Indicators for Tracheostomy in Patients with Traumatic Brain Injury

Abstract

Our objective was to develop criteria to identify patients with traumatic brain injury (TBI) who require a tracheostomy (TR). From January 1994 to May 2000 all TBI patients requiring intubation on presentation and who survived <7 days were identified from our trauma registry. Demographics, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and ventilator days, ICU days, hospital days, need for TR, and development of pneumonia were statistically analyzed. Of 246 patients with TBI 211 without TR and 35 with TR were identified (mean time to TR 13.3 ± 7.0 days). Logistic regression analysis identified presenting GCS ≤8, ISS ≤25, and ventilator days <7 as significant predictors for TR. Applying these three predictors to our population identified 48 patients (21 with TR, 18 without TR, and nine who died on the ventilator without TR) with a sensitivity of 60 per cent, a specificity of 87 per cent, a positive predictive value of 44 per cent, and a negative predictive value of 93 per cent. Patients with TR had lower presenting GCS and higher ventilator, ICU, and hospital days ( P < 0.05). Pneumonia rates were similar. Time to neurologic recovery (GCS ≤9) was longer for the TR patients as compared with the patients without TR. We conclude that patients with TBI presenting with a GCS ≤8, an ISS ≤25, and ventilator days <7 are more likely to require TR. Performing TR late did not reduce pneumonia rates or ventilator, ICU, or hospital days. By identifying the at-risk population early TR could be performed in an attempt to decrease morbidity and length of stay.

Associated factors for Tracheostomy in adults with severe traumatic brain injury. Score proposal

“…In our study, patients younger than 44 years had less risk of tracheostomy; Shamim et al and Goettler et al found the same results as ours, as younger the patient, less frequent the tracheostomy was 12,13 .…”

“…A total of 12 patients died before we were able to decide if they were going to need tracheostomy. Analyzing this situation and along with the findings reported by other authors that suggest that early tracheostomy has to be performed after day 3 and before the 1 st week of stay 4,[11][12][13]19,20 , led us to suggest that this procedure should be done between day 3 and 4 of stay because before day 3 critically ill patients should not be exposed to unnecessary procedures as they will die during hospitalization as reported by Major et al and Bouderka et al 4,21 We did not found a relationship between the time of performing the tracheostomy and mortality rate. The deaths in the tracheostomy group were 22.9% versus 0% in the non-tracheostomy group, as also days of AMV and total length of stay were higher in the tracheostomy group, this can be explained because this group of patients was critically ill.…”

“…These results show the direct relationship between the number of days with AMV and frequency of pneumonia and also this with the total length of stay. Some other authors have found that the use of early tracheostomy decreases the number of days with AMV 5,7,11,12 .…”

Disfagia orofaríngea neurogénica: concepto, fisiopatología, clínica y terapéutica

“…Predictors of long-term oropharyngeal dysphagia in TBI patients include low initial Glasgow Coma Scale scores, specific findings on computed tomography (e.g., displacement of structures, brainstem involvement), prolonged ventilator use (≥15 days), and tracheostomy placement. [88][89][90][91] Studies focused on the characteristics of dysphagia in post-TBI patients describe prolonged oral transit time, delayed swallowing reflex, and altered tongue control. 92 One study evaluated swallowing characteristics using VFSS in 41 TBI patients and found that the most common findings were aspiration, penetration, decreased laryngeal elevation, and reduced epiglottic inversion.…”