A. Nordin1,2, K. Jalal2, J. Wilkins2, J. Jordan1,2 1State University Of New York At Buffalo,Buffalo, NY, USA 2Erie County Medical Center,Buffalo, NY, USA
Introduction:
Patients sustaining severe Traumatic Brain Injury (TBI; Glasgow Coma Scale [GCS] ≤8) require airway securement, often progressing to tracheostomy. The benefits of tracheostomy are well-documented, including improved patient comfort, more rapid ventilator weaning, and decreased risk of pneumonia. However, the optimal time to perform tracheostomy remains unclear. The literature on the timing of tracheostomy is contradictory, especially in this patient population. We sought to evaluate the relationship between timing of tracheostomy in severe TBI and the development of ventilator-associated pneumonia (VAP) at our level 1 trauma center.
Methods:
We performed a retrospective analysis of all patients admitted with a TBI and GCS ≤8 who underwent tracheostomy from 2002 to 2017 at our level 1 trauma center. Data points collected included age, gender, Injury Severity Score (ISS), ventilator days, time to tracheostomy, and the development of VAP. We compared patients who developed VAP against those who did not using chi square analysis and Wilcoxon rank-sum tests; multivariate logistic regression analysis was also performed to determine the odds of developing VAP based on time to tracheostomy.
Results:
A total of 457 TBI patients were identified, 207 (45.3%) of whom developed pneumonia. Interestingly, males were more likely to develop pneumonia, although there were no other noted differences in demographics. In this sample, the mean duration of mechanical ventilation was 18.7 days (SD 22.3), and patients underwent tracheostomy an average of 9.8 days (SD 6.6) after intubation. On univariate analysis, patients who did not develop pneumonia had a shorter time to tracheostomy (9.46 days vs 10.29 days; p = 0.026) and consequently had decreased ventilator days (16.22 days vs 21.83 days; p = 0.006). On multivariate analysis, increased ventilator days increased the odds of developing pneumonia (OR = 1.018; 95% CI 1.00-1.04).
Conclusion:
In conclusion, among severe TBI patients requiring tracheostomy, a decreased time to tracheostomy, and therefore a decreased duration of mechanical ventilation, was associated with a reduced risk of ventilator-associated pneumonia. Further analysis will clarify the individual roles of demographics and other traditional risk factors in VAP development. Future studies should examine the potential benefits of early tracheostomy in a prospective fashion and determine the optimal time for tracheostomy in this patient population.