at 0.8. This resulted in a total required
sample size of 184 participants, distributed evenly into two groups of
92 each. To correct for multiple comparisons, the Bonferroni method was
used, and the statistical significance was set to\emph{P}
\textless{}.0167 to account for our three primary outcomes. Of note,
secondary findings of significance are to be interpreted with caution.
Missing data were handled by listwise deletion.

\textbf{Results}

There were 318 patients who met inclusion. The mean time for follow-up
was 2.3 years (range = 0.1 to 7.8 years). The final status at the end of
the follow-up period was N=140 (44\%) alive with a tracheostomy in
place, N=96 (30\%) decannulated, N=61 (19\%) died with a tracheostomy in
place, and N=21 (6.6\%) lost to follow up.

Tracheostomies were placed at a median age of 6.9 months (IQR: 4.1 --
49.2 months). The population was N=170 (53\%) male and N=148 (47\%)
female. There were N=175 (55\%) White, N=105 (33\%) Black, N=15 (4.7\%)
Asian, and N=23 (2.7\%) other. There were N=96 (30\%) who identified as
Hispanic. The preferred language was predominately English (N= 270,
86\%) followed by Spanish (N=39, 12\%). For further details, please
refer to \textbf{Table 1} .

Socioeconomic findings for the population were based on zip-code and
county level measurements obtained from the Opportunity Insights'
databases on Social Capital and Opportunity Indices. The median (IQR)
range for the economic connectiveness ratio was 0.73 (0.58-0.92); the
support ratio was 0.85 (0.81-0.94); the fraction of single parents was
0.37 (0.28 -- 0.38), and median household income was \$53,442 (\$49,529
-- \$62,463).

\textbf{Table 2} shows associated conditions for the patient population.
Notable findings include 41\% (N=121) short gestation; N=72 (23\%)
having a history of respiratory distress syndrome; and N=133 (42\%)
being diagnosed with pulmonary hypertension. Other associated conditions
included cardiac conditions (42\%), birth hypoxia (11\%), and
tracheobronchomalacia (7.5\%).

The median length of stay for the index stay when the tracheostomy was
placed was 101 days (IQR: 52-166 days). The total number of patients
discharged on a ventilator was N=272 (86\%). The median time to
ventilator liberation and eventual decannulation was 2.3 and 1.9 years,
respectively. The median time to death for patient who expired with a
tracheostomy in place was 0.70 years. The level of neurocognitive
disability was considered severe in N=170 (59\%) of children.

The number of children with BPD was N=136 (43\%). Almost all were
discharged on a ventilator. There were several statistically significant
differences between children with tracheostomies with and without BPD.
Children with BPD tended to be younger at the time of tracheostomy
placement (5.2 months vs. 24.5 months, \emph{P} \textless{}.001), have
shorter gestational ages (28 weeks vs. 38 weeks,\emph{P}
\textless{}.001), and weighed less at tracheostomy placement (1.1 vs.
2.9 kg, \emph{P} \textless{}.001). A higher proportion were Black (44\%
vs. 25\%, \emph{P} =.004). The level of social support by neighborhood
level was slightly decreased among children with BPD (0.83 vs. 0.86,
\emph{P} =.021). Severe disabilities such as non-ambulant cerebral palsy
or profound sensorineural hearing loss were also more common among those
with BPD (63\% vs. 57\%, \emph{P} =.003). See Table 3 for additional
details.

Unadjusted estimates of time to mechanical ventilator liberation for
children with BPD, compared to non-BPD children, showed a hazard ratio
of 0.81 (95\%, CI 0.63 -- 1.04, \emph{P} =.10). A confounder-adjusted
estimation also did not find any variable associated with time to
ventilator liberation. Additional analysis showed children with BPD
spent a median of 2.92 years (IQR 1.60 -- 4.03, \emph{P} =.003) on
mechanical ventilation compared to 1.84 years (IQR 0.84 -- 3.60,\emph{P}
=.003) for children without BPD. See \textbf{Table 4} for further
details.

Unadjusted estimation of time to decannulation for children with BPD
yielded HR=0.92 (95\% CI, 0.62 -- 1.38). The adjusted model found the
time on a ventilator interacted with BPD (see \textbf{Table 5} ). The
model suggests that children with BPD on a ventilator are more likely to
take longer to decannulate than a child on a ventilator who does not
have BPD. Using the 25\textsuperscript{th}, 50\textsuperscript{th}, and
75\textsuperscript{th} percentiles for time to decannulation, the median
times to decannulation would be 2.6, 3.2, and 4.5 years for BPD and 1.8,
3.1, and 5.8 years for non-BPD children. The model's goodness-of-fit is
presented in \textbf{Figure 1} . In addition, statistical significance
held when using jackknife regression variance components estimation for
model validation suggesting that outliers did not have a substantial
impact on regression coefficients.

