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Timing of Mechanical Ventilation

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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

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.