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Tracheostomy timing in traumatic brain injury: A propensity-matched cohort study

Alali, Aziz S. MD; Scales, Damon C. MD, PhD; Fowler, Robert A. MDCM, MSc; Mainprize, Todd G. MD; Ray, Joel G. MD, MSc; Kiss, Alexander PhD; de Mestral, Charles MD; Nathens, Avery B. MD, PhD, MPH

Journal of Trauma and Acute Care Surgery: January 2014 - Volume 76 - Issue 1 - p 70–78
doi: 10.1097/TA.0b013e3182a8fd6a
AAST 2013 Plenary Papers

BACKGROUND The optimal timing of tracheostomy in patients with severe traumatic brain injury (TBI) is controversial; observational studies have been challenged through confounding by indication, and interventional studies have rarely enrolled patients with isolated TBI.

METHODS We included a cohort of adults with isolated TBI who underwent tracheostomy within 1 of 135 participating centers in the American College of Surgeons’ Trauma Quality Improvement Program, during 2009 to 2011. Patients were classified as having undergone early tracheostomy (ET, ≤8 days) versus late tracheostomy (>8 days). Outcomes were compared between propensity score–matched groups to reduce confounding by indication. In sensitivity analyses, we used time-dependent proportional hazard regression to address immortal time bias and assessed the association between hospital ET rate and patients’ outcome at the hospital level.

RESULTS From 1,811 patients, a well-balanced propensity-matched cohort of 1,154 patients was defined. After matching, ET was associated with fewer mechanical ventilation days (median, 10 days vs. 16 days; rate ratio [RR], 0.70; 95% confidence interval [CI], 0.66–0.75), shorter intensive care unit stay (median, 13 days vs. 19 days; RR, 0.70; 95% CI, 0.66–0.75), shorter hospital length of stay (median, 20 days vs. 27 days; RR, 0.80; 95% CI, 0.74–0.86), and lower odds of pneumonia (41.7% vs. 52.7%; odds ratio [OR], 0.64; 95% CI, 0.51–0.80), deep venous thrombosis (8.2% vs. 14.4%; OR, 0.53; 95% CI, 0.37–0.78), and decubitus ulcer (4.0% vs. 8.9%; OR, 0.43; 95% CI, 0.26–0.71) but no significant difference in pulmonary embolism (1.8% vs. 3.3%; OR, 0.52; 95% CI, 0.24–1.10). Hospital mortality was similar between both groups (8.4% vs. 6.8%; OR, 1.25; 95% CI, 0.80–1.96). Results were consistent using several alternate analytic methods.

CONCLUSION In this observational study, ET was associated with a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay but not hospital mortality. ET may represent a mechanism to reduce in-hospital morbidity for patients with TBI.

LEVEL OF EVIDENCE Therapeutic study, level II.

Supplemental digital content is available in the article.

From the Sunnybrook Research Institute (A.S.A., D.C.S., R.A.F., A.K., C.D.M., A.B.N.), Department of Critical Care (D.C.S., R.A.F.), Division of Neurosurgery (T.G.M.), Department of Research Design and Biostatistics (A.K.), and Department of Surgery (A.B.N.), Sunnybrook Health Sciences Center; Clinical Epidemiology Program (A.S.A., D.C.S., R.A.F., J.G.R., A.K., A.B.N.), Institute of Health Policy, Management and Evaluation, Interdepartmental Division of Critical Care (D.C.S., R.A.F.), and Keenan Research Centre of the Li Ka Shing Knowledge Institute (J.G.R, A.B.N) and Department of Medicine (J.G.R.), St. Michael’s Hospital, University of Toronto, Toronto; and Division of Neurosurgery (A.S.A.), University of Ottawa, Ottawa, Ontario, Canada.

Submitted: June 3, 2013, Revised: July 29, 2013, Accepted: July 29, 2013.

This study was presented at the 72nd annual meeting of the American Association for the Surgery of Trauma, September 18–21, 2013, in San Francisco, California.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Address for reprints: Aziz S. Alali, MD, Sunnybrook Research Institute, Sunnybrook Health Sciences Center, 2075 Bayview Ave, Room D-574, Toronto, ON, Canada, M4N 3M5; email:

© 2014 Lippincott Williams & Wilkins, Inc.