The use of early tracheostomy has increased among acute care patients with stroke who are receiving mechanical ventilation, and more of these patients are being discharged to skilled nursing facilities as a result. But the intervention may not significantly improve the rate of survival without disability, a new study finds.
Investigators looked at outcomes in 366 hospitalized stroke patients with tracheostomies at 26 United States and German neurocritical care centers. Most of the interventions (95%) were performed in about four days after intubation. Researchers compared findings with outcomes in a control group, 67% of whom received the procedure in the standard way — about 11 days after intubation.
The strategy of early tracheostomy, compared with a standard approach, did not significantly improve survival without severe disability at six months, they found.
The uptick in tracheostomy use among patients with stroke who require mechanical ventilation has occurred over the last two decades, according to the authors of an earlier study. But the procedure may be seen as futile by some clinicians due to high morbidity in these patients, and the researchers sought more information about outcomes.
Tracheostomies in SNFs
The increased rate of the procedure is tied to decreased acute-care mortality and length of stay, the earlier study found. This has resulted in higher — and earlier — rates of post-acute care placement and lower rates of home discharge, they reported in 2018.
“[T]he concurrent rise in discharges to nonacute care settings and the decrease in home discharges suggest that burden of care for these patients may be shifting to long-term care facilities,” they wrote at the time.
This is notable, considering that the rate of home discharge in the general stroke population is stable, and it suggests downsides to use of tracheostomy, they added.
For patients who remain dependent on ventilators, tracheostomy can ease transition to a post-acute setting and “allow supportive respiratory care until any potential recovery,” the authors of the 2018 study explained. But the study results “may indicate that the increased use of tracheostomy has not necessarily improved functional outcomes or quality of life,” they concluded.
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