Tracheostomy Practices in Neurocritical Care
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INVITED EDITORIAL COMMENTARY
Tracheostomy Practices in Neurocritical Care David B. Seder* © 2019 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
Historically, the outcomes of patients requiring mechanical ventilation for acute brain injury were poor, with a high percentage being reported dead or fully dependent at 6 months after admission [1]. These data led to a certain amount of therapeutic nihilism, and a tendency to early withdrawal of life support [2, 3] that neurocritical care as a field has worked hard to reverse [4]. Outcomes of mechanically ventilated patients with severe acute brain injury have improved [5], but a current review of tracheostomy practices nationally in patients with severe acute brain injury [6] suggests the possible evolution of two different treatment environments. Tracheostomy in patients with severe acute brain injury is a marker for treatment—it signifies an ongoing commitment to care and is not performed when there is the intention to discontinue supportive measures. Conversely, tracheostomy is often—but not always required in severely braininjured patients until their airway protective reflexes, pharyngeal tone, and levels of activation and cognition have improved enough to at least clear secretions and maintain a patent upper airway [7, 8]. This analysis used the large National Inpatient Sample (NIS) administrative database to review tracheostomy epidemiology and practices among patients with diagnoses of stroke, traumatic brain injury (TBI), and hypoxicischemic encephalopathy (HIE) after cardiac arrest. The NIS includes 20% of non-federal hospitalizations, and this study reviewed 94,082 hospitalizations from 2002 to 2011 of patients admitted with a severe acute brain injury that underwent at least 96 h of mechanical ventilation. Thirty-two percent of these patients overall received tracheostomy, a number that rose from 28 to 32.1% during
*Correspondence: [email protected] Department of Critical Care Services, Maine Medical Center, Tufts University School of Medicine, 22 Bramhall St., Portland, ME 04102, USA This comment refers to the article available at https://doi.org/10.1007/ s12028-019-00697-5.
the study period and from 34.5 to 42.1% in the youngest cohort. Of the patients with severe acute brain injuries, most tracheostomies were performed for stroke (14,167) followed by TBI (11,587), and HIE (4701)—considered another way; however, 46.8% of the patients with severe TBI underwent tracheostomy versus 33% with stroke and 18% with HIE. The most striking finding in multivariable modeling is that although undergoing tracheostomy was associated with younger age, male gender, and nonwhite race, it was also strongly and independently associated with larger (OR 1.34 [1.18–1.53]), urban (OR 1.6 [1.33–1.92]), and teaching (OR 1.15 [1.06–1.25]) hospitals. Looking at the raw data, a patient presenting with a severe acute brain injury to a small hospital had a 23% chance of receiving tracheostomy compared to 33% in a large hospital. Patients p
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