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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 34  |  Issue : 2  |  Page : 127-131

Does early tracheostomy affect the duration of mechanical ventilation in patients with severe traumatic head injuries?


1 Department of Otorhinolaryngology, Assiut University Hospital, Assuit, Egyp
2 Department of Anaesthesia and Intensive Care Units, Assiut University Hospital, Assuit, Egyp

Date of Submission25-Nov-2017
Date of Acceptance27-Dec-2017
Date of Web Publication9-May-2018

Correspondence Address:
A E Saleh
Department of Otorhinolaryngology, 5th Floor Main Building, Assiut University Hospital, Assiut, 71516
Egyp
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejo.ejo_76_17

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  Abstract 

Background and purpose Tracheostomy is a surgical procedure performed frequently in intensive care units (ICUs). Prolonged mechanical ventilation (MV) is the main indication for tracheostomy in ICUs. This study was conducted to investigate if early tracheostomy affects the duration of mechanical ventilation in patients with severe traumatic head injuries.
Patients and methods It is a prospective, randomized study in which patients with severe post-traumatic head injuries, with a Glasgow Coma Scale of less than 8, were included. Patients were randomized into two groups; group of early tracheostomy (ET) included 53 patients subjected to tracheostomy before the seventh day of intubation and group of late tracheostomy (LT) included 34 patients subjected to tracheostomy on or after the seventh day of intubation. The total duration of mechanical ventilation, the complications of tracheostomy, and mortality were recorded.
Results The mean duration of mechanical ventilation of ET group (ET=10.97±6.82) was statistically significantly shorter than the LT group (LT=16.28±8.65) (P=0.002). Complications were minor and not life threating. No mortalities were detected because of tracheostomy.
Conclusion Tracheostomy is a safe procedure with acceptable rate of minor complications. Early tracheostomy, before the seventh day of intubation, significantly shortens the duration of mechanical ventilation in patients with severe traumatic head injuries.

Keywords: early tracheostomy, head trauma, mechanical ventilation


How to cite this article:
Roushdy M M, Abdel-Ghaffar H S, Saleh A E. Does early tracheostomy affect the duration of mechanical ventilation in patients with severe traumatic head injuries?. Egypt J Otolaryngol 2018;34:127-31

How to cite this URL:
Roushdy M M, Abdel-Ghaffar H S, Saleh A E. Does early tracheostomy affect the duration of mechanical ventilation in patients with severe traumatic head injuries?. Egypt J Otolaryngol [serial online] 2018 [cited 2018 May 23];34:127-31. Available from: http://www.ejo.eg.net/text.asp?2018/34/2/127/232179


  Introduction Top


The tracheotomy is an old surgical procedure; it dates back to ancient Egypt [1]. From the first tracheostomy until early decades of the 20th century, tracheostomy was done exclusively for laryngeal obstruction [2]. Recently, tracheostomy was performed frequently in ICUs for patients subjected to prolonged intubation and ventilation [3]. Tracheostomy in ICUs is usually a procedure done electively to gain alternative aperture to the airway, instead of endotracheal tubes, to conduct mechanical ventilation (MV) [2]. By reviewing the literature, debates were found about the timing of performing tracheostomy in critically ill patients.


  Patients and methods Top


This prospective, randomized study was conducted in trauma ICUs in Assiut University Hospital, Assiut, in Egypt after obtaining an Institutional Review Board (IRB) approval and issued IRB no: 00008718 from the Committee of Medical Ethics, Faculty of Medicine, Assiut University. It was conducted for 1 year between 1st of June 2015 and 31st of May 2016.

Inclusion criteria

Patients with severe post-traumatic head injuries with a Glasgow Coma Scale (GCS) of less than 8 requiring intubation and MV were included in the study. All age groups and both sexes were included. Before including participants into the study, the purpose and nature of the study were explained to their guardians as all our participants were critically ill patients and incapacitated. Their guardians agreed that they understand the investigational nature of the study benefits. They were free to terminate participation in this study without affection of clinical service or clinical management. They were free to ask about the nature of the study. An informed consent for the tracheostomy procedure was obtained from the guardians.

The patients were randomized according to the willingness of their guardians or families to perform early (ET) or late tracheostomy (LT). Patients of the ET group were subjected to tracheostomy before the seventh day of intubation, whereas patients of the LT group were subjected to tracheostomy at or after the seventh day.

Surgical technique

Tracheostomy was done in all patients by an open surgical technique under general anesthesia with hyperextended neck over a roll under their shoulders and was done in ICUs without the need to transfer the patients to the operating theater.

Patients were followed up during their stay in ICUs. Age, sex, timing of tracheostomy, and duration of MV were recorded. Complications of tracheostomy were managed and recorded as well as mortalities during hospital stay. The two groups were compared regarding age, sex, duration of MV, and hospital mortality.

