Original ArticleExperience with Traumatic Brain Injury: Is Early Tracheostomy Associated with Better Prognosis?
Introduction
Traumatic brain injury (TBI) is among the most severe types of trauma and presents as one of the most challenging medical conditions, leading to mortality rates of up to 35% in a 12-month period following the initial injury.1
One of the most important issues in the management of TBI is respiratory failure and the endeavor to maintain a secure airway. Tracheostomy and prolonged endotracheal intubation are 2 different interventions applied in airway management of patients with TBI. Common indicators for tracheostomy include Glasgow Coma Scale (GCS) ≤8 and ventilator dependency of >7 days.2
Previous studies have documented tracheostomy to have certain advantages over prolonged intubation.3 Although these findings are consistent among most studies, the optimal time for performing a tracheostomy remains a subject of great controversy. Previous literature has documented that the peak time for laryngeal damage to occur due to an inserted endotracheal tube (ETT) is 3–7 days. Hence removing the ETT before day 3 would result in less damage and fewer complications to the larynx.4 Early literature, in the 1980s, supported the idea of performing an early tracheostomy before day 21; however, new evidence suggests performing a tracheostomy before days 7–105, 6 and even recently 2 studies proposed performing an early tracheostomy before day 3.7, 8
Up to this date no definite evidence has been documented for the beneficial effects of early tracheostomy (ET) over late tracheostomy (LT). Some studies have shown ET to decrease ventilator-associated pneumonia (VAP) rates, mortality rates, hospital and intensive care unit (ICU) stays,3, 8 but meta-analysis and randomized clinical trials have documented no decrease in mortality and VAP rates after performing ET in comparison with LT among ICU patients.9, 10 Different designs and settings have all contributed to inconclusive results regarding the advantages of ET in comparison with LT.
Currently, ET is performed on the basis of the opinion and experience of the specialist and up to this date no specific guideline has mandated the use of ET. There is lack of homogeneity between studies and definite evidence to completely support ET. Furthermore, to date, not many studies have investigated the efficacy of ET in TBI patients.9 Considering the great influence of TBI on health, especially in a country like Iran, where the majority of the population is young and has greater life expectancy, and considering that Iran is among those countries with the highest trauma rates,11, 12 we conducted a study to investigate the impact of ET as early as 6 days versus LT on TBI-related outcomes and prognosis in a sample of the Iranian population.
Section snippets
Study Design and Patient Selection
Data on 152 consecutive patients admitted with GCS ≤8 (classified as severe TBI), admitted between March 1, 2014 and August 23, 2015 to Rajaee Hospital in Southern Iran, were collected. Rajaee Hospital is the main referral trauma center in southern Iran and is affiliated to Shiraz University of Medical Sciences.
Patients with pulmonary diseases such as asthma, interstitial lung disease, chronic obstructive pulmonary disease, and concomitant chest and lung injury; those who died before day 10;
Results
One hundred and fifty-two patients entered the study. Overall, 53 patients had early tracheostomy and 99 patients had late tracheostomy. Baseline characteristics of the 2 groups are displayed in Table 1.
Comparison of the 2 groups showed that patients who underwent ET had a significantly lower hospital stay (46.4 vs. 38.6 days; P = 0.048) and ICU stay (34.9 vs. 26.7 days; P = 0.003). Mortality rates were not significantly different between the 2 groups (P > 0.99). Favorable outcomes were higher,
Discussion
The purpose of this study was to compare the effects of early tracheostomy (as <6 days after admission) with late tracheostomy in patients with severe TBI. We found that performing ET significantly decreases hospital and ICU stay. More importantly, 6-month prognosis (determined by GOS score) was significantly improved by ET. Aniso pupil response was associated with favorable 6-month prognosis, and older age was associated with unfavorable 6-month prognosis.
Among the main differences between
Acknowledgments
The authors would like to thank all patients and their family members who patiently took part in the study.
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Cited by (29)
Timing of tracheostomy in patients with severe traumatic brain injuries: The need for tailored practice management guidelines
2022, InjuryCitation Excerpt :Similarly, Rizk et al. reported decreased adverse occurrences, including acute respiratory failure, VAP, ARDS, DVT/PE, pneumothorax, and pleural effusion, within the early tracheostomy group versus the late group [25]. While these studies found early tracheostomy was associated with significantly lower rates of complications [19,21,22,24], other studies reported no significant differences [17,18,20,23]. It is likely that the studies that reported no significant findings may have not had the statistical power to detect significant differences between the groups [27].
Predicting the need for tracheostomy in trauma patients without severe head injury
2020, American Journal of SurgeryTracheostomies and PEGs: When Are They Really Indicated?
2019, Surgical Clinics of North AmericaDeterminants of reoperation after decompressive craniectomy in patients with traumatic brain injury: A comparative study
2019, Clinical Neurology and NeurosurgeryIs Early Tracheostomy Better for Severe Traumatic Brain Injury? A Meta-Analysis
2018, World NeurosurgeryCitation Excerpt :Our literature search identified a total of 71 potentially relevant articles. After a review of titles and abstracts, 8 articles that met our inclusion criteria were selected (Figure 1).9-16 The details of these studies are presented in Table 1.
Conflict of interest statement: The authors have no conflict of interest to declare regarding the manuscript.