Association Between Tracheostomy and Functional, Neuropsychological, and Healthcare Utilization Outcomes in the RECOVER Cohort

Abstract

Tracheostomy is commonly performed in critically ill patients requiring prolonged mechanical ventilation (MV). We evaluated the outcomes of tracheostomy in patients who received greater than or equal to 1 week MV and were followed for 1 year.

Design: In this secondary analysis of a prospective observational study, we compared outcomes in tracheostomy versus nontracheostomy patients. Outcomes post ICU included Functional Independence Measure (FIM) subscales, 6-Minute Walk Test (6MWT), Short Form 36 (SF36), Medical Research Council (MRC) Scale, pulmonary function tests (PFTs), Impact of Event Scale (IES), Beck Depression Inventory-II (BDI-II), and vital status and disposition.

Setting: Nine University affiliated ICUs in Canada.

Patients: Medical/surgical patients requiring MV for 7 or more days who were enrolled in the Towards RECOVER Study.

Measurements and main results: Of 398 ICU survivors, 193 (48.5%) received tracheostomy, on median ICU day 14 (interquartile range [IQR], 8-0 d). Patients with tracheostomy were older, had similar severity of illness, had longer MV duration and ICU and hospital stays, and had higher risk of ICU readmission (odds ratio [OR], 1.9; 95% CI, 1.0-3.2) and hospital mortality (OR, 2.6; 95% CI, 1.1-6.1), but not 1-year mortality (hazard ratio, 1.41; 95% CI, 0.88-1.2). Over 1 year, tracheostomy patients had lower FIM-Total (7.7 points; 95% CI, 2.2-13.2); SF36, IES, and BDI-II were similar. From 3 months, tracheostomy patients had 12% lower 6MWT (p = 0.0008) and lower MRC score (3.4 points; p = 0.006). Most PFTs were 5-8% lower in the tracheostomy group. Tracheostomy patients had similar specialist visits (rate ratio, 0.63; 95% CI, 0.28-2.4) and hospital readmissions (OR, 0.82; 95% CI, 0.54-1.3) but were less likely to be at home at hospital discharge and 1 year.

Conclusions: Patients who received tracheostomy had more ICU and hospital care and higher hospital mortality compared with patients who did not receive a tracheostomy. In 1 year follow-up, tracheostomy patients required a higher daily burden of care, expressed by FIM.

Keywords: critical illness; disposition; mechanical ventilation; outcomes; tracheostomy.

Figure 1.

Kaplan-Meier curves showing cumulative post-ICU mortality by tracheostomy in RECOVER groups 2–4. Numbers at risk for the tracheostomy and nontracheostomy groups are shown beneath the figure. The unadjusted hazard ratio comparing those with and without tracheostomy is 1.6 (95% CI, 1.0–2.5; p = 0.04). After adjusting for RECOVER group, the hazard ratio comparing those with and without tracheostomy is 1.4 (95% CI, 0.9–2.2; p = 0.15).

Figure 2.

Mean Functional Independence Measure (FIM) in RECOVER groups 2–4. From left to right: FIM Cognitive Subscale, FIM Motor Subscale, and FIM Total Score. In linear mixed effects models adjusting for RECOVER group, tracheostomy patients had on average, across all time points, lower FIM Motor Subscale (by 6.5 points, 95% CI, 2.3–10.8; p = 0.003) and FIM Total Scores (by 7.7 points 95% CI, 2.2–13.2; p = 0.006) than nontracheostomy patients.

Figure 3.

Functional and neuropsychologic outcomes in RECOVER groups 2–4. Adjusted for RECOVER groups, from 3 mo onwards, those who had a tracheostomy had a 10% lower percent predicted 6-min walk test with continuous oximetry (6MWT) distance (p = 0.004) and a lower Medical Research Council (MRC) score (2.6 points; p = 0.04). The tracheostomy patients exhibited only small decrements in SF36-PCS (1 point; p = 0.45), SF-36-MCS (0.7 points; p = 0.67), IES (1.2 points; p = 0.66) and BDI (0.8 points; p = 0.51) with adjustment for RECOVER groups. BDI = Beck Depression Inventory-II, IES = Impact of Event Scale, PCS and MCS = Physical and Mental Component Summary scores of the Health Related Quality of Life (Medical Outcome Study Short Form-36 Questionnaire, SF-36).

Figure 4.

Pulmonary function tests in RECOVER groups 2–4 (%). Mean percent predicted values on pulmonary function tests in RECOVER groups 2–4 were significantly reduced in tracheostomy patients compared with nontracheostomy patients by an amount that did not vary appreciably with time since ICU discharge for: total lung capacity (6.4%; 95% CI, 1.6–11.2%), vital capacity (8.3%; 95% CI, 2.5–14.1%), forced vital capacity (7.6%; 95% CI, 2.3–13.0%), forced expiratory volume 1 s (7.9%; 95% CI, 2.4–13.4%), and percent carbon monoxide lung diffusion (7.5%; 95% CI, 1.7–13.4%). Percent residual volume was also lower (4.6%; 95% CI, –4.5% to 13.6%) in tracheostomy patients, but the CIs were wide.