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Timing of Mechanical Ventilation

Many recent studies have focused on patient outcomes based on when individuals received mechanical ventilation (Beom & Seo, 2018; Flanagan et al., 2018; Choi et al., 2013). There has been debate as to whether early tracheostomies result in better outcomes, fewer ventilator days, decreased rates of pneumonia, and even cognitive decline.

Table 5. Evaluation of the Use of Early versus Late Tracheostomy during Acute SCI

Author Year

Country

Research Design

Sample Size

Methods            Outcomes
 

Beom and Seo (2018)

Korea

Case Control

N=48

Population: Mean age: 53.6 yr; Gender: male=43, female=5; Level of injury: N/R; Severity of injury: Mean ASIA impairment scale score (tracheostomy)=14.1 points, mean ASIA impairment scale score (non-tracheostomy)=23.4 points.

Intervention: Patients either received an early tracheostomy (within 7 days of initial SCI surgery) or a late tracheostomy (after 7 days of initial SCI surgery) or no tracheostomy.

Outcome Measures: Length of ventilation, ICU duration.

Chronicity: Time since injury not specified, patients were treated on average 29 days after initial SCI surgical intervention.

1.     There were no significant differences in the duration of post-operative ventilation between early vs late tracheostomy patients.

2.     The early tracheostomy group had a significantly shorter length of stay in the ICU than the late tracheostomy group (p=0.03).

Flanagan et al. (2018)

United States

Case Control

N=70

Population: Mean age: 50.5 yr; Gender: male=53, female=17; Level of injury: C2=10, C3=12, C4=19, C5=9, C6=6, C7=2; Severity of injury: Mean ISS=19.6;

Intervention: Patients either received an early tracheostomy (<7 days) or late (>7 days) from their initial intubation.

Outcome Measures: Ventilator days, tracheostomy days, ICU length of stay, early pneumonia and surgical site infections, in-hospital mortality, 90-day mortality, 90-day readmission.

Chronicity: Patients are defined as being in the acute stage.

 

1.     Early tracheotomy patients had fewer ventilator days compared to late tracheotomy patients (p=0.028).

2.     There was no significant difference in the number of days from tracheostomy to decannulation between early and late tracheostomy patients.

3.     Patients with early tracheostomy had significantly fewer ICU stays (p=0.021).

4.     There was no significant difference in the rates of early pneumonia and surgical site infections between the two groups, although both groups had high incidences.

5.     There were no significant differences between groups in terms of in-hospital mortality, 90-day mortality, and 90-day readmission.

Kornblith et al. (2014)

USA

Case Control

N=344

Population: Mean age: 43 yr; Gender: male=275, female=69; Level of injury: cervical to lumbar; Severity of injury: complete=69, incomplete=275.

Intervention: Patients either had a tracheostomy or did not. Of those requiring a tracheostomy, patients either experienced an early tracheostomy or a late tracheostomy. In addition, patients were either mechanically ventilated at discharge or were not.

Outcome Measures: The following retrospectively: instances of prolonged mechanical ventilation, ventilator-associated pneumonia (VAP), acute lung injury (ALI), acute respiratory distress syndrome (ARDS), duration in intensive care unit (ICU), duration in hospital, number of ventilator-free days, extubation attempts, injury severity score (ISS).

Chronicity: Time since injury not specified. Average number of hospital days=20.

1.     Patients who received a tracheostomy had higher rates of VAP (p<0.05), higher rates of ALI (p<0.01), spent significantly more days in ICU (p<0.05) and hospital (p<0.05), and had fewer ventilator-free days (p<0.05) compared to patients who did not receive a tracheostomy.

2.     There were no significant differences with regards to death (p>0.05) between patients who received a tracheostomy and patients who did not.

3.     Patients who had a late tracheostomy had higher rates of VAP (p<0.05), ALI (p<0.05), and ARDS (p<0.05) compared to patients who had an early tracheostomy.

4.     Patients who required mechanical ventilation at discharge had a higher ISS (p<0.05), significantly higher rates of VAP (p<0.05) and ALI (p<0.05), and longer ICU (p<0.05) and hospital stays (p<0.05) compared to patients who did not require mechanical ventilation at discharge.

