Introduction: The optimal timing for tracheostomy in severe traumatic brain injury (sTBI) remains controversial. While Brain Trauma Foundation provides general guidelines, evidence on the impact of early vs. late tracheostomy on functional recovery and resource utilization is limited. We investigated the association between tracheostomy timing and discharge disposition, hospital length of stay (LOS) and mechanical ventilation (MV) duration.
Methods: We conducted a retrospective cohort study at a Level I trauma center, including adult patients (≥18 years) with sTBI admitted between April 2018 and June 2022. Patients were stratified based on tracheostomy timing: early (5 days). The primary outcome was discharge disposition, categorized as: (1) independent (home or acute rehabilitation), (2) dependent (skilled nursing or long-term care), and (3) death or hospice care. Secondary outcomes included total hospital LOS and MV duration.
Results: Among 553 screened patients, 295 met inclusion criteria, of whom 109 underwent tracheostomy (early: 14, late: 95). Early tracheostomy (ET) was noted to have the highest rate of mortality of 21.4% compared to 4% in late tracheostomy (p=0.049) attributable to the small sample size receiving ET. However, further analysis showed a positive correlation suggesting a very slight trend where later tracheostomy is associated with worse discharge outcomes (p=0.495). Mean hospital LOS for ET group was 20.5 days and late tracheostomy group was 29.3 days (p=0.0031). Regression analysis demonstrated that each day of tracheostomy delay increased hospital LOS by 0.96 days (p < 0.001). MV duration was significantly shorter in the ET (13.2 days) compared to late (17.6 days) groups (p=0.028).
Conclusions: ET in sTBI was associated with higher mortality in our cohort, likely due to small sample size. Nonetheless, later tracheostomy showed a weak positive association with worse discharge outcomes. ET was significantly linked to reduced mechanical ventilation duration and shorter hospital stays. Larger prospective studies are needed to confirm these findings and define optimal timing.
