Impact of Attempted Extubation Before Tracheostomy on Clinical Outcomes

Background: Tracheostomy is a common surgical procedure performed in patients requiring prolonged mechanical ventilation (MV) secondary to acute respiratory failure. However, there is limited evidence evaluating a patient’s potential for weaning off invasive MV before performing a tracheostomy. Specifically, there is a lack of data on whether planned extubation should be attempted to assess a patient’s ability to be liberated from MV before proceeding with a tracheostomy. Hence, the purpose of this research study is to evaluate the impact of attempted extubation on clinical outcomes of patients undergoing a tracheostomy due to respiratory failure. Methods: This is a retrospective, cohort study of a random sample of adult patients who received MV ≥ 24 h and underwent a new tracheostomy due to a non-airway reason at an academic medical center from January 2012 through December 2022. The study protocol was approved by the Institutional Review Board. Non-airway reasons were defined as inability to be weaned from invasive MV in the absence of any airway reasons such as airway pathology or trauma, inability to protect airway secondary to any neurological impairment. Direct tracheostomy was defined as tracheostomy without any extubation attempt. Study outcomes included in-hospital mortality, total duration of MV before receiving tracheostomy, ICU length of stay (LOS), and hospital LOS. Study outcome data was analyzed using the Chi-square test for categorial variables and Mann-Whitney test for continuous variables via SPSS software (version 26.0). A P-value of < .05 was considered clinically significant. Results: A total of 244 subjects [median age = 60 y; male 124 (50.8%); African American 104 (42.6%); median BMI = 28.8, respiratory failure as primary indication for MV 142 (58.2%)] were included in the analysis. Of these, 120 (49%) underwent an attempted extubation prior to receiving a tracheostomy and 124 (51%) received a direct tracheostomy. There was no difference between the two study groups in terms of age (P = .69), gender (.45), race (.07) or BMI (.23). The study groups did not differ in terms of hospital mortality (29.8% vs 30.8%; P = .89). Similarly, there was no significant difference between the two groups in terms of median hospital days [34.5 vs 35; P = .46] or ICU LOS [33 vs 31; P = .52]. Conclusions: This retrospective study findings reveal that attempted extubation before tracheostomy did not impact patient’s mortality rate or any other clinical outcomes.