Tracheostomy Placement and Decannulation
People with SCI often undergo tracheostomy if it is anticipated that they are going to require ventilatory support for longer than 3 weeks. There is limited evidence for the timing for tracheostomy in spinal cord injured subjects who require prolonged mechanical ventilation. A 2005 systematic review of adult subjects (not SCI specific) reported a decrease in mechanical ventilation and ICU length of stay in subjects who had early tracheostomy. There is one retrospective study in SCI looking at early versus late tracheostomy placement. Evidence for the decannulation of subjects with SCI is lacking. Subjects may not meet the traditional criteria for decannulation and should be assessed on an individualized basis (Bach and Alba 1990; Ross & White 2003).
| Author Year; Country Score Research Design Total Sample Size |
Methods | Outcome |
|---|---|---|
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Quesnel et al. 2015; France |
Population: N=108 tetraplegic cervical SCI patients (86M, 22F) Mean (SD) age: 49.0 (21.1) years 51 AIS-A, 22 AIS-B, 19 AIS-C, 10 AIS-D (out of 103 patients) Treatment: Tracheostomy (44/108 patients) Outcome Measures: Institutionalization status, decannulation status, length of treatment |
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Holscher et al. 2014; United States |
Population: N=91 SCI or TBI patients <18 years old who underwent tracheostomy (67M, 24F) Mean (SD) age: 13 (5) years 29 are ≤12 years old 62 are 13-18 years old Treatment: Early (≤7 days post-injury) vs. late tracheostomy Outcome Measures: Number of ventilator days, ICU days, hospital days, number of patients who developed pneumonia and airway complications |
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Luo et al. 2014; China |
Population: N=21 successfully decannulated cervical SCI individuals (17M, 4F) Mean (range) age: 44.57(12-68) years 10 tracheostomized <24h post injury 16 AIS-A, 5 AIS-B/C/D Treatment: Tracheostomy Outcome Measures: Time between tracheostomy to decannulation, time between closed tracheostomy to decannulation |
*Until decannulation |
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Ganuza et al. 2011; Spain |
Population: 256 males, 67 females; mean(SD) age 42.3(13.7); 208 cervical SCI, 115 thoracic SCI Treatment: Tracheostomy: early (1-7 days from intubation) vs. late (>7 days); surgical vs. percutaneous Outcome Measures: Medical record review (tracheostomy technique/timing, duration of mechanical ventilation (MV), length of stay in ICU, incidence of complications) |
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Romero-Ganuza et al. 2011; Spain |
Population: N=28 people with SCI (23M 5F) admitted to ICU with traumatic cervical SCI treated with anterolateral cervical spine fixation surgery (21 AIS A, 4 AIS B, 3 AIS C); mean age was 39.6 ± 13.7 years (range: 21-74y) Treatment: percutaneous tracheostomy Outcome Measures: outcome of percutaneous tracheostomy technique, ICU stay after tracheostomy, surgical wound infection rate |
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Cameron et al. 2009; USA |
Population: Matched pair design based on level of SCI, AIS score, then age with 34 participants in the pre-TRAMS group (70% male, mean age 25.5, IQR 23.8-51.8) matched with 34 in the post-TRAMS group (82 % male, mean age 44, IQR 30.8-51.0). Treatment: Tracheostomy Review and Management Service (TRAMS), which provides support and education to patients, caregivers, and staff Outcome Measures: Length of Stay (LOS), duration of cannulation (DOC), communication through use of a one-way valve, and number of adverse events and related costs |
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Romero et al. 2009; Spain |
Population: 152 traumatic SCI participants, 122 male and 30 female, mean age 41 (range 13-77), including 79 participants with injury level C3-C5, 42 from C6-C8, 22 from T1-T5, and 9 from T6-T10 Treatment: Early tracheotomy (performed from 1-7 days after intubation) (n = 71) or late tracheotomy (performed after 7 days) (n = 81). Outcome Measures: Medical records of the patients, including mortality, length of stay, time on mechanical ventilation, and incidence of pneumonia |
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| Author Year; Country Score Research Design Total Sample Size |
Methods | Outcome |
|---|---|---|
| Ross & White 2003; Australia Case Series N=4 |
Population: Tetraplegia (n=3) and paraplegia (n=1), level: C5-T9, AIS (n=3) & B (n=1), age: 20-71 yrs. Treatment: Interdisciplinary evaluation and assessment. Outcome Measures: Successful decannulation. |
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Discussion
Romero et al. (2009) performed a retrospective review of 152 subjects with early (ETG) or late (LTG) tracheostomy placement. Overall, subjects with earlier tracheostomy placement were significantly younger, had fewer complications and had significantly shorter times on mechanical ventilation and shorter lengths of stay in ICU. A second retrospective review showed that patients with earlier tracheostomy had fewer ICU stays, reduced tracheostomy duration, reduced length of time on mechanical ventilation and less tracheal stenosis (Ganuza et al. 2011). Overall percutaneous tracheostomy appears to be safe in cervical spinal cord injuries (Romero-Ganuza et al. 2011) including when compared to surgical tracheostomy (Ganuza et al. 2011).
Compared to subjects with LTG, subjects with ETG had no difference in pneumonia rates or mortality although there was a trend toward lower mortality in the ETG group. One of the drawbacks of these studies are their retrospective nature and the inability to account for decision factors regarding early versus late tracheostomy. In other words, there may have been a selection bias for early tracheostomy that influenced a more favourable outcome. Despite these limitations, the findings in these studies are corroborated by a meta-analysis performed on the efficacy of ETG in adults (Griffiths et al. 2005). There is a need to develop guidelines for timing of tracheostomy placement in SCI subjects.
Cameron et al. (2009) compared the outcomes of 34 tracheostomized subjects with SCI prior to the implementation of an interdicisplinary tracheostomy team to the outcomes of 34 subjects following implementation of the team. The implementation of a tracheostomy team (known as TRAMS) resulted in shorter acute care lengths of stay, shorter periods of cannulation, increase in speaking valve usage and reduced costs.
Ross and White (2003) describe a case series of 4 subjects with SCI who were successfully decannulated despite the presence of traditional contraindications for decannulation such as evidence of aspiration. These 4 subjects were carefully selected by a multidisciplinary team who opted for decannulation after assessing the overall risks of decannulation versus the risks of prolonged tracheostomy. Further studies examining the criteria for decannulation of subjects with SCI are required.
Conclusions
There is level 2 evidence (from 1 cohort study: Cameron et al. 2009) that the Tracheostomy Review and Management Service (TRAMS) reduces length of stay (LOS), duration of cannulation (DOC) and saves costs, while increasing speaking valve usage.
There is level 4 evidence (from 2 case series and 1 retrospective review: Romero et al. 2009, Ganuza et al. 2011, Holscher et al. 2014) that early tracheostomy and decannulation, performed within a week of intubation, is beneficial, and can lead to fewer days in the ICU and on the ventilator.
There is level 4 evidence (from 1 case series study: Ross & White 2003) that decannulation can be successful in subjects with evidence of aspiration.
