Tracheostomy practice and timing in traumatic brain-injured patients: a CENTER-TBI study

Abstract

Indications and optimal timing for tracheostomy in traumatic brain-injured (TBI) patients are uncertain. This study aims to describe the patients' characteristics, timing, and factors related to the decision to perform a tracheostomy and differences in strategies among different countries and assess the effect of the timing of tracheostomy on patients' outcomes. Methods: We selected TBI patients from CENTER-TBI, a prospective observational longitudinal cohort study, with an intensive care unit stay ≥ 72 h. Tracheostomy was defined as early (≤ 7 days from admission) or late (> 7 days). We used a Cox regression model to identify critical factors that affected the timing of tracheostomy. The outcome was assessed at 6 months using the extended Glasgow Outcome Score. Results: Of the 1358 included patients, 433 (31.8%) had a tracheostomy. Age (hazard rate, HR = 1.04, 95% CI = 1.01-1.07, p = 0.003), Glasgow coma scale ≤ 8 (HR = 1.70, 95% CI = 1.22-2.36 at 7; p < 0.001), thoracic trauma (HR = 1.24, 95% CI = 1.01-1.52, p = 0.020), hypoxemia (HR = 1.37, 95% CI = 1.05-1.79, p = 0.048), unreactive pupil (HR = 1.76, 95% CI = 1.27-2.45 at 7; p < 0.001) were predictors for tracheostomy. Considerable heterogeneity among countries was found in tracheostomy frequency (7.9-50.2%) and timing (early 0-17.6%). Patients with a late tracheostomy were more likely to have a worse neurological outcome, i.e., mortality and poor neurological sequels (OR = 1.69, 95% CI = 1.07-2.67, p = 0.018), and longer length of stay (LOS) (38.5 vs. 49.4 days, p = 0.003). Conclusions: Tracheostomy after TBI is routinely performed in severe neurological damaged patients. Early tracheostomy is associated with a better neurological outcome and reduced LOS, but the causality of this relationship remains unproven.

Injury Causes and Severity in Pediatric Traumatic Brain Injury Patients Admitted to the Ward or Intensive Care Unit: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

“…Secondary systemic insults such as hypoxia and hypotension were significantly more common in patients with unfavorable outcome which seems to confirm previous studies from both pediatric and adult patient cohorts (15)(16)(17)(18)(19)(20)(21)(22). Importantly, these physiological parameters impose potential treatment targets: Active airway management such as early intubation and early tracheostomy have been shown to be associated with better outcomes in adults (23)(24)(25)(26). Similarly, the relationship between low preadmission blood pressures and mortality is well established and recent results from large multi-center trials suggest to consider notably higher blood pressure targets than the >90 mmHg systolic blood pressure threshold stated in current guidelines (27,28).…”

Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus

“…Timely tracheotomy represents a means of effectively weaning sedation and discontinuing mechanical ventilation in patients who require an artificial airway but are otherwise able to breathe independently. Yet studies indicate that the selection of ABI patients for tracheostomy is highly variable, often dependent on regional or institutional factors [31,32]. Our panel recommended consideration of this procedure in mechanically ventilated ABI patients who are persistently unconscious (but with an expected acceptable quality of life) or when one or several trials of extubation have failed; however, there was no consensus on the optimal timing of tracheostomy.…”

Tracheostomy in 80 COVID-19 patients: a multicenter, retrospective, observational study

“…Compared with an orotracheal tube, a shorter tracheostomy tube that bypasses the mouth and pharynx can avoid oropharyngeal and laryngeal lesions, improve patient comfort and reduce sedative drug use [5]. In addition, a tracheostomy tube can provide less airway dead space and thus less work of breathing, facilitate weaning from mechanical ventilation, make airway suctioning much easier, and potentially reduce the incidence of ventilator-associated pneumonia [6].…”