The unadjusted survival analysis for time to mortality found that the HR
for BPD was 0.58 (95\% CI, 0.34 -- 0.98). The adjusted model includes
pulmonary hypertension as a variable of significance (aHR = 2.5, 95\%
CI: 1.43 -- 4.40) while reducing the confidence interval of the effects
of BPD on mortality (aHR = 0.38, 95\% CI: 0.22 -- 0.69). The model did
not reveal a statistical interaction between the two variables
suggestive of an additive effect (\textbf{Table 6)} . Goodness-of-fit
plots (\textbf{Figure 2} ) and jackknife regression of the model
suggested a good fit. Additional subgroup or sensitivity analyses were
not performed.

\textbf{Discussion}

This prospective study of children with a tracheostomy found that the
diagnosis of BPD had a statistically significant impact on time to
ventilator liberation as well as decannulation. Children with BPD
obtaining a tracheostomy required increased duration of ventilation and
took longer to achieve decannulation compared to non-BPD children.
Additionally, BPD was associated with a lower hazard of mortality,
although this effect was influenced by the presence of pulmonary
hypertension. This data can further guide clinicians as they care for
this critical population of tracheostomy patients.

The presence of BPD was associated with an increased time to ventilator
liberation. Prior studies have similarly demonstrated that successful
liberation from the ventilator is likely within the first few years of
life across patients with different classes of BPD
severity.\textsuperscript{17,20} While these findings are encouraging,
it remains important to note that increased durations of mechanical
ventilation are likely to be required by children with BPD. This
increased duration of mechanical ventilation can have a significant
impact on not only the quality of life of the patient, but also their
caregivers. These impacts manifest as patients and their families
navigate challenges associated with medical equipment, physician visits,
financial responsibilities, and potential complications such as
infections that may necessitate readmission.\textsuperscript{4,13,25} In
order to improve care for this vulnerable population, physicians should
recognize how social determinants of health can impact outcomes. Further
studies examining these factors will be beneficial when managing BPD
patients with a tracheostomy.

Children with BPD on mechanical ventilation had increased times to
tracheostomy decannulation. Patients who undergo tracheostomy are more
likely to be medicaly complex and thus more likely to experience higher
rates of complications due to the presence of comorbid
conditions.\textsuperscript{33,34} Moreover, children with a
tracheostomy for respiratory support in the setting of BPD have higher
rates of hospitalization and morbidity.\textsuperscript{14} These
findings suggest that BPD is associated with an increased duration that
a tracheostomy remains in place. This may be due to higher rates of
complications in pediatric tracheostomy patients such as respiratory
infections and subsequent readmissions that have been examined in prior
studies.\textsuperscript{25} Of note, the median time to ventilator
liberation and eventual decannulation for our study population was 2.3
and 1.9 years, respectively. This result is likely the consequence of
children who did not require mechanical ventilation undergoing
decannulation earlier than their peers who did require advanced
respiratory support which adds to the overall time that the tracheostomy
is in place.\textsuperscript{35} At present there are no studies that
have directly examined the relationship between the presence of BPD,
pulmonary hypertension, and time to decannulation. However, existing
literature does suggest that decannulation within the first few years of
life is likely across a spectrum of BPD severity with excellent survival
rates.\textsuperscript{17, 28} The addition of BPD to a complex patient
profile may also contribute to the development of other exacerbating
pathologies such as pulmonary hypertension that worsen overall clinical
status.\textsuperscript{5,16,18} It is likely that the added complexity
of BPD and its sequelae contributed to the increased time to
decannulation amongst BPD patients when compared to non-BPD patients
within this study. Further studies directed at intervention strategies
to reduce complications associated with BPD may provide further insight
into these findings and allow for better care of this vulnerable patient
population.

While the presence of BPD was associated with a decreased mortality
hazard ratio, the additional diagnosis of pulmonary hypertension was
associated with an increased mortality hazard ratio. Prior studies have
found an increased risk of mortality amongst patients with moderate to
severe BPD and comorbid pulmonary
hypertension.\textsuperscript{36,37}This increase in mortality has
previously been hypothesized as being related to prolonged hypoxemic
events that are associated with BPD-associated pulmonary
hypertension.\textsuperscript{38} These recurrent episodes of hypoxemia
may also offer insight into the increased prevalence of disability
identified amongst patients within the present sample. While adequate
oxygenation and pulmonary function is of well-understood importance in
premature newborns, it may play an even more significant role in long
term outcomes than previously anticipated in those with BPD and
pulmonary hypertension. Thus, the increased prevalence of disability
identified by this study as well as others\textsuperscript{8,39}
suggests that neurodevelopmental follow up to evaluate for additional
care needs may be warranted to optimize outcomes for this vulnerable
patient population, even after eventual ventilator liberation and
decannulation.

