Characterizing the need for tracheostomy placement and decannulation after cervical spinal cord injury

Abstract

Purpose There have been few reports on the risk factors for tracheostomy and the possibility of patients for decannulation. The purpose of this study was to identify factors necessitating tracheostomy after cervical spinal cord injury (SCI) and detect features predictive of successful decannulation in tracheostomy patients. Methods One hundred and sixty four patients with cervical fracture/dislocation were retrospectively reviewed. The patients comprised 142 men and 22 women with a mean age of 44.9 years. The clinical records were reviewed for patients' demographic data, smoking history, level of cervical spine injury, injury patterns, neurological status, evidence of direct thoracic trauma and head injury, tracheostomy placement, and decannulation. Risk factors necessitating tracheostomy and factors predicting decannulation were statistically analysed. Results Twenty-five patients (15.2 %) required tracheostomy. Twenty-one patients were successfully decannulated. Smoking history (relative risk [RR], 3.05; p = 0.03) and complete SCI irrespective of injury level (C1-4 complete SCI: RR, 67.55; p \ 0.001, C5-7 complete SCI: RR, 57.88; p \ 0.001) were significant risk factors necessitating tracheostomy. C1-4 complete SCI was more frequent among those who could not be decannulated. However, even in patients with high cervical complete SCI at the time of injury, patients regaining sufficient movement to shrug their shoulders within 3 weeks after injury could later be decannulated. Conclusions The risk factors for tracheostomy after complete SCI were a history of smoking and complete paralysis irrespective of the level of injury. High cervical level complete SCI was found to be a risk factor for the failure of decannulation in patients without shoulder shrug within 3 weeks after injury.

A Meta-Analysis of the Influencing Factors for Tracheostomy after Cervical Spinal Cord Injury

“…Importantly, AIS A grade with an OR value of 7.79 was indicated to have a significant role in determining tracheostomy performance. In line with our results, several previous reports support the idea that AIS A grade is an independent predictor for tracheotomy with multivariate logistic regression analyses [ 8 , 9 , 11 , 13 , 16 , 19 , 21 , 22 ]. Lee et al proposed that AIS A grade was the most important predictor of tracheotomy for patients with CSCI [ 11 ].…”

“…As previously reported, male patients have a high rate of smoking, which can affect the function of ventilation and reduce the FEV1 and FEV1/FVC [ 29 ]. Other scholars have indicated that smoking often causes excessive airway secretions and airway inflammation [ 30 , 31 ] and that the increased secretion of bronchial mucus ultimately leads to pneumonia in patients with CSCI [ 16 ]. However, our meta-analysis results showed that smoking was not an influencing factor for tracheostomy after CSCI (OR=1.45, 95% CI: 0.99 to 2.13, p=0.06).…”

“…Because the diaphragm, which is mainly responsible for respiratory function, is primarily innervated by C4 and partially innervated by C3 and C5, many researchers believe that upper CSCI is an influential factor for tracheotomy. However, several research teams, such as Branco et al [ 8 ], McCully et al [ 14 ], Nakashima et al [ 16 ], and Childs et al [ 22 ], demonstrated that there was no significant correlation between NLI (upper CSCI) and tracheotomy. Childs et al noted that the auxiliary muscles important for breathing are affected by lower cervical cord injury and that though lower CSCI does not directly affect the innervation of the diaphragm, chest wall and abdominal muscle paralysis can lead to dyspnea [ 22 ].…”

“…The influencing factors for tracheostomy after CSCI have been widely studied. Among these previous studies, age [ 8 – 21 ], sex [ 8 , 9 , 11 , 12 , 14 – 16 , 19 , 20 , 22 ], AIS (American Spinal Injury Association Impairment Scale) [ 8 – 22 ], neurological level of injury (NLI) [ 8 , 9 , 11 , 12 , 14 , 16 – 23 ], injury seventy score (ISS) [ 8 , 9 , 12 , 14 , 19 , 20 , 22 ], Glasgow Coma Scale (GCS) score [ 8 , 11 , 14 , 15 ], associated injury [ 8 , 9 , 11 , 12 , 16 , 19 ], respiratory complications [ 9 , 10 , 12 , 13 , 19 ], smoking history [ 9 , 16 , 19 , 21 ], and other factors have been reported. However, a consensus has not been reached due to the differences among these previous results.…”

Respiratory Management in the Patient with Spinal Cord Injury

“…For patients with incomplete injuries, evidence of respiratory failure should prompt immediate airway intervention, half of whom will require tracheostomy [73]. Many studies [3, 74–76] have tried to identify several risk factors for postinjury tracheostomy: rostral ASIA A level (C2–C4), age (>45 years), comorbid lung diseases, smoking history, preexisting comorbid illness, the severity of impaired consciousness, high level injury severity score, and active pneumonia. Specific to a cervical SCI cohort, the extent of injury was the most important factor in determining the need for a tracheostomy [77].…”