Early tracheostomy in Spontaneous Intracerebral Hemorrhage
The TRACH Score is a practical clinical grading scale that will allow identifying patients who will be needing tracheostomy. Application of this scale could have a significant impact on the length of stay and cost of hospitalization 1).
Early tracheostomy in Spontaneous Intracerebral Hemorrhage patients was associated with decreased pneumonia risk, decreased length of ICU care, and no difference in mortality at 90 and 365 days 2).
Independent predictors of Nosocomial pneumonia included early hospital admission, in-hospital aspiration, intubation, and tracheostomy. Nosocomial pneumonia was associated with prolonged hospital length of stay 3).
Yaghi et al. could potentially predict the need for tracheostomy early in the course of intracerebral Hemorrhage based on the admission GCS score; duration of intubation is another predictor for tracheostomy. Early tracheostomy could decrease the time, and therefore risks of prolonged endotracheal intubation and length of hospital stay 4).
Luo et al. conducted a retrospective database search and assessed 267 consecutive patients who underwent endotracheal intubation (175 of whom underwent tracheostomy) and Intracerebral Hemorrhage between July 2017 and June 2021. A logistic regression model was applied to identify the critical factors that influenced the decision for tracheostomy by comparing factors in a tracheostomy group and a non-tracheostomy group. Patients were divided into an early tracheostomy (≤5 days) or a late (>5 days) group according to the median time of tracheostomy. Propensity score matching was performed to adjust for possible confounders and investigate differences in outcomes between ET and late tracheostomy (LT).
Among the 267 enrolled patients with ICH and endotracheal intubation, 65.5% received tracheostomy during hospitalization, and 52.6% received ET. The independent risk factors for tracheostomy included National Institute of Health Stroke Scale (NIHSS) (odds ratio [OR]: 1.179; 95% confidence interval [CI]: 1.028-1.351; P = 0.018), aspiration (OR: 2.171; 95% CI: 1.054-4.471; P = 0.035) and infiltrates (OR: 2.149; 95% CI: 1.088-4.242; P = 0.028). Using propensity matching, we found that ET was associated with fewer antibiotic-using days (15 vs. 18; P < 0.001) and sedative-using days (6 vs. 8; P < 0.001), shorter intensive care unit (ICU) length of stay (LOS) (9 vs. 12; P < 0.05) and reduced in-ICU costs (3.59 vs. 7.4; P < 0.001) and total hospital costs (8.26 vs. 11.28, respectively; P < 0.001). Muscle relaxants (31.8% vs. 60.6%) were used less frequently in patients with ET (P = 0.001). However, there were no differences between the ET and LT groups in terms of modified Rankin Scale (mRS) (4 vs. 4; P = 0.932), in-general-ward costs (4.74 vs. 4.37; P = 0.052), mechanical ventilation days (6 vs. 6; P = 0.961) and hospital LOS (23 vs. 23; P = 0.735) as well as the incidences of ventilator-associated pneumonia (28.8% vs. 37.9%; P = 0.268), tracheostomy-related complications (16.7% vs. 19.7%; P = 0.652), respiratory failure (24.2% vs. 31.8%; P = 0.333), all-cause deaths (15.2% vs. 16.7%; P = 0.812) and pneumonia (77.3% vs. 87.9%; P = 0.108).
Luo et al. recommend early tracheostomy for high-risk patients with Intracerebral Hemorrhage. Although ET cannot reduce in-hospital mortality or improve patient prognosis, it may help reduce hospital costs and ICU LOS as well as the use of antibiotics, sedatives, and muscle relaxants 5).
Data on 136 patients with brainstem hemorrhage and Glasgow Coma Scale score ≤ 8, were retrospectively collected from 2012 to 2019. Patients were divided into the early tracheostomy group and the late tracheostomy group. Patients in the early tracheostomy group had a significantly lower neurosurgical intensive care unit stay (both overall and survival) compared with the late tracheostomy group (15.6 days vs. 19.0 days, P = 0.041, overall and 14.5 vs. 19.5 days, P = 0.023, survival). Also, the good outcomes (modified Rankin Score ≤ 3) were higher in the early tracheostomy group (P = 0.036). Multivariate analysis demonstrated that less hemorrhagic volume, high Glasgow Coma Scale score on admission, young age, and early tracheostomy were significantly associated with a better 30-day functional outcome. In conclusion, an early tracheostomy in patients with brainstem hemorrhage can reduce neurosurgical intensive care unit stay, and in addition to improvements in prognosis at 30 days 6).