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Outcomes After Tracheostomy in Patients with Severe Acute Brain Injury: A Systematic Review and Meta-Analysis

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Abstract

Objective

To synthesize reported long-term outcomes in patients undergoing tracheostomy after severe acute brain injury (SABI).

Methods

We systematically searched PubMed, EMBASE, and Cochrane Library for studies in English, German, and Spanish between 1990 and 2019, reporting outcomes in patients with SABI who underwent tracheostomy. We adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines and the meta-analyses of observational studies in epidemiology guidelines. We excluded studies reporting on less than 10 patients, mixed populations with other neurological diseases, or studies assessing highly select subgroups defined by age or procedures. Data were extracted independently by two investigators. Results were pooled using random effects modeling. The primary outcome was long-term functional outcome (mRS or GOS) at 6–12 months. Secondary outcomes included hospital and long-term mortality, decannulation rates, and discharge home rates.

Results

Of 1405 studies identified, 61 underwent full manuscript review and 19 studies comprising 35,362 patients from 10 countries were included in the meta-analysis. The primary outcome was available from five studies with 451 patients. At 6–12 months, about one-third of patients (30%; 95% confidence interval [CI] 17–48) achieved independence, and about one-third survived in a dependent state (36%, 95% CI 28–46%). The pooled short-term mortality for 19,048 patients was 12%, (95% CI 9–17%) with no significant difference between stroke (10%) and TBI patients (13%), and the pooled long-term mortality was 21% (95% CI 11–36). Decannulation occurred in 79% (95% CI 51–93%) of survivors. Heterogeneity was high for most outcome assessments (I2 > 75%).

Conclusions

Our findings suggest that about one in three patients with SABI who undergo tracheostomy may eventually achieve independence. Future research is needed to understand the reasons for the heterogeneity between studies and to identify those patients with promising outcomes as well as factors influencing outcome.

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References

  1. Creutzfeldt CJ, Longstreth WT, Holloway RG. Predicting decline and survival in severe acute brain injury: the fourth trajectory. BMJ. 2015;351:h3904.

    PubMed  Google Scholar 

  2. Quill TE, Holloway R. Time-limited trials near the end of life. JAMA. 2011;306(13):1483–4.

    CAS  PubMed  Google Scholar 

  3. Kurtz P, Fitts V, Sumer Z, et al. How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU? Neurocrit Care. 2011;15(3):477–80.

    PubMed  Google Scholar 

  4. Mehta AB, Syeda SN, Bajpayee L, et al. Trends in tracheostomy for mechanically ventilated patients in the United States, 1993–2012. Am J Respir Crit Care Med. 2015;192(4):446–54.

    PubMed  PubMed Central  Google Scholar 

  5. Damuth E, Mitchell JA, Bartock JL, et al. Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med. 2015;3(7):544–53.

    PubMed  Google Scholar 

  6. Unroe M, Kahn JM, Carson SS, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med. 2010;153(3):167–75.

    PubMed  PubMed Central  Google Scholar 

  7. Skolarus LE, Morgenstern LB, Zahuranec DB, et al. Acute care and long-term mortality among elderly patients with intracerebral hemorrhage who undergo chronic life-sustaining procedures. J Stroke Cerebrovas Dis. 2013;22(1):15–211.

    Google Scholar 

  8. Pelosi P, Ferguson ND, Frutos-Vivar F, et al. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med. 2011;39(6):1482–92.

    PubMed  Google Scholar 

  9. Steidl C, Boesel J, Suntrup-Krueger S, et al. Tracheostomy, extubation, reintubation: airway management decisions in intubated stroke patients. Cerebrovas Dis (Basel, Switzerland). 2017;44(1–2):1–9.

    Google Scholar 

  10. Anderson CD, Bartscher JF, Scripko PD, et al. Neurologic examination and extubation outcome in the neurocritical care unit. Neurocrit Care. 2011;15(3):490–7.

    PubMed  Google Scholar 

  11. Krishnamoorthy V, Hough CL, Vavilala MS, et al. Tracheostomy after severe acute brain injury: trends and variability in the USA. Neurocrit Care. 2019;30(3):546–54.

    PubMed  PubMed Central  Google Scholar 

  12. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

    PubMed  PubMed Central  Google Scholar 

  13. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–12.

  14. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.

    PubMed  PubMed Central  Google Scholar 

  15. https://www.rdocumentation.org/packages/meta/versions/4.9-2/topics/metaprop

  16. RStudio Team (2016). RStudio: Integrated Development for R. RStudio, Inc., Boston, MA URL https://www.rstudio.com/

  17. Gessler F, Mutlak H, Lamb S, et al. The impact of tracheostomy timing on clinical outcome and adverse events in poor-grade subarachnoid hemorrhage. Crit Care Med. 2015;43(11):2429–38.