There are multiple limitations to this study. First, this study was
conducted using data with unidentified factors influencing the outcomes
of this study not controlled for during analysis. Additionally, given
the variance of criteria for diagnosis of BPD across institutions, these
findings may not be generalizable to all populations based on
non-homogenous standards of diagnosis as previously discussed. To
minimize misclassification bias, multiple authors of this study verified
diagnoses and other key datapoints collected from patient charts. The
risk of misclassification is also mitigated by the fact that this data
is from a single institution and is thus not as susceptible to
variations in diagnostic criteria. Finally, children who have undergone
tracheostomy are more likely to present with multiple medical
comorbidities that may complicate the respiratory-related outcomes
examined within this sample. Though variables of interest like BPD and
pulmonary hypertension were directly examined, it is possible that there
are other unidentified factors that influenced the outcomes of this
study. Despite these limitations, this study allows for the exploration
of the relationship between BPD and comorbidities like pulmonary
hypertension and their associations with key respiratory outcome
measures. This study was also conducted utilizing data from patients who
were cared for at a tertiary care children's hospital with a Level I
pediatric trauma center and Level IV neonatal intensive care unit
(NICU). As a result, this study was able to capture important data on a
high number of clinically complex patients, thus offering further
information on a particularly vulnerable population with a stable
incidence across the United States.

Overall, this information can generalize and inform individuals caring
for pediatric tracheostomy patients with BPD and pulmonary hypertension.
The presence of these two comorbid diseases did impact
respiratory-related outcomes, particularly time to decannulation, as
anticipated. Thus, this data may inform teams caring for this vulnerable
patient population as they seek to provide high-quality long-term care
for these children with regards to ventilator liberation and
decannulation. Regarding future research opportunities, comorbidities
like subglottic stenosis or reasons for delays in decannulation such as
a failed sleep study thus requiring adenotonsillectomy could be further
explored. These efforts could further guide care efforts for this
patient population and eventually lead to optimization of existing
protocols for these individuals.

