Tracheostomy
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; Como et al., 2005). 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 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 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. Other complications have been reported to include tightness at the scar location, difficulty swallowing, and cosmetic inconveniences (Biering-Sorensen & Biering-Sorensen 1992). Several studies have retrospectively examined the predictors for needing a tracheostomy and complications associated with the procedure; these are presented in Table 3.
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). Lastly, patients who required a tracheostomy had longer length of stay in hospitals as well as higher hospital costs (Winslow et al. 2002).
Several studies have investigated factors associated with needing a tracheostomy in acute SCI patients, 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. 2011a; 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).
| Author Year
Country Research Design Sample Size |
Methods | Outcome |
|---|---|---|
| Sustic et al. (2002)
Croatia RCT PEDro=3 N=16 |
Population: Age range: 19-59 yr; Gender: male=13, female=3; Level of injury: C3-C6; Severity of injury: not specified.
Intervention: Patients were randomized to receive either a surgical tracheostomy (ST) or an ultrasound-guided percutaneous dilational tracheostomy (PDT). Outcome Measures: The following post procedure: incidence of complications, duration of procedure. Chronicity: Time since injury not specified. Average intensive care unit length of stay=22 days (ST) and 20 days (PDT). |
1. No patients experienced any major complications due to either tracheostomy procedure.
2. The duration of the PDT procedure was significantly shorter than the duration of the ST procedure (p<0.05). |
| Leelapattana et al. (2012)
Canada Cohort N=66 |
Population: Mean age: 38 yr; Gender: male=50, female=16; Level of injury: C4-C7; Severity of injury: complete=12, incomplete=45.
Intervention: Patients either received a tracheostomy or did not. Outcome Measures: The following at discharge: duration of mechanical ventilation, injury severity score (ISS). The following after three days of ventilation: ratio of arterial oxygen partial pressure to fractional inspired oxygen. Chronicity: Patients included in the study were within 24 hr of sustaining injury upon hospital admission. |
1. Patients who had a tracheostomy had a significantly lower motor score at discharge (p=0.04), a longer hospital stay (p<0.001), a longer ICU stay (p=0.002), and required mechanical ventilation for longer (p=0.001) compared to patients who did not have a tracheostomy.
2. Patients who had a tracheostomy had fewer pulmonary complications (p=0.001) and fewer cases of death (p=0.025) than patients who did not have a tracheostomy. 3. Early tracheostomy correlated to fewer days on ventilation (p=0.038) and fewer days spent in the hospital (p=0.004) compared to late tracheostomy. 4. The number of days spent in hospital increased by 2.3 days for every additional day from injury to tracheostomy (p<0.001). 5. An ISS score >32, complete SCI, and a PF ratio <300 on day 3 of ventilation were predictors for requiring mechanical ventilation for greater than 7 days. |
| Romero-Ganuza et al. (2011a)
Spain Cohort N=28 |
Population: Mean age: 40 yr; Gender: male=23, female=5; Level of injury: cervical; Severity of injury: complete=21, incomplete=7; AIS A-C.
Intervention: All patients received a percutaneous tracheostomy following anterior cervical spine fixation. Outcome Measures: Timing of tracheostomy, neurological deterioration, incidence of complications. Chronicity: The mean time from injury to fixation surgery was 2.25 days. The mean time from surgery to tracheostomy was 8.25 days. |
1. Patients received a tracheostomy an average of 8.25 days after they received spinal fixation surgery. Tracheostomy was performed within 6 days or less in 42.9% (12/28) of cases.
2. No patients experienced neurological deterioration as a result of spinal surgery or tracheostomy procedure. 3. No patient experienced an infection at the cervical fixation wound, however, 10.7% (3/28) of patients experienced minor complications at the tracheostomy site. 4. The authors note that tracheostomy quickly performed after fixation surgery does not increase the rate of surgical wound infection. |
| McCully et al. (2014)
USA Case Control N=256 |
Population: Mean age: 46 yr; Gender: male=192, female=64; Level of injury: C1-T3; Severity of injury: complete=77, incomplete=179.
Intervention: Patients either received a tracheostomy or did not. Outcome Measures: The following retrospectively: number of days on ventilator, severity of injury. Chronicity: Time since injury not specified. Median hospital length of stay was 7 days (no tracheostomy) and 33 days (tracheostomy). |
1. Patients who received a tracheostomy had more days on a ventilator than patients who did not receive a tracheostomy (p<0.05).
2. The occurrence of complete injury and intubation was higher in patients who received a tracheostomy (p<0.05) than patients who did not. |
| Berney et al. (2011)
Australia Case Control N=114 |
Population: Mean age: 32 yr; Gender: male=86, female=28; Level of injury: C0-C8; Severity of injury: complete=72, incomplete=42; AIS A-D.
Methods: Patients who were extubated were compared to patients who received a tracheostomy. Outcome Measures: The following during hospital stay: pulmonary secretion production, number of associated injuries, mental state, ASIA score, ratio of arterial oxygen partial pressure to fractional inspired oxygen, forced vital capacity (FVC). Chronicity: Time since injury not specified. |
1. Patients with a tracheostomy produced significantly more pulmonary secretions (p=0.003), had significantly more associated injuries (p=0.02), had a more alert mental state (p=0.005), and had more complete injuries (p=0.026) compared to patients who were extubated.
