Between 21% and 77% of patients with cervical SCI require a tracheostomy, with the variability of these numbers being due to the influence of at least 16 other factors (e.g., severity of the injury, presence of other injuries, admission Glasgow Coma Scale score, age, etc; Branco et al. 2011). The interactions of these other parameters make it difficult to establish clear criteria for who should receive a tracheostomy. Identifying when a tracheostomy should be performed is also important to determine, as timing may impact a patient’s recovery with regards to developing complications and weaning from ventilation. In a systematic review of non-SCI patients who required tracheostomies, Griffiths et al. (2005) concluded that individuals who received an early tracheostomy did not experience fewer complications, but did experience a shorter duration of mechanical ventilation. The timing of tracheostomy following spinal fixation should also be considered. Currently, the typical time period is 1-2 weeks post surgery, but this timing lacks conclusive evidence (Galeiras Vázquez et al. 2013). In addition to who should receive a tracheostomy and when it should be performed, there is also controversy surrounding whether or not tracheostomies are always beneficial, effective in ventilator weaning and result in a reduced number of pulmonary complications. In fact, complications resulting from tracheostomies, such as tracheal stenosis, occur in up to 6% of patients (Lissauer, 2013), so the risks and benefits must be evaluated. Several studies have retrospectively examined the predictors for needing a tracheostomy, complications associated with the procedure and the effect of an early versus late tracheostomy on patient outcomes; these studies are presented in the table below.
There are two techniques for tracheostomy: surgical (open) and percutaneous. Surgical tracheostomy is the traditional technique that requires opening up the entire trachea to insert the tube. Percutaneous tracheostomy is an alternative procedure that was first developed in the late 1950s and can be performed at the patient’s bedside with fewer materials (Gysin et al. 1999). Percutaneous tracheostomy is less invasive and involves inserting a tracheostomy tube through the skin without directly visualizing the trachea. Due to its less invasive nature, this procedure was thought to be associated with fewer complications and infections, although this relationship is unclear (Gysin et al. 1999).
Several studies have investigated factors predicting the need for tracheostomy in acute SCI patients, many of which have identified factors such as higher injury severity and complete lesions (Leelapattana et al. 2012; McCully et al. 2014; Menaker et al. 2013; O’Keeffe et al. 2004; Yugue et al. 2012), as well as a cervical level of injury (Biering-Sorensen & Biering-Sorensen, 1992; McCully et al. 2014; Romero-Ganuza et al. 2011; Seidl et al. 2010; Yugue et al. 2012). Other reported factors include older age (Harrop et al. 2004; Yugue et al. 2012) and a lower ASIA motor grade upon hospital admission (Menaker et al. 2013).
Tracheostomy is believed to facilitate weaning because it reduces the effort required to breathe (Peterson et al. 1994). Several studies examined the effect of tracheostomy on duration of mechanical ventilation. Among studies that did not stratify for time, tracheostomy was consistently reported to prolong mechanical ventilation (Berney et al. 2002; Leelapattana et al. 2012; McCully et al. 2014). However, when the results were separated into patients who received an ‘early tracheostomy’ versus those who received a ‘late tracheostomy,’ every study reported that early tracheostomies significantly reduced the time required on mechanical ventilation (Leelapattana et al. 2012; Romero-Ganuza et al. 2011; Romero et al. 2009). This finding highlights the importance of procedural timing that can make a significant difference in patient outcomes and ultimately hospital costs. Leelapattana et al. (2012) recommend an early tracheostomy be conducted if two of three factors are present: 1) the patient has a complete injury, 2) the patient produces a ratio of arterial oxygen partial pressure to fractional inspired oxygen less than 300 by the third day of ventilation, and 3) the patient has an Injury Severity Score greater than 32.
The influence of tracheostomy procedures on the development of respiratory complications has also been examined by a number of studies. Patients who have had a tracheostomy have been reported to have fewer pulmonary complications when compared to patients who have not had a tracheostomy (Leelapattana et al. 2012). In terms of the timing of tracheostomy procedures, those performed early (6 and 7 days after fixation surgery and intubation, respectively) have been found to be associated with a reduced risk for pulmonary complications compared to those performed later (Babu et al. 2013; Romero et al. 2009), although both early (1 to 10 days post intubation) and late (10 or more days) have been reported to have the same effect on the incidence of pneumonia (Choi et al. 2013). Regarding type of tracheostomy, Sustic et al. (2002) compared percutaneous dilational tracheostomy with surgical tracheostomy, investigating the development of perioperative and postoperative complications associated with each procedure. The authors found that no patients, regardless of intervention received, developed any major complication in relation to tracheostomy.
There is level 2 evidence (from four case controls, one case series and one cohort study; McCully et al. 2014; Menaker et al. 2013; Yugue et al. 2012; Harrop et al. 2004; O’Keeffe et al. 2004; Leelapattana et al. 2012) that complete injuries predict the need for tracheostomy in acute SCI patients.
There is level 3 evidence (from two case controls and three case series; McCully et al. 2014; Yugue et al. 2012; Romero-Ganuza et al. 2011a; Seidl et al. 2010; Biering-Sorensen and Biering-Sorensen 1992) that having a cervical level of injury predicts the need for tracheostomy in acute SCI patients.
Cervical lesions and high injury severity have been identified as factors predictive of the need for tracheostomy during the acute phase post SCI. Tracheostomy procedures may reduce the risk for pulmonary complications, particularly if performed early.