Statistical analysis

The data were tested for normality using the Kolmogorov–Smirnov test and for homogeneity variances before further statistical analysis. Categorical variables were described by number and percent [n (%)]; continuous variables were described by mean and SD. χ2 and Fisher’s exact tests were used to compare between categorical variables. Unpaired t-test was used to compare between continuous variables for normally distributed data and Mann–Whitney U-test for non-normally distributed data. P value less than 0.05 was considered statistically significant. All analyses were performed with the International Business Machines Statistical Package for the Social Sciences IBM SPSS 20.0 software (IBM Corp., New York, USA).


  Results Top


Out of the 237 patients who were intubated and mechanically ventilated in trauma ICUs during the period of the study, 87 patients fulfilled the inclusion criteria of the study and were included in the study ([Figure 1]). After randomization, there were 53 patients in the ET group and 34 patients in the LT group.
Figure 1 Flow chart of studied patients.

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The mean age of the ET group was 25.4±17.5 years, whereas that of the LT group was 24.05±17.52 years. Men were more than women in both groups with a percentage of 86.7 and 82.5% for the ET and the LT group, respectively. There were no statistically significant difference between the two groups regarding age and sex ([Table 1]).
Table 1 Demographic and clinical data of the patients in early tracheostomy and late tracheostomy groups

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The mean duration of intubation before tracheostomy in patients of ET groups was 5.4 days and ranged from 2 to 6 days, whereas that of the LT group was 11 days and ranged from 8 to 20 days. The mean duration of MV of the ET group (ET=10.97±6.82) was statistically significantly shorter than that of the LT group (LT=16.28±8.65) (P=0.002) ([Table 1]).

Complications were recorded in 8% of the patients. They were minor and not life threatening. Tracheostomy stoma wound sepsis was the most common complication ([Table 2]).
Table 2 Complications of tracheostomy

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Twenty-four (27.5%) of the studied patients died during hospital stay. Of those deaths, five patients were of the LT group, whereas 19 were of the ET group. Hospital mortality was found statistically significantly associated with early tracheostomy. (P=0.0325) ([Table 1]). However, no mortalities occurred during the tracheostomy procedure or because of one of the complications of tracheostomy.


  Discussion Top


In this current study, ET before the seventh day of intubation was found to be of significantly shorter duration of MV. In the literature, few studies were found discussing the effect of tracheostomy on the condition of head-injured patients [4],[5],[6],[7],[8],[9],[10]. However, most of them recorded a decrease in the duration of MV with early tracheostomy [7],[8],[10],[11]. Lee et al. [12] found that tracheostomy increases the success rate of weaning in patients with a low GCS, but not in patients with high GCS. According to meta-analysis done by Griffiths [10], tracheostomy before the seventh day of intubation may lead to reduced duration of ventilation and shorten stays in ICUs in mechanically ventilated critically ill adult patients. A retrospective study reported significantly shorter duration of MV in patients with early tracheostomy before the fifth day of intubation [11]. Sanabria et al. [13] found that the probability of weaning patients from MV after the eighth day of intubation without a tracheostomy was low. Lim et al. [14] found that tracheostomy significantly improved the measured values of weaning parameters in patients who were difficult to be weaned.

These results can be explained by the fact that tracheostomy decreases dead space, airway resistance and increases tidal volume [14]. ET was associated with a decrease the incidence of ventilator-associated pneumonia and provided an effective way of airway suction [8],[14]. In addition, it shortens the duration of stay in ICUs as well as the duration of hospital stay [5]. Tracheostomy improves the patient’s comfort and decreases the required sedation [15].

In spite of that most of the published papers recorded a shorter duration of MV with early tracheostomy. There were debates about how early should tracheostomy be performed in critically ill patients especially those with severe brain injury. According to Rodriguez et al. [16] and Bouderka et al. [8] early tracheostomy should be before the seventh and sixth day of intubation, respectively. However, Zirpe et al. [11] considered tracheostomy before the fifth day of intubation as ET. Dunham et al. [7] and Rumbak et al. [17] considered early tracheostomy before the third and fourth day of intubation. All of them recorded a decreased duration of MV after ET, in spite of the different definition of early tracheostomy according to each of them. Determination of an optimal timing of tracheostomy in severe head-injured patients requires additional multicentric studies. There are many factors affecting the decision of timing of tracheostomy, such as hemodynamic instability, fears of tracheostomy from the side of the guardians, and presence of cervical trauma that hinders neck mobility and may delay the decision of tracheostomy.

This study recorded that tracheostomy was a safe procedure. It was done in ICUs without significant complications. Also, no mortalities were recorded due to the tracheostomy procedure. These results were identical to Pogue et al. [18] and Vergas et al. [19].

In this study, the mortality rate was lower than other studies [8],[11]. Also, no mortalities occurred during the tracheostomy procedure or because of complications of tracheostomy. However, hospital mortality was higher in patients with ET. Higher mortalities in patients with ET were in consistence with meta-analysis conducted by Dunham and colleagues and other studies [5],[7],[11],[20]. However, all of these studies had no clear explanation to this finding. Further investigations and studies are required to explain this finding. In contrast, Koch et al. [21] and Siempos et al. [22] recorded nonsignificant low hospital mortality after ET.


