Current Status of Indications, Timing, Management, Complications, and Outcomes of Tracheostomy in Traumatic Brain Injury Patients

Abstract

Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.

Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus

“…However, there was a lack of agreement on the use of short-term mild hyperventilation (PaCO 2 target 30-35 mmHg) to treat elevations in ICP. Although it is part of the staircase approach for the management of ICP, hyperventilation causes cerebral vasoconstriction and has been associated with poor outcome in the Lung Safe cohort [28], perhaps due to an increase in mechanical Little is known about how ventilator liberation should be accomplished in the setting of ABI [31]. Available evidence and clinical experience suggest that decisions on ventilator weaning and tracheal extubation must integrate neurological features with other systemic variables, and this is the approach recommended by the panel.…”

“…Timely tracheotomy represents a means of effectively weaning sedation and discontinuing mechanical ventilation in patients who require an artificial airway but are otherwise able to breathe independently. Yet studies indicate that the selection of ABI patients for tracheostomy is highly variable, often dependent on regional or institutional factors [31,32]. Our panel recommended consideration of this procedure in mechanically ventilated ABI patients who are persistently unconscious (but with an expected acceptable quality of life) or when one or several trials of extubation have failed; however, there was no consensus on the optimal timing of tracheostomy.…”

“…Little is known about how ventilator liberation should be accomplished in the setting of ABI [ 31 ]. Available evidence and clinical experience suggest that decisions on ventilator weaning and tracheal extubation must integrate neurological features with other systemic variables, and this is the approach recommended by the panel.…”

Coronavirus Disease 2019: A Wake-Up Call for Neurosurgeons to Learn Percutaneous Tracheostomy

“…Prolonged endotracheal intubation and ventilation is associated with complications like ventilator-associated pneumonia, vocal cord damage, difficulty in weaning, and sinusitis. 1 For patients in whom airway protection is required even after the first few days, tracheostomy helps by preventing iatrogenic vocal cord injury, aids in weaning patients off the ventilator by decreasing dead space, and enabling them to breathe with a lesser tidal volume and helps in tracheobronchial toileting and treating associated respiratory tract infections. Further, it is associated with greater patient comfort and decreased sedation requirements.…”

“…5,6 Several studies have stated safety in OST in patients with COVID-19 can be increased by techniques like (1) advancing the endotracheal tube till the carina to prevent inadvertent rupture of the cuff while incising the trachea, 5,7 (2) performing tracheostomy under muscle relaxants to prevent coughing J Neurosci Rural Pract:2021;12:197-199 during the procedure, 5 (3) applying sutures from inferior margin of skin till the trachea to prevent false passage of the tube and to draw the trachea upwards for ease of insertion, 7 and (4) switching of the ventilator during insertion to prevent movement of air in the patients respiratory tract. 5,6 In the scenario of the current pandemic, we feel percutaneous tracheostomy (PCT) has an advantage over OST as (1) there is no need for any coagulation (potential for virus dissemination by cautery plumes is less), (2) lesser personnel required (no need for retraction of muscles by an assistant and a single operator can do the job even without a scrub nurse), (3) the dilatation of the tracheal opening is done in a closed manner by a dilator (passed over a guide wire inserted through a cannula via a stab incision on the neck) with no exposure of the trachea to the outside environment, (4) no fear of false passage of the tube in the pretracheal space after trachea is opened obviating the need for repeated manipulation, and finally, (5) lesser time consumed in the procedure.…”