2. Patients with a tracheostomy had significantly lower gas exchange (p=0.02) and FVC (p<0.001) than patients who were extubated. |
| Berney et al. (2008)
Australia Case Control N=71 |
Population: Mean age: 40 yr; Gender: male=46, female=25; Level of injury: C1-C8; Severity of injury: complete=45, incomplete=26; AIS A-D.
Intervention: Patients either received tracheostomy following anterior cervical spine fixation or posterior spine fixation (control group). Outcome Measures: The following retrospectively: timing of the tracheostomy since surgery, prevalence of infection. Chronicity: The median time from injury to stabilization surgery was 3 days. The mean time from surgery to tracheostomy was 3.8 days (anterior fixaton) and 3.1 days (posterior fixation). |
1. There were no significant differences between the timing of tracheostomy in patients who received it after anterior cervical spine fixation compared to patients who received it after posterior fixation (p=0.09).
2. 24% (17/71) of patients developed an infection at the tracheostomy site or cervical site. Patients who received a tracheostomy after posterior fixation developed significantly more incision site infections than patients who received a tracheostomy after anterior fixation (p<0.05). |
| Berney et al. (2002)
Australia Case Control N=14 |
Population: Mean age 28 yr; Gender: male=11, female=3; Level of injury: cervical; Severity of injury: complete.
Intervention: Patients who received a tracheostomy were compared to patients who were extubated and received physiotherapy. Outcome Measures: The following at the time of extubation/the day of tracheostomy: forced vital capacity (FVC), ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2), total number of physiotherapy treatments, number of physiotherapy treatments in intensive care unit (ICU), length of stay in ICU, days requiring mechanical ventilation, length of stay in acute ward after discharge from ICU, days from injury to fixation. Chronicity: The mean time from injury to fixation was 1.9 days. |
1. There was no significant difference in FVC between tracheostomized patients and physiotherapy patients (p>0.05).
2. There was no significant difference in PaO2/FiO2 ratios between tracheostomized patients and physiotherapy patients (p>0.05). 3. There was no significant difference in total number of physiotherapy treatments between tracheostomized patients and extubated patients. Patients who were extubated and received physiotherapy required significantly fewer treatments compared to tracheostomized patients in ICU (p=0.047). 4. Tracheostomized patients spent significantly more days in ICU than physiotherapy patients (p=0.006) and required mechanical ventilation for significantly longer than the physiotherapy group (p=0.018). 5. There was no significant difference in the length of stay in the acute ward between groups (p>0.05). 6. There was no significant difference in the time from injury to fixation between groups (p>0.05). |
| Kornblith et al. (2014)
USA Case Series 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. 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), 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 were associated with a 14.1-fold higher odds of requiring prolonged mechanical ventilation (p<0.05) compared to patients who did not receive a tracheostomy.
2. Patients who received a tracheostomy had fewer ventilator-free days (p<0.05) compared to patients who did not receive a tracheostomy. 3. Patients who had a tracheostomy required mechanical ventilation at discharge more often than patients who did not have a tracheostomy (p<0.05). 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. |
| O’Keeffe et al. (2004)
USA Case Series N=17 |
Population: Mean age 43 yr; Gender: male=12, female=5; Level of injury: cervical; Severity of injury: not specified.
Intervention: All patients received a tracheostomy following anterior cervical spine fixation. Outcome Measures: The following after tracheostomy: neurologic deterioration, incidence of complications, mortalities, injury severity. Chronicity: Time since injury not specified. |
Overall Analyses:
1. No patients experienced neurologic deterioration after tracheostomy following spine fixation. 2. No patients developed infections at the anterior cervical fusion site following tracheostomy. 82% (14/17) patients developed pneumonia. There were no deaths related to airway difficulties. Analyses of entire population of patients with cervical SCI, including patients that did not receive an anterior cervical spine fixation (N=60): 3. The need for a tracheostomy correlated with injury severity (p<0.001) with ASIA level A and B patients requiring the most tracheostomies. |
Discussion
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).
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). 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, however the percutaneous dilational tracheostomy was a significantly shorter procedure. Kornblith et al. (2014) found that patients who received a tracheostomy were associated with a 14.1-fold higher odds of requiring prolonged mechanical ventilation (p<0.05) compared to patients who did not receive a tracheostomy.
Conclusion
There is level 2 evidence (from one RCT: Sustic et al. 2002) that percutaneous dilational tracheostomies are a significantly shorter procedure and have fewer pulmonary complications compared to surgical tracheostomies for individuals with acute SCI.
There is level 2 evidence (from one cohort study: Leelapattana et al. 2012) that tracheostomies can reduce the number of pulmonary complications in individuals with acute SCI compared to late or no tracheostomy.
There is level 2 evidence (from one cohort study: Romero-Ganuza et al. 2011a) that tracheostomies performed directly after spinal fixation surgery do not increase the rate of surgical wound infection compared to non-immediate tracheostomies in acute SCI individuals.
There is level 3 evidence (from one case control study and one case series: McCully et al. 2014; Kornblith et al. 2014) that acute SCI individuals who receive a tracheostomy may spend more days on a ventilator than those who do not.
There is level 3 evidence (from one case control study: Berney et al. 2011) that acute SCI individuals who receive a tracheostomy, compared to those who are extubated, may have more pulmonary secretions, lower gas exchange, and lower forced vital capacity.
There is level 4 evidence (from one case series: O’Keeffe et al. 2004) that tracheostomies in acute SCI individuals may not increase the risk of neurologic deterioration or surgical site infection.
