The Timing of Tracheostomy and Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Analysis

  • Hormuzdiyar H. Dasenbrock
  • Robert F. Rudy
  • William B. Gormley
  • Kai U. Frerichs
  • M. Ali Aziz-Sultan
  • Rose Du
Original Article



The goal of this study was to investigate the association of tracheostomy timing with outcomes after aneurysmal subarachnoid hemorrhage (SAH) in a national population.


Poor-grade aneurysmal SAH patients were extracted from the Nationwide Inpatient Sample (2002–2011). Multivariable linear regression was used to analyze predictors of tracheostomy timing and multivariable logistic regression was used to evaluate the association of timing of intervention with mortality, complications, and discharge to institutional care. Covariates included patient demographics, comorbidities, severity of subarachnoid hemorrhage (measured using the NIS-SAH severity scale), hospital characteristics, and other complications and length of stay.


The median time to tracheostomy among 1380 poor-grade SAH admissions was 11 (interquartile range: 7–15) days after intubation. The mean number of days from intubation to tracheostomy in SAH patients at the hospital (p < 0.001) was the strongest predictor of tracheostomy timing for a patient, while comorbidities and SAH severity were not significant predictors. Mortality, neurologic complications, and discharge disposition did not differ significantly by tracheostomy time. However, later tracheostomy (when evaluated continuously) was associated with greater odds of pulmonary complications (p = 0.004), venous thromboembolism (p = 0.04), and pneumonia (p = 0.02), as well as a longer hospitalization (p < 0.001). Subgroup analysis only found these associations between tracheostomy timing and medical complications in patients with moderately poor grade (NIS-SAH severity scale 7–9), while there were no significant differences by timing of intervention in very poor-grade patients (NIS-SAH severity scale > 9).


In this analysis of a large, national data set, variation in hospital practices was the strongest predictor of tracheostomy timing for an individual. In patients with moderately poor grade, later tracheostomy was independently associated with pulmonary complications, venous thromboembolism, pneumonia, and a longer hospitalization, but not with mortality, neurological complications, or discharge disposition. However, tracheostomy timing was not significantly associated with outcomes in very poor-grade patients.


Cerebral aneurysm Nationwide Inpatient Sample Subarachnoid hemorrhage Timing Tracheostomy 


Author contribution

HHD contributed to conception and design, acquisition of data, analysis and interpretation of data, drafting the article, critically revising the article, reviewed submitted version of the manuscript, and statistical analysis. RFR contributed to acquisition of data, analysis and interpretation of data, critically revising the article, reviewed submitted version of the manuscript, and statistical analysis. WBG contributed to analysis and interpretation of data, critically revising the article, reviewed submitted version of the manuscript, and administrative/technical/material support. KUF contributed to analysis and interpretation of data, critically revising the article, reviewed submitted version of the manuscript, and administrative/technical/material support. MAA-S contributed to