\textbf{Conclusion}

This prospective study of children with a tracheostomy found that the
diagnosis of BPD was associated with an increased time to decannulation
as well as an increased duration of mechanical ventilation. While
bronchopulmonary dysplasia alone was associated with a decreased hazard
ratio for mortality, the added presence of pulmonary hypertension was
associated with an increased hazard ratio for mortality. Further
investigation using multinstituonal data to explore and corroborate
these findings would be valuable.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Malloy, K. W., \& Austin, E. D. (2021). Pulmonary hypertension in the
  child with bronchopulmonary dysplasia. \emph{Pediatric pulmonology}
  ,\emph{56} (11), 3546--3556. https://doi.org/10.1002/ppul.25602
\item
  Jensen, E. A., \& Schmidt, B. (2014). Epidemiology of bronchopulmonary
  dysplasia. \emph{Birth defects research. Part A, Clinical and
  molecular teratology} , \emph{100} (3), 145--157.
  https://doi.org/10.1002/bdra.23235
\item
  Hansmann, G., Sallmon, H., Roehr, C. C., Kourembanas, S., Austin, E.
  D., Koestenberger, M., \& European Pediatric Pulmonary Vascular
  Disease Network (EPPVDN) (2021). Pulmonary hypertension in
  bronchopulmonary dysplasia. \emph{Pediatric research} , \emph{89} (3),
  446--455. https://doi.org/10.1038/s41390-020-0993-4
\item
  Homan, T. D., \& Nayak, R. P. (2021). Short- and Long-Term
  Complications of Bronchopulmonary Dysplasia. \emph{Respiratory care}
  ,\emph{66} (10), 1618--1629. https://doi.org/10.4187/respcare.08401
\item
  Sullivan, R. T., Tandel, M. D., Bhombal, S., Adamson, G. T.,
  Boothroyd, D. B., Tracy, M., Moy, A., \& Hopper, R. K. (2022). Role of
  left atrial hypertension in pulmonary hypertension associated with
  bronchopulmonary dysplasia. \emph{Frontiers in pediatrics} , \emph{10}
  , 1012136. https://doi.org/10.3389/fped.2022.1012136
\item
  Sheth, S., Goto, L., Bhandari, V., Abraham, B., \& Mowes, A. (2020).
  Factors associated with development of early and late pulmonary
  hypertension in preterm infants with bronchopulmonary
  dysplasia.\emph{Journal of perinatology: official journal of the
  California Perinatal Association} , \emph{40} (1), 138--148.
  https://doi.org/10.1038/s41372-019-0549-9
\item
  Oluwole, I., Tan, J. B. C., DeSouza, S., Hutchinson, M., Leigh, R. M.,
  Cha, M., Rodriguez, A., Hou, G., Rao, S. S., Narang, A., \& Chou, F.
  S. (2023). The association between bronchopulmonary dysplasia grade
  and risks of adverse neurodevelopmental outcomes among preterm infants
  born at less than 30 weeks of gestation. \emph{The journal of
  maternal-fetal \& neonatal medicine : the official journal of the
  European Association of Perinatal Medicine, the Federation of Asia and
  Oceania Perinatal Societies, the International Society of Perinatal
  Obstetricians} , \emph{36} (1), 2167074.
  https://doi.org/10.1080/14767058.2023.2167074
\item
  Gallini, F., Coppola, M., De Rose, D. U., Maggio, L., Arena, R.,
  Romano, V., Cota, F., Ricci, D., Romeo, D. M., Mercuri, E. M., \&
  Vento, G. (2021). Neurodevelopmental outcomes in very preterm infants:
  The role of severity of Bronchopulmonary Dysplasia. \emph{Early human
  development} , \emph{152} , 105275.
  https://doi.org/10.1016/j.earlhumdev.2020.105275
\item
  Dassios, T., Williams, E. E., Hickey, A., \& Greenough, A. (2021).
  Duration of mechanical ventilation and prediction of bronchopulmonary
  dysplasia and home oxygen in extremely preterm infants. \emph{Acta
  paediatrica (Oslo, Norway : 1992)} , \emph{110} (7), 2052--2058.
  https://doi.org/10.1111/apa.15801
\item
  Yallapragada, S., Savani, R. C., M\selectlanguage{polish}ū\selectlanguage{english}noz-Blanco, S., Lagatta, J. M.,
  Truog, W. E., Porta, N. F. M., Nelin, L. D., Zhang, H., Vyas-Read, S.,
  DiGeronimo, R., Natarajan, G., Wymore, E., Haberman, B., Machry, J.,
  Potoka, K., Children's Hospital Neonatal Consortium severe
  bronchopulmonary dysplasia subgroup, \& Murthy, K. (2021). Qualitative
  indications for tracheostomy and chronic mechanical ventilation in
  patients with severe bronchopulmonary dysplasia. \emph{Journal of
  perinatology : official journal of the California Perinatal
  Association} , \emph{41} (11), 2651--2657.
  https://doi.org/10.1038/s41372-021-01165-9
\item
  Chang, H. P., Lien, R., Chu, S. M., Lin, J. J., \& Chiang, M. C.
  (2023). Outcomes of and factors associated with the development of
  bronchopulmonary dysplasia with pulmonary hypertension in very low
  birth weight infants: A retrospective study in a medical