    PubMed  Google Scholar 

  18. Bosel J, Schiller P, Hook Y, et al. Stroke-related Early Tracheostomy versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke. 2013;44(1):21–8.

    PubMed  Google Scholar 

  19. Rabinstein AA, Wijdicks EF. Outcome of survivors of acute stroke who require prolonged ventilatory assistance and tracheostomy. Cerebrovas Dis (Basel, Switzerland). 2004;18(4):325–31.

    Google Scholar 

  20. Schneider H, Hertel F, Kuhn M, et al. Decannulation and functional outcome after tracheostomy in patients with severe stroke (DECAST): a prospective observational study. Neurocrit Care. 2017;27(1):26–34.

    PubMed  Google Scholar 

  21. Wabl R, Williamson CA, Pandey AS, et al. Long-term and delayed functional recovery in patients with severe cerebrovascular and traumatic brain injury requiring tracheostomy. J Neurosurg. 2018;131(1):114–21.

    PubMed  Google Scholar 

  22. Ahmed N, Kuo YH. Early versus late tracheostomy in patients with severe traumatic head injury. Surg Infect. 2007;8(3):343–7.

    Google Scholar 

  23. Alali AS, Scales DC, Fowler RA, et al. Tracheostomy timing in traumatic brain injury: a propensity-matched cohort study. J Trauma Acute Care Surg. 2014;76(1):70–6.

    PubMed  Google Scholar 

  24. Baron DM, Hochrieser H, Metnitz PG, et al. Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury. Wien Klin Wochenschr. 2016;128(11–12):397–403.

    PubMed  PubMed Central  Google Scholar 

  25. Bouderka MA, Fakhir B, Bouaggad A, et al. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma. 2004;57(2):251–4.

    PubMed  Google Scholar 

  26. Gandia-Martinez F, Martinez-Gil I, Andaluz-Ojeda D, et al. Analysis of early tracheostomy and its impact on development of pneumonia, use of resources and mortality in neurocritically ill patients. Neurocirugia (Astur). 2010;21(3):211–21.

    CAS  Google Scholar 

  27. Khalili H, Paydar S, Safari R, et al. Experience with traumatic brain injury: is early tracheostomy associated with better prognosis? World Neurosurg. 2017;103:88–93.

    PubMed  Google Scholar 

  28. Rizk EB, Patel AS, Stetter CM, et al. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care. 2011;15(3):481–9.

    PubMed  Google Scholar 

  29. Siddiqui UT, Tahir MZ, Shamim MS, et al. Clinical outcome and cost effectiveness of early tracheostomy in isolated severe head injury patients. Surg Neurol Int. 2015;6:65.

    PubMed  PubMed Central  Google Scholar 

  30. Wang HK, Lu K, Liliang PC, et al. The impact of tracheostomy timing in patients with severe head injury: an observational cohort study. Injury. 2012;43(9):1432–6.

    PubMed  Google Scholar 

  31. Villwock JA, Villwock MR, Deshaies EM. Tracheostomy timing affects stroke recovery. J Stroke Cerebrovas Dis. 2014;23(5):1069–72.

    Google Scholar 

  32. Sugerman HJ, Wolfe L, Pasquale MD, et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma. 1997;43(5):741–7.

    CAS  PubMed  Google Scholar 

  33. Shibahashi K, Sugiyama K, Houda H, et al. The effect of tracheostomy performed within 72 h after traumatic brain injury. Br J Neurosurg. 2017;31(5):564–8.

    PubMed  Google Scholar 

  34. Lahiri S, Mayer SA, Fink ME, et al. Mechanical ventilation for acute stroke: a multi-state population-based study. Neurocrit Care. 2015;23(1):28–322.

    PubMed  Google Scholar 

  35. Roch A, Michelet P, Jullien AC, et al. Long-term outcome in intensive care unit survivors after mechanical ventilation for intracerebral hemorrhage. Crit Care Med. 2003;31(11):2651–6.

    PubMed  Google Scholar 

  36. Avesani R, Roncari L, Khansefid M, et al. The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients. Eur J Phys Rehabil Med. 2013;49(5):611–8.

    CAS  PubMed  Google Scholar 

  37. Ponfick M, Wiederer R, Nowak DA. Outcome of intensive care unit-dependent, tracheotomized patients with cerebrovascular diseases. J Stroke Cerebrovas Dis. 2015;24(7):1527–31.