Choi et al. (2013)

Korea

Case Control

N=21

 

Population: Mean age: 50 yr; Gender: male=19, female=2; Level of injury: C1-C7; Severity of injury: complete=8, incomplete=13; AIS A-D.

Intervention: Patients either received an early tracheostomy (≤10 days after injury) or a late tracheostomy (>10 days after injury).

Outcome Measures: The following retrospectively: duration of mechanical ventilation.

Chronicity: Time since injury not specified. Average number of hospital days=78.

1.     Patients who received an earlier tracheostomy had a significantly shorter total ICU stay than patients who received a late tracheostomy (p=0.01).

2.     Patients who received an earlier tracheostomy experienced a significantly shorter duration of mechanical ventilation (p=0.009).

3.     There were no significant differences with regards to pneumonia (p=0.283) or tracheal stenosis (p=0.999) between the two groups.

Babu et al. (2013)

USA

Case Control

N=20

Population: Mean age: 47 yr; Gender: male=18, female=2; Level of injury: cervical; Severity of injury: complete=11, incomplete=9; AIS A-E.

Intervention:  Patients either received an early tracheostomy (≤6 days after anterior cervical spine fixation) or a late tracheostomy (>6 days after anterior cervical spine fixation).

Outcome Measures: The following retrospectively: length of hospital stay, incidence of complications, incidence and risk of complications.

Chronicity: Time since injury not specified. The mean time from hospital presentation to anterior cervical spine fixation was 2.8 days. The mean length of hospital stay was 39 days.

1.     Patients who underwent an early tracheostomy had a shorter hospitalization stay compared to those who received a late tracheostomy, but this difference was not significant (p=0.11).

2.     One patient developed pneumonia after tracheostomy. Patients who received a late tracheostomy were at a significantly increased risk for developing pulmonary complications (p=0.033).

Romero-Ganuza et al. (2011b)

Spain

Case Control

N=323

Population: Mean age: 42 yr; Gender: male=255, female=68; Level of injury: cervical to thoracic; Severity of injury: complete=229, incomplete=94.

Intervention: Patients either received a tracheostomy or did not. Of those who did, they either received a surgical tracheostomy or a percutaneous tracheostomy. They also either received an early tracheostomy (≤7 days post intubation) or a late tracheostomy (>7 days post intubation).

Outcome Measures: The following during hospital stay: incidence of mechanical ventilation and tracheostomy, injury level, injury severity, acute physiology and chronic health evaluation II (APACHE II) scores, incidence of complications, duration of mechanical ventilation, duration of intensive care unit (ICU) stay.

Chronicity: Mean interval from injury to admission=11.4 days.

1.     92% (297/323) of patients required mechanical ventilation and 67% (215/323) required a tracheostomy.

2.     Patients who received a tracheostomy had significantly higher injury levels (p<0.001) more severe injuries (p<0.001), more associated injuries (p=0.003), and higher APACHE II scores (p=0.03) than patients who did not require a tracheostomy.

3.     There were 69 cases of perioperative complications following tracheostomy. Patients who received an early tracheostomy had significantly fewer cases of tracheal stenosis than patients who received a late tracheostomy (p=0.003). There were no significant differences in pneumonia (p=0.81), stomal cellulitis (p=0.45), bleeding (p=0.96), or mortality rate (p=0.22) between the two groups.

4.     Patients who received an early tracheostomy spent significantly fewer days on mechanical ventilation (p<0.001) and significantly fewer days in ICU (p<0.001) compared to patients who received a late tracheostomy.

5.     Patients who received a percutaneous tracheostomy spent significantly fewer days in ICU (p=0.004) and experienced fewer cases of pneumonia (p=0.011) compared to patients who received a surgical tracheostomy.

Romero et al. (2009)

Spain

Case Control

N=152

Population: Mean age: 41 yr; Gender: male=122, female=30; Level of injury: cervical to thoracic; Severity of injury: complete=119, incomplete=33; AIS A-D.