  center.\emph{Frontiers in pediatrics} , \emph{11} , 1055439.
  https://doi.org/10.3389/fped.2023.1055439
\item
  Karkoutli, A. A., Brumund, M. R., \& Evans, A. K. (2020).
  Bronchopulmonary dysplasia requiring tracheostomy: A review of
  management and outcomes. \emph{International journal of pediatric
  otorhinolaryngology} , \emph{139} , 110449.
  https://doi.org/10.1016/j.ijporl.2020.110449
\item
  Lodha, A., Ediger, K., Rabi, Y., Lodha, S., Tang, S., Bhandari, A.,
  Sauve, R., \& Bhandari, V. (2015). Does chronic oxygen dependency in
  preterm infants with bronchopulmonary dysplasia at NICU discharge
  predict respiratory outcomes at 3 years of age?. \emph{Journal of
  perinatology: official journal of the California Perinatal
  Association} , \emph{35} (7), 530--536.
  https://doi.org/10.1038/jp.2015.7
\item
  Upadhyay, K., Vallarino, D. A., \& Talati, A. J. (2020). Outcomes of
  neonates with tracheostomy secondary to bronchopulmonary
  dysplasia.\emph{BMC pediatrics} , \emph{20} (1), 414.
  https://doi.org/10.1186/s12887-020-02324-1
\item
  Ong, J. W. Y., Everitt, L., Hiscutt, J., Griffiths, C., McEvoy, A.,
  Goss, K. C. W., Johnson, M. J., \& Evans, H. J. (2022).
  Characteristics and outcome of infants with bronchopulmonary dysplasia
  established on long-term ventilation from neonatal intensive
  care.\emph{Pediatric pulmonology} , \emph{57} (11), 2614--2621.
  https://doi.org/10.1002/ppul.26072
\item
  Morrow, C. B., McGrath-Morrow, S. A., \& Collaco, J. M. (2018).
  Predictors of length of stay for initial hospitalization in infants
  with bronchopulmonary dysplasia. \emph{Journal of perinatology:
  official journal of the California Perinatal Association} ,\emph{38}
  (9), 1258--1265. https://doi.org/10.1038/s41372-018-0142-7
\item
  Akangire, G., Lachica, C., Noel-MacDonnell, J., Begley, A., Sampath,
  V., Truog, W., \& Manimtim, W. (2023). Outcomes of infants with severe
  bronchopulmonary dysplasia who received tracheostomy and home
  ventilation. \emph{Pediatric pulmonology} , \emph{58} (3), 753--762.
  https://doi.org/10.1002/ppul.26248
\item
  House, M., Nathan, A., Bhuiyan, M. A. N., \& Ahlfeld, S. K. (2021).
  Morbidity and respiratory outcomes in infants requiring tracheostomy
  for severe bronchopulmonary dysplasia. \emph{Pediatric pulmonology}
  ,\emph{56} (8), 2589--2596. https://doi.org/10.1002/ppul.25455
\item
  Smith, M. A., Steurer, M. A., Mahendra, M., Zinter, M. S., \& Keller,
  R. L. (2023). Sociodemographic factors associated with tracheostomy
  and mortality in bronchopulmonary dysplasia. \emph{Pediatric
  pulmonology} , \emph{58} (4), 1237--1246.
  https://doi.org/10.1002/ppul.26328
\item
  Cristea, A. I., Carroll, A. E., Davis, S. D., Swigonski, N. L., \&
  Ackerman, V. L. (2013). Outcomes of children with severe
  bronchopulmonary dysplasia who were ventilator dependent at
  home.\emph{Pediatrics} , \emph{132} (3), e727--e734.
  https://doi.org/10.1542/peds.2012-2990
\item
  McKinney, R. L., \& Agarwal, A. (2023). Transition from intensive care
  unit to a portable ventilator in children with severe bronchopulmonary
  dysplasia. \emph{Pediatric pulmonology} , \emph{58} (3), 712--719.
  https://doi.org/10.1002/ppul.26274
\item
  Murthy, K., Savani, R. C., Lagatta, J. M., Zaniletti, I., Wadhawan,
  R., Truog, W., Grover, T. R., Zhang, H., Asselin, J. M., Durand, D.
  J., Short, B. L., Pallotto, E. K., Padula, M. A., Dykes, F. D., Reber,
  K. M., \& Evans, J. R. (2014). Predicting death or tracheostomy
  placement in infants with severe bronchopulmonary
  dysplasia.\emph{Journal of perinatology : official journal of the
  California Perinatal Association} , \emph{34} (7), 543--548.
  https://doi.org/10.1038/jp.2014.35
\item
  Lloyd AM, Behzadpour HK, Rana MS, Espinel AG. Factors associated with
  tracheostomy decannulation in infants with bronchopulmonary
  dysplasia.\emph{International journal of pediatric
  otorhinolaryngology} . 2023 Dec 1;175:111754.
\item
  Liao K, Chorney SR, Brown AB, et al. The Impact of Socioeconomic
  Disadvantage on Pediatric Tracheostomy Outcomes. \emph{Laryngoscope} .
  2021;131(11):2603-2609. doi:10.1002/lary.29576
\item
  Beams, D. R., Chorney, S. R., Kou, Y. F., Teplitzky, T. B., Wynings,
  E. M., \& Johnson, R. F. (2022). Emergency Department Visits and
  Hospitalizations After Pediatric Tracheostomy. \emph{The Laryngoscope}
  , 10.1002/lary.30416. Advance online publication.
  https://doi.org/10.1002/lary.30416
\item
  Johnson, R. F., Brown, C. M., Beams, D. R., Wang, C. S., Shah, G. B.,