    Google Scholar 

  38. Ponfick M, Wiederer R, Bosl K, et al. The influence of weaning duration on rehabilitative outcome in early neurological rehabilitation. NeuroRehabilitation. 2014;34(3):493–8.

    PubMed  Google Scholar 

  39. Formisano R, Azicnuda E, Sefid MK, et al. Early rehabilitation: benefits in patients with severe acquired brain injury. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2016.

  40. Mitton K, Walton K, Sivan M. Tracheostomy weaning outcomes in relation to the site of acquired brain injury: a retrospective case series. Brain Inj. 2017;31(2):267–71.

    PubMed  Google Scholar 

  41. Chiavaroli F, Derraik JG, Zani G, et al. Epidemiology and clinical outcomes in a multicentre regional cohort of patients with severe acquired brain injury. Disabil Rehabil. 2016;38(20):2038–46.

    PubMed  Google Scholar 

  42. Becker KJ, Baxter AB, Cohen WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56(6):766–72.

    CAS  PubMed  Google Scholar 

  43. Creutzfeldt CJ, Becker KJ, Weinstein JR, et al. Do-not-attempt-resuscitation orders and prognostic models for intraparenchymal hemorrhage. Crit Care Med. 2011;39(1):158–62.

    PubMed  PubMed Central  Google Scholar 

  44. Schonenberger S, Niesen W, Fuhrer, et al. Early tracheostomy in ventilated stroke patients: Study protocol of the international multicentre randomized trial SETPOINT2 (Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial 2). Int J Stroke. 2016 Apr;11(3):368–79.

  45. Young D, Harrison DA, Cuthbertson BH, et al. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121–9.

    CAS  PubMed  Google Scholar 

  46. Schonenberger S, Al-Suwaidan F, Kieser M, et al. The SET score to predict tracheostomy need in cerebrovascular neurocritical care patients. Neurocrit Care. 2016;25(1):94–104.

    PubMed  Google Scholar 

  47. McCredie VA, Alali AS, Scales DC, et al. Effect of early versus late tracheostomy or prolonged intubation in critically Ill patients with acute brain injury: a systematic review and meta-analysis. Neurocrit Care. 2017;26(1):14–25.

    PubMed  Google Scholar 

  48. Elkbuli A, Narvel RI, Spano PJ, et al. Early versus Late tracheostomy: is there an outcome difference? Am Surg. 2019;85(4):370–5.

    PubMed  Google Scholar 

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Acknowledgements

Dr. Claire J. Creutzfeldt receives funding from the NIH–National Institutes of Neurological Disease and Stroke (NINDS) (K23 NS099421). We would like to thank Dr. Renato Avesani (Department of Rehabilitation, Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy) and Dr. Florian Gessler (Department of Neurosurgery, Universitaetsklinikum Frankfurt, Germany) for sharing unpublished data, outlining details of neurological outcomes within their studies, which were highly relevant for our analysis and this manuscript.

Funding

The authors received no direct funding for this work.

Author information

Authors and Affiliations

  1. Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359775, Seattle, WA, 98104, USA

    Sarah Wahlster, W. T. Longstreth & Claire J. Creutzfeldt

  2. Department of Global Health, University of Washington, Seattle, WA, USA

    Monisha Sharma

  3. Health Science Library, University of Washington, Seattle, WA, USA

    Frances Chu

  4. Department of Neurological Surgery, Mount Sinai Hospital, New York, NY, USA

    Justin H. Granstein

  5. Department of Emergency Medicine, University of Washington, Seattle, WA, USA

    Nicholas J. Johnson

  6. Department of Epidemiology, University of Washington, Seattle, WA, USA

    W. T. Longstreth

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  1. Sarah Wahlster
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  7. Claire J. Creutzfeldt
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Contributions

SW contributed to study concept and design, data acquisition, data analysis, writing and editing of the manuscript. MS contributed to the statistical analysis, and editing of the manuscript. FC contributed to the literature search, data management, and editing of the manuscript. JG contributed to data analysis and editing of the manuscript. NJJ contributed to data analysis, and editing of the manuscript. WL contributed to study concept and design, data analysis, and editing of the manuscript. CJC contributed to study concept and design, data acquisition, data analysis, writing and editing of the manuscript.

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Correspondence to Sarah Wahlster.

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Wahlster, S., Sharma, M., Chu, F. et al. Outcomes After Tracheostomy in Patients with Severe Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 34, 956–967 (2021). https://doi.org/10.1007/s12028-020-01109-9

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  • DOI: https://doi.org/10.1007/s12028-020-01109-9

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