  Conclusion Top


Tracheostomy is a safe procedure with an acceptable rate of minor complications. ET, before the seventh day of intubation, significantly shortens the duration of MV in patients with severe traumatic head injuries. Hospital mortality after ET should be investigated in further studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blomstedt P. Tracheostomy in ancient Egypt. J Laryngol Otol 2014; 128:665–668.  Back to cited text no. 1
    
2.
Paul J, Pracy M, Rogers M. Tracheostomy. In: Watkinson JC, Gilbert RW, editors. Stell & Maran’s textbook of head and neck surgery and oncology. 5th ed. New York: Taylor & Francis; 2012.  Back to cited text no. 2
    
3.
Durbin CG Jr. Indications for and timing of tracheostomy. Respir Care 2005; 50:483–487.  Back to cited text no. 3
    
4.
Ahmed N, Kuo YH. Early versus late tracheostomy in patients with severe traumatic head injury. Surg Infect (Larchmt) 2007; 8:343–347.  Back to cited text no. 4
    
5.
Rizk EB, Patel AS, Stetter CM, Chinchilli VM, Cockroft KM. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care 2011; 15:481–489.  Back to cited text no. 5
    
6.
Sabouri M, Esmaili TM, Hosseini B. The effects of early tracheostomy on outcomes of patients with severe head injury. J Isfahan Med School 2009; 27:211–216.  Back to cited text no. 6
    
7.
Dunham CM, Cutrona AF, Gruber BS, Calderon JE, Ransom KJ, Flowers LL. Early tracheostomy in severe traumatic brain injury: evidence for decreased mechanical ventilation and increased hospital mortality. Int J Burns Trauma 2014; 4:14–24.  Back to cited text no. 7
    
8.
Bouderka MA, Fakhir B, Bouaggad A, Hmamouchi B, Hamoudi D, Harti A. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma 2004; 57:251–254.  Back to cited text no. 8
    
9.
Sugerman HJ, Wolfe L, Pasquale MD, Rogers FB, O’Malley KF, Knudson M et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma 1997; 43:741–747.  Back to cited text no. 9
    
10.
Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005; 330:1243.  Back to cited text no. 10
    
11.
Zirpe KG, Tambe DV, Deshmukh AM, Gurav SK. The impact of early tracheostomy in neurotrauma patients: a retrospective study. Indian J Crit Care Med. 2017; 21:6–10.  Back to cited text no. 11
    
12.
Lee YC, Wang HC, Hsu CL, Wu HD, Hsu HS, Kuo CD. The importance of tracheostomy to the weaning success in patients with conscious disturbance in the respiratory care center. J Chin Med Assoc. 2016; 79:72–76.  Back to cited text no. 12
    
13.
Sanabria A, Gomez X, Vega V, Dominguez LC, Osorio C. Prediction of prolonged mechanical ventilation in patients in the intensive care unit: a cohort study. Colomb Med (Cali). 2013; 44:184–188.  Back to cited text no. 13
    
14.
Lim C-K., Ruan S-Y., Lin F-C., Wu CL, Chang HT, Jerng JS et al. Effect of tracheostomy on weaning parameters in difficult-to-wean mechanically ventilated patients: a prospective observational study. PLoS One 2015; 10:e0138294.  Back to cited text no. 14
    
15.
Nieszkowska A, Combes A, Luyt CE, Ksibi H, Trouillet JL, Gibert C, Chastre J. Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med. 2005; 33:2527–2533.  Back to cited text no. 15
    
16.
Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery 1990; 108:655–659.  Back to cited text no. 16
    
17.
Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004; 32:1689–1694.  Back to cited text no. 17
    
18.
Pogue MD, Pecaro BC. Safety and efficiency of elective tracheostomy performed in the intensive care unit. J Oral Maxillofac Surg. 1995; 53:895–897.  Back to cited text no. 18
    
19.
Vargas M, Sutherasan Y, Antonelli M, Brunetti I, Corcione A, Laffey JG et al. Tracheostomy procedures in the intensive care unit: an international survey. Crit Care 2015; 19:291.  Back to cited text no. 19
    
20.
Wang HK, Lu K, Liliang PC, Wang KW, Chen HJ, Chen TB, Liang CL. The impact of tracheostomy timing in patients with severe head injury: an observational cohort study. Injury 2012; 43:1432–1436.  Back to cited text no. 20
    
21.
Koch T, Hecker B, Hecker A, Brenck F, Preuß M, Schmelzer T. Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study. Langenbecks Arch Surg. 2012; 397:1001–1008.  Back to cited text no. 21
    
22.
Siempos II, Ntaidou TK, Filippidis FT, Choi AM. Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med. 2015; 3:150–158.  Back to cited text no. 22
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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