Outcomes Associated With Airway Management of Adult Trauma Patients Admitted to Surgical Intensive Care

Introduction: Advanced airway management and ventilation of trauma patients are often needed during acute stabilization and resuscitation and later, in those admitted. In addition to endotracheal intubation for advanced airway management, tracheostomy is commonly used in critically ill patients when prolonged mechanical ventilation is required. However, the outcomes associated with airway management approaches and the timing of a tracheostomy in critically ill patients are mixed. This protocol intended to compare the effect of tracheostomy in major trauma patients vs. management with non-invasive techniques and endotracheal intubation during admission, examine complications and outcomes associated with the three types of airway management approaches, and explore the association of clinical and social determinants of health variables with complications in patients requiring advanced airway management.

Methods: A total of 911 adult trauma patients admitted to a Level 1 trauma center surgical intensive care unit (SICU) were included in this retrospective, single-center, quantitative study from 2019 to 2021. Descriptive and correlational analyses were used to examine outcomes of ventilator days, length of stay, pneumonia, readmission, mortality, and associations with the airway management approach. The outcomes of ventilator days and length of stay were compared between groups with a one-way ANOVA, and differences between groups on outcomes of pneumonia, readmission, and mortality were estimated using crosstabulations and chi-square (x²) statistics. Hypothesized relationships of clinical and social determinants of health variables associated with outcomes of ventilator days, hospital length of stay, pneumonia, readmission, and mortality in patients requiring advanced airway management ≥ four days were estimated.

Results: There was no significant difference in outcomes of pneumonia and mortality between the advanced airway management groups (p=0.856 and p=0.167, respectively). There were significant differences in ventilator days, length of stay (LOS), and readmission. Between the groups: endotracheal intubation only, early (<10 days post-intubation) tracheostomy, and late (>10 days post-intubation) tracheostomy in SICU patients (p <0.001, p=0.028, and p=0.003, respectively). Specifically, patients in the early tracheostomy group had a higher readmission rate (33.3%) as compared to endotracheal tube patients (2.3%) and late tracheostomy patients (0.0%). Social determinants of health variables (smoking and functional dependence) were also significantly correlated with readmission in the early tracheostomy and endotracheal tube airway management groups (p=.047 and p=.022, respectively). Additionally, clinical variables of injury severity scores, ED arrival systolic blood pressure (SBP), and presence of pre-existing comorbidities were found to be significantly associated with complications of pneumonia, readmission, and mortality within the patients (n=229) requiring advanced airway approaches.

Conclusion: Adult trauma patients with early tracheostomy airway management may experience a higher readmission rate related to the complexity of their injuries than patients managed with endotracheal intubation or late tracheostomy. Clinical and social determinants of health factors may be associated with complications. Further studies examining these associations in larger samples are needed to examine the validity of these findings.