  Mitchell, R. B., \& Chorney, S. R. (2022). Racial Influences on
  Pediatric Tracheostomy Outcomes. \emph{The Laryngoscope} ,\emph{132}
  (5), 1118--1124. https://doi.org/10.1002/lary.29847
\item
  Chorney, S. R., Brown, A. F., Brooks, R. L., Bailey, C., Whitney, C.,
  Sewell, A., \& Johnson, R. F. (2021). Pediatric Tracheostomy Outcomes
  After Development of a Multidisciplinary Airway Team: A Quality
  Improvement Initiative. \emph{OTO open} , \emph{5} (3),
  2473974X211045615. https://doi.org/10.1177/2473974X211045615
\item
  Manimtim, W. M., Agarwal, A., Alexiou, S., Levin, J. C., Aoyama, B.,
  Austin, E. D., Bansal, M., Bauer, S. E., Cristea, A. I., Fierro, J.
  L., Garey, D. M., Hayden, L. P., Kaslow, J. A., Miller, A. N., Moore,
  P. E., Nelin, L. D., Popova, A. P., Rice, J. L., Tracy, M. C., Baker,
  C. D., \ldots{} Collaco, J. M. (2023). Respiratory Outcomes for
  Ventilator-Dependent Children With Bronchopulmonary
  Dysplasia.\emph{Pediatrics} , \emph{151} (5), e2022060651.
  https://doi.org/10.1542/peds.2022-060651
\item
  PA Harris, R Taylor, R Thielke, J Payne, N Gonzalez, JG. Conde,
  Research electronic data capture (REDCap) -- A metadata-driven
  methodology and workflow process for providing translational research
  informatics support, \emph{J Biomed Inform} . 2009 Apr;42(2):377-81.
\item
  Jackson, M., Kuchler, T., Stroebel, J., Hendren, N., Fluegge, R.,
  Gong, S., \ldots{} \& Wernerfelt, N. (2022). Social Capital I:
  Measurement and Associations With Economic Mobility. \emph{Nature} ,
  7921(608), 108-121.\emph{https://doi.org/10.1038/s41586-022-04996-4}
\item
  Jackson, M. O., Kuchler, T., Stroebel, J., Hendren, N., Fluegge, R.
  B., Gong, S., \ldots{} \& Wernerfelt, N. (2022). Social Capital Ii:
  Determinants Of Economic Connectedness. \emph{Nature} , 7921(608),
  122-134.\emph{https://doi.org/10.1038/s41586-022-04997-3}
\item
  Watters, K., O'Neill, M., Zhu, H., Graham, R., Hall, M., Berry, J.
  (2016). Two-year Mortality, Complications, and Healthcare Use In
  Children With Medicaid Following Tracheostomy. \emph{The Laryngoscope}
  , 11(126), 2611-2617.\emph{https://doi.org/10.1002/lary.25972}
\item
  Pettitt-Schieber B, Mahendran G, Tey CS, Prickett KK. Risk factors for
  return visits in children discharged with tracheostomy. \emph{Int J
  Pediatr Otorhinolaryngol} . 2021;150:110860.
  doi:10.1016/j.ijporl.2021.110860, 10.1016/j.ijporl.2021.110860
\item
  Davidson C, Jacob B, Brown A, et al. Perioperative Outcomes After
  Tracheostomy Placement Among Complex Pediatric
  Patients.\emph{Laryngoscope} . 2021;131(8):E2469-E2474.
  doi:10.1002/lary.29402
\item
  Sekioka, A., Fukumoto, K., Miyake, H., Nakaya, K., Nomura, A., Yamada,
  S., Kanai, R., \& Urushihara, N. (2020). Long-Term Outcomes After
  Pediatric Tracheostomy-Candidates for and Timing of
  Decannulation.\emph{The Journal of surgical research} , \emph{255} ,
  216--223. https://doi.org/10.1016/j.jss.2020.05.061
\item
  Branescu, I., Shetty, S., Richards, J., Vladareanu, S., \& Kulkarni,
  A. (2023). Pulmonary hypertension in preterm infants with
  moderate-to-severe bronchopulmonary dysplasia (BPD). \emph{Acta
  paediatrica (Oslo, Norway : 1992)} , 10.1111/apa.16863. Advance online
  publication. https://doi.org/10.1111/apa.16863
\item
  Lagatta, J. M., Hysinger, E. B., Zaniletti, I., Wymore, E. M.,
  Vyas-Read, S., Yallapragada, S., Nelin, L. D., Truog, W. E., Padula,
  M. A., Porta, N. F. M., Savani, R. C., Potoka, K. P., Kawut, S. M.,
  DiGeronimo, R., Natarajan, G., Zhang, H., Grover, T. R., Engle, W. A.,
  Murthy, K., \& Children's Hospital Neonatal Consortium Severe BPD
  Focus Group (2018). The Impact of Pulmonary Hypertension in Preterm
  Infants with Severe Bronchopulmonary Dysplasia through 1
  Year.\emph{The Journal of pediatrics} , \emph{203} , 218--224.e3.
  https://doi.org/10.1016/j.jpeds.2018.07.035
\item
  Gentle, S. J., Travers, C. P., Nakhmani, A., Indic, P., Carlo, W. A.,
  \& Ambalavanan, N. (2023). Intermittent Hypoxemia and Bronchopulmonary
  Dysplasia with Pulmonary Hypertension in Preterm
  Infants.\emph{American journal of respiratory and critical care
  medicine} ,\emph{207} (7), 899--907.
  https://doi.org/10.1164/rccm.202203-0580OC
\item
  Nakanishi, H., Uchiyama, A., \& Kusuda, S. (2016). Impact of pulmonary
  hypertension on neurodevelopmental outcome in preterm infants with
  bronchopulmonary dysplasia: a cohort study. \emph{Journal of
  perinatology: official journal of the California Perinatal
  Association} , \emph{36} (10), 890--896.
  https://doi.org/10.1038/jp.2016.108
\end{enumerate}

