See All Evidence Sections
Respiratory Management (Rehab Phase)

Tracheostomy Placement and Decannulation

Subjects 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

Quesnel et al. 2015; France
Retrospective Review
N = 108

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
  1. Out of 44 tracheotomized patients, 25 decannulated at mean of 84.1(59.1) days; 12 expired; 7 could not be weaned (3 of which expired at a mean treatment duration of 202.3(121.7) days; the others have had 727.7(283.6) days of treatment at end of study)
  2. At end of study, 9 patients definitively institutionalized, 61 returned home

Holscher et al. 2014; United States
Retrospective Chart Review
N = 33

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
  1. Significantly reduced ventilator days, ICU days, hospital days for those younger than 13 who received early tracheostomy, compared to those younger than 13 who received late tracheostomy.
  2. The same measures are not significantly different between groups in those who are 13 or older.
  3. Significantly reduced prevalence of airway complications in those who received early tracheostomy (all ages).
  4. No significant between group difference in prevalence of pneumonia.

Luo et al. 2014; China
Retrospective Chart Review
N = 21

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
  1. Mean duration* (range) of tracheostomy was 40 (14-104) days
  2. Mean duration* (SD) of closed tracheostomy was 18.8 (13.5) days
  3. No significant difference in mean duration of tracheostomy or closed tracheostomy between C2-C4 and C5-C7 SCI patients, and between AIS-A and AIS-B/C/D patients
  4. Significantly shorter duration of tracheostomy in those ventilated for <10 days (compared to >10 days), and in those tracheostomized >24h post-injury (compared to <24h)

*Until decannulation

Ganuza et al. 2011; Spain
Case series
N=323

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)
  1. Of the 323 patients included, 297 required MV, and 215 required tracheostomy.
  2. Early tracheostomy was performed in 101 (47%) patients, late in 114 (53%) cases. There were 25 complications in 21 patients (21%) after early procedure and 38 complications in 32 patients (28%) after late procedure (non-significant at p=0.14).
  3. The early group had fewer ICU stays, reduced tracheostomy duration, reduced length of time on mechanical ventilation and less tracheal stenosis.
  4. Surgical tracheostomy was performed in 119 (55%) of patients, and percutaneous in 94 (45%). There were no significant differences in related complications.
  5. Surgical group had more ICU stays than the percutaneous tracheostomy attributed death
  6. There were no tracheostomy attributed deaths.

Romero-Ganuza et al. 2011; Spain
Prospective Cohort Study
N = 28

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
  1. None of the patients had neurologic deterioration related to spinal stabilization surgery or tracheostomy procedure.
  2. Complications in tracheostomy in only 3 cases: minor bleeding occurred in 1 patient and stomal infection, not propagated to the fixation surgery wound, was observed in 2 patients.
  3. Of the 28 patients, 2 died. The deaths were not related to this tracheostomy technique.
  4. The ICU stay after tracheostomy ranged from 4-38 days, with a mean(SD) of 23.08(9.77) days.

Cameron et al. 2009; USA
Cohort Study
N = 68

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
  1. Median LOS decreased from 60 days (IQR 38-106) to 41.5 days (IQR 29-62).
  2. Median DOC decreased from 22.5 days (IQR 17-58) to 16.5 days (IQR 12-25).
  3. Speaking valve usages increased from 35% to 82%.
  4. Cost savings were realized with the implementation of the TRAMS protocol.

Romero et al. 2009; Spain
Case Series
N = 152

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
  1. ETG group younger than the LTG group.
  2. The ETG patients had significantly shorter time on mechanical ventilation compare to the LTG patients (26.1(7) days vs. 48.8(3.5) days).
  3. The ETG patients had a significantly shorter length of stay in the intensive care unit compared to LTG patients (36.5(6) days vs. 54.6(2.9) days).
  4. There was a lower complication rate in the ETG group. There was no difference in mortality or incidence of pneumonia between the two groups, although there was a trend towards lower mortality rate in the ETG group (1 patient, compared to 5 in LTG).
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.
  1. 4 participants who had evidence of aspiration were successfully decannulated after assessment by a multidisciplinary team.
  2. None experienced respiratory deterioration.

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.

Related Downloads
Related Toolkits