Tracheostomy After Severe Acute Brain Injury: Trends and Variability in the USA

Abstract

Background/objective: Severe acute brain injury (SABI) is responsible for 12 million deaths annually, prolonged disability in survivors, and substantial resource utilization. Little guidance exists regarding indication or optimal timing of tracheostomy after SABI. Our aims were to determine national trends in tracheostomy utilization among mechanically ventilated patients with SABI in the USA, as well as to examine factors associated with tracheostomy utilization following SABI.

Methods: We conducted a population-based retrospective cohort study using the National Inpatient Sample from 2002 to 2011. We identified adult patients with SABI, defined as a primary diagnosis of stroke, traumatic brain injury or post-cardiac arrest who received mechanical ventilation for greater than 96 h. We analyzed trends in tracheostomy utilization over time and used multilevel mixed-effects logistic regression to analyze factors associated with tracheostomy utilization.

Results: There were 94,082 hospitalizations for SABI during the study period, with 30,455 (32%) resulting in tracheostomy utilization. The proportion of patients with SABI who received a tracheostomy increased during the study period, from 28.0% in 2002 to 32.1% in 2011 (p < 0.001). Variation in tracheostomy utilization was noted based on patient and facility characteristics, including higher odds of tracheostomy in large hospitals (OR 1.34, 95% CI 1.18-1.53, p < 0.001, compared to small hospitals), teaching hospitals (OR 1.15, 95% CI 1.06-1.25, p = 0.001, compared to non-teaching hospitals), and urban hospitals (OR 1.60, 95% CI 1.33-1.92, p < 0.001, compared to rural hospitals).

Conclusions: Tracheostomy utilization has increased in the USA among patients with SABI, with wide variation by patient and facility-level factors.

Keywords: Brain injury; Respiratory failure; Tracheostomy.

Figure 1:

Trend in tracheostomy utilization among patients with severe acute brain injury in the U.S. from 2002 to 2011; A) Overall trend, B) By different age groups, and C) By types of acute brain injury.

Figure 2:

Discharge/disposition outcomes among patients with severe acute brain injury who received tracheostomy from 2002 to 2011.

Figure 3:

Proportion of patients receiving tracheostomy among individual hospitals that admitted an average of 20 or more SABI patients/year from 2002–2011. Solid horizontal line represents the total proportion of patients receiving a tracheostomy in the study cohort. Each bar represents an individual hospital, and x-axis represents proportion of all individual hospitals.