\textbf{Figure 1:} Goodness-of-fit Plot for Decannulation Model

\textbf{Figure 2.} Goodness-of-fit Plot for Mortality Model

\textbf{Table 1.} Demographics of Children with a Tracheostomy by
Presence of Bronchopulmonary Dysplasia\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Variable & BPD Absent & BPD Present & Total & \emph{P}
value\tabularnewline
\midrule
\endhead
Total, n (\%) & 182 (57) & 136 (43) & 318 (100) & -\tabularnewline
Age at tracheostomy, mo. (IQR) & 24.5 (4.2-127.6) & 5.2 (3.9-7.1) & 6.9
(4.1-49.2) & \textless{}.001\tabularnewline
Gestational Age, mo. (IQR) & 38.0 (36.0-40.0) & 28.0 (25.0-37.0) & 36.0
(28.0-39.0) & \textless{}.001\tabularnewline
Birth Weight, kilograms, IQR & 2.9 (2.4-3.4) & 1.1 (0.76-2.4) & 2.4
(1.1-3.1) & \textless{}.001\tabularnewline
Weight at tracheostomy, kg. (IQR) & 10.3 (5.4-28.0) & 5.1 (4.1-6.4) &
6.2 (4.5-14.5) & \textless{}.001\tabularnewline
Corrected age, mo. (IQR) & 7.9 (-4.8-99.3) & -0.89 (-3.0-0.53) & -0.20
(-3.9-28.5) &\tabularnewline
Sex, n (\%) & & & &\tabularnewline
Female & 91 (50) & 57 (42) & 148 (47) & .15\tabularnewline
Male & 91 (50) & 79 (58) & 170 (54) &\tabularnewline
Race, n (\%) & & & &\tabularnewline
American Indian/Alaska Native & 0 (0) & 1 (0.7) & 1 (0.3) &
.004\tabularnewline
Asian & 7 (3.8) & 8 (5.9) & 15 (4.7) &\tabularnewline
Black or African American & 45 (25) & 60 (44) & 105 (33)
&\tabularnewline
White & 116 (64) & 59 (43) & 175 (55) &\tabularnewline
More Than One Race & 4 (2.2) & 2 (1.5) & 6 (1.9) &\tabularnewline
Unknown / Not Reported & 10 (5.5) & 6 (4.4) & 16 (5.0) &\tabularnewline
Ethnicity, n (\%) & & & &\tabularnewline
Hispanic & 59 (32) & 37 (27) & 96 (30) & .32\tabularnewline
Not Hispanic & 123 (68) & 98 (72) & 221 (70) &\tabularnewline
Unknown / Not Reported & 0 (0) & 1 (0.7) & 1 (0.3) &\tabularnewline
Primary Language, n (\%) & & & &\tabularnewline
English & 153 (85) & 117 (87) & 270 (86) & .24\tabularnewline
Spanish & 26 (14) & 13 (9.7) & 39 (12) &\tabularnewline
Other & 2 (1.1) & 4 (3.0) & 6 (1.9) &\tabularnewline
Primary Payer, n (\%) & & & &\tabularnewline
Medicaid & 134 (74) & 107 (79) & 241 (76) & .57\tabularnewline
Private & 44 (24) & 27 (20) & 71 (22) &\tabularnewline
Other & 4 (2.2) & 2 (1.5) & 6 (1.9) &\tabularnewline
Economic connectiveness, (IQR) & 0.76 (0.58-0.94) & 0.72 (0.55-0.90) &
0.73 (0.58-0.92) & .17\tabularnewline
Support ratio, (IQR) & 0.86 (0.81-0.96) & 0.83 (0.79-0.90) & 0.85
(0.81-0.94) & .02\tabularnewline
Fraction single parents, (IQR) & 0.36 (0.26-0.38) & 0.38 (0.28-0.38) &
0.37 (0.28-0.38) & .27\tabularnewline
Median Household Income, USD (IQR) & 53442 (48901-62463) & 53442
(53442-62178) & 53442 (49530-62463) & .89\tabularnewline
\bottomrule
\end{longtable}

Continuous variable P values based on Kruskal--Wallis
equality-of-populations rank test

Categorical variable P values based on Pearson's \selectlanguage{greek}χ\selectlanguage{english}2 test

\textbf{Table 2.} Associated Conditions of Children with Tracheostomies
by Presence of Bronchopulmonary Dysplasia\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Variable & BPD Absent & BPD Present & Total & \emph{P}
value\tabularnewline
\midrule
\endhead
Total, n (\%) & 182 (57) & 136 (43) & 318 (100) & -\tabularnewline
Short gestation & 41 (23) & 90 (66) & 131 (41) &
\textless{}.001\tabularnewline
Congenital Malformations & 72 (40) & 57 (42) & 129 (41) &
.67\tabularnewline
Newborn complications & 62 (34) & 83 (61) & 145 (46) &
\textless{}.001\tabularnewline
Maternal complications & 37 (20) & 58 (43) & 95 (30) &
\textless{}.001\tabularnewline
Bacterial sepsis of newborn & 1 (0.5) & 2 (1.5) & 3 (0.9) &
.40\tabularnewline
Respiratory Distress Syndrome & 41 (23) & 31 (23) & 72 (23) &
.96\tabularnewline
Birth Hypoxia & 19 (10) & 15 (11) & 34 (11) & .87\tabularnewline
Sepsis & 12 (6.6) & 9 (6.6) & 21 (6.6) & .99\tabularnewline
Cardiac conditions & 67 (37) & 66 (49) & 133 (42) & .04\tabularnewline
Chronic respiratory & 95 (52) & 94 (69) & 189 (59) & .002\tabularnewline
Trauma & 19 (10) & 2 (1.5) & 21 (6.6) & .001\tabularnewline
Pulmonary HTN & 44 (24) & 89 (65) & 133 (42) &
\textless{}.001\tabularnewline
Tracheobronchomalacia & 9 (4.9) & 15 (11) & 24 (7.5) &
.04\tabularnewline
\bottomrule
\end{longtable}

Categorical variable P values based on Pearson's \selectlanguage{greek}χ \selectlanguage{english}2 test

\textbf{Table 3.} Outcomes of Children with a Tracheostomy by Presence
of Bronchopulmonary Dysplasia\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
Variable & BPD Absent & BPD Present & Total & \emph{P}
value\tabularnewline
\midrule
\endhead
Total, n (\%) & 182 (57.2\%) & 136 (42.8\%) & 318 (100.0\%)
&\tabularnewline
Time on ventilator, y. (IQR) & 1.84 (0.84-3.60) & 2.92 (1.60-4.03) &
2.34 (1.16-3.82) & .003\tabularnewline
Time with tracheostomy, y. (IQR) & 1.21 (0.40-2.64) & 2.73 (1.60-3.89) &
1.88 (0.68-3.60) & \textless{}.001\tabularnewline
Current Status, n (\%) & & & &\tabularnewline
Alive with tracheostomy & 81 (45) & 59 (43) & 140 (44) &
.03\tabularnewline
Decannulated & 46 (25) & 50 (37) & 96 (30) &\tabularnewline
Died & 38 (21) & 23 (17) & 61 (19) &\tabularnewline
Lost to Follow Up & 17 (9.3) & 4 (2.9) & 21 (6.6) &\tabularnewline
Neurocognitive Disability, n (\%) & & & &\tabularnewline
Normal & 28 (17) & 5 (4.1) & 33 (12) & .003\tabularnewline
Mild/moderate & 43 (26) & 41 (33) & 84 (29) &\tabularnewline
Severe & 93 (57) & 77 (63) & 170 (59) &\tabularnewline
\bottomrule
\end{longtable}

Continuous variable P values based on Kruskal--Wallis
equality-of-populations rank test

Categorical variable P values based on Pearson's \selectlanguage{greek}χ \selectlanguage{english}2 test

\textbf{Table 4.} Parametric Survival Analysis of Time to Ventilator
Liberation Among Children with a Tracheostomy\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
Variable & Hazard Ratio & Standard error & z-score & \emph{P} value &
95\% CI\tabularnewline
\midrule
\endhead
No BPD & 0.25 & 0.03 & -10.34 & \textless{}.001 &
0.19-0.33\tabularnewline
BPD & 0.84 & 0.10 & -1.63 & .10 & 0.63-1.04\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: BPD= Bronchopulmonary dysplasia

\textbf{Table 5.} Parametric Survival Analysis of Time to Decannulation
Among Children with a Tracheostomy\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
Variable & Hazard Ratio & Standard error & z-score & \emph{P} value &
95\% CI\tabularnewline
\midrule
\endhead
BPD & 0.12 & 0.09 & -2.94 & .003 & 0.03-0.49\tabularnewline
Time on ventilator & 0.19 & 0.05 & -6.51 & \textless{}.001 &
0.11-0.31\tabularnewline
BPD*Time on ventilator & 2.23 & 0.61 & 3.09 & .002 &
1.35-3.84\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: BPD= Bronchopulmonary dysplasia

\textbf{Table 6.} Parametric Survival Analysis Among Children with a
Tracheostomy\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
Variable & Hazard Ratio & Standard Error & z-score & \emph{P} value &
95\% CI\tabularnewline
\midrule
\endhead
BPD & 0.39 & 0.11 & -3.25 & .001 & 0.22-0.69\tabularnewline
pHTN & 2.52 & 0.72 & 3.24 & .001 & 1.44-4.40\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: BPD= Bronchopulmonary dysplasia; pHTN= pulmonary
hypertension\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/BPD-Figure-1/BPD-Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/BPD-Figure-2/BPD-Figure-2}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

