Early Versus Late Tracheostomy in Spontaneous Intracerebral Hemorrhage

Introduction: Recent literature supports early tracheostomy (<=7 days) over delayed tracheostomy (>7 days-3 months) to improve overall clinical outcomes for patients admitted with an acute head injury. There is conflicting evidence for the same in hemorrhagic stroke. Using a multi-institutional database, we explored this question in nontraumatic spontaneous intracerebral hemorrhage (sICH) patients. Methods: We used a de-identified database network (TriNetXʼs Research Network) to gather information on early tracheostomy (<=7 days) and late tracheostomy (>7d-3 months) in sICH patients. After accounting for the most common comorbidities, we explored the impact of this intervention on multiple patient outcomes including intensive care unit (ICU) length of stay, pneumonia, and mortality at 30, 90, and 365 days. Results: After propensity score matching, a total of 1210 patients were identified for both early tracheostomy (cohort 1) and late tracheostomy (cohort 2) cohorts. The 30-day survival rate was 0.9287 in cohort 1 vs 0.9536 in cohort 2, with a risk difference of 2.39% (95% confidence interval (CI) 0.557%-4.23%; relative risk (RR) 1.54, 95% CI (1.10-2.15); OR 1.577, 95% CI (1.11-2.24); p = 0.006). The 90-day and 365-day end-point survival rates were not statistically different between cohorts. ICU level of care codes were billed an average of 9.76 (SD 8.964) times in cohort 1 vs 14.618 (SD 11.851) in cohort 2 (p<0.0001). At 365 days, there were no differences between the two groups for pulmonary embolism, myocardial infarction, deep venous thrombosis, palliative care consultation, and percutaneous endoscopic gastrostomy tube placement. Cohort 1 had decreased incidence of pneumonia with 665 (54.95%) patients compared to cohort 2 with 725 (59.91%) (RR 0.917, 95% CI (0.856-0.983), OR 0.816, 95% CI (0.695-0.95), p = 0.013). Conclusion: Early tracheostomy in sICH patients was associated with decreased pneumonia risk, decreased length of ICU care, and no difference in mortality at 90 and 365 days.