Intervention: Patients either received a tracheostomy early (≤7 days of admission) or late (>7 days of admission).

Outcome Measures: The following retrospectively: total time of mechanical ventilation, time of mechanical ventilation post tracheostomy.

Chronicity: Mean time interval between injury and admission=27 days.

1.     Patients who received an early tracheostomy had significantly fewer episodes of pneumonia during intubation than patients who received a late tracheostomy (p<0.001). There were no significant differences in incidences of pneumonia post tracheostomy (p=0.80) and total incidences of pneumonia (p=0.27) between the two groups.

2.     There were no differences in mortality between early vs late tracheostomy (p=0.12).

3.     Patients who received an early tracheostomy had significantly shorter post tracheostomy duration on mechanical ventilation (p<0.005) and total duration on mechanical ventilation (p<0.001) compared to patients who received a late tracheostomy.

4.     Patients who received an early tracheostomy spent significantly fewer post tracheostomy days in ICU (p<0.05) and total days in ICU (p<0.0010) than patients who received a late tracheostomy.

5.     Patients who received an early tracheostomy had significantly fewer total complications than patients who received a late tracheostomy (p<0.05).

Discussion

Seven case control studies have examined the use of early versus late tracheostomy during acute SCI. Beom and Seo (2018) reported no difference in the number of ventilator days between early versus late patients, while other studies found that early patients had significantly fewer ventilator days compared to late (Flanagan et al. 2018; Choi et al. 2013; Romero-Ganuza et al. 2011b; Romero et al. 2009). Multiple studies found that early tracheostomy patients had significantly fewer ICU days than the late group (Beom & Seo, 2018; Flanagan et al., 2018; Choi et al., 2013; Romero et al., 2009; Romero-Ganuza et al. 2011b), with the exception of one study (Babu et al. 2013). In addition, Flanagan et al. (2018) also found that there were no differences in the number of days to decannulation, rates of pneumonia, or in-hospital mortality between early versus late tracheostomy patients. However, multiple studies have also found conflicting results as to whether an early tracheostomy results in higher rates of medical complications in SCI patients. Choi et al. (2013) found no significant differences between groups in terms of rates of pneumonia, or tracheal stenosis, while other case control studies (Babu et al., 2013; Kornblith et al., 2014) have found an increased risk of pneumonia for late tracheostomy patients. A large case control by Romero-Ganuza et al. (2011b) (N=323) found that patients who received an early tracheostomy had a significantly increased risk of tracheal stenosis, but no significant differences in rates of pneumonia. Lastly, early tracheostomies, compared to late, did not seem to affect rates of in-hospital mortality (Romero-Ganuza et al. 2011b; Romero et al., 2009; Flanagan et al., 2018).

Conclusion

There is level 3 evidence (from five case control studies; Beom and Seo, 2018; Flanagan et al., 2018; Choi et al. 2013; Romero-Ganuza et al. 2011b; Romero et al. 2009) that early tracheostomies may result in fewer ICU days than late tracheostomies in acute SCI patients.

There is level 3 evidence (from four case control studies; Flanagan et al., 2018; Choi et al. 2013; Romero-Ganuza et al. 2011b; Romero et al. 2009) that early tracheostomies may result in fewer ventilation days compared to late tracheostomies in acute SCI patients.

There is conflicting level 3 evidence (from six case control studies; Flanagan et al., 2018; Choi et al., 2013; Babu et al., 2013, Romero-Ganuza et al., 2011b; Romero et al., 2009; Kornblith et al. 2014) as to whether or not early tracheostomies decrease the risk of medical complications compared to late tracheostomies in acute SCI patients.

There is level 3 evidence (from 3 case control studies; Flanagan et al., 2018; Romero-Ganuza et al., 2011b; Romero et al., 2009) that the timing of tracheostomy may not influence in-hospital mortality rates in acute SCI individuals.

  • Early tracheostomies may result in fewer ICU days and ventilation days, however they may not impact in-hospital mortality, compared to late tracheostomies.

    The evidence is inconsistent regarding whether or not early tracheostomies reduce medical complications associated with tracheostomies compared to late tracheostomies.