Elsevier

World Neurosurgery

Volume 103, July 2017, Pages 88-93
World Neurosurgery

Original Article
Experience with Traumatic Brain Injury: Is Early Tracheostomy Associated with Better Prognosis?

https://doi.org/10.1016/j.wneu.2017.02.060Get rights and content

Objective

In this study we compared the effects of early tracheostomy (ET) versus late tracheostomy on traumatic brain injury (TBI)-related outcomes and prognosis.

Patients and Methods

Data on 152 TBI patients with a Glasgow Coma Scale (GCS) score of ≤8, admitted to Rajaee Hospital between March 1, 2014 and August 23, 2015, were collected. Rajaee Hospital is the main referral trauma center in southern Iran and is affiliated with Shiraz University of Medical Sciences. Patients who had tracheostomy before or at the sixth day of their admission were considered as ET, and those who had tracheostomy after the sixth day of admission were considered as late tracheostomy.

Results

Patients with ET had a significantly lower hospital stay (46.4 vs. 38.6 days; P = 0.048) and intensive care unit stay (34.9 vs. 26.7 days; P = 0.003). Mortality rates were not significantly different between the 2 groups (P > 0.99). Although not statistically significant, favorable outcomes (Glasgow Outcome Scale >4) were higher and ventilator-associated pneumonia rates were lower among the ET group (P = 0.346 and P = 492, respectively).

Multivariate analysis showed that ET significantly improves 6-month prognosis (Glasgow Outcome Scale >4) (odds ratio = 2.535; 95% confidence interval: 1.030–6.237). Higher age was inversely associated with favorable prognosis (odds ratio = −0.958; confidence interval: 0.936–0.981). Glasgow Coma Scale and Rotterdam score did not show any effect on 6-month prognosis.

Conclusion

Despite previous concern regarding increased mortality rates among patients who undergo ET, performing a tracheostomy for patients with severe TBI <6 days after their hospital admission, in addition to decreasing hospital and intensive care unit stays, will improve patient 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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    Conflict of interest statement: The authors have no conflict of interest to declare regarding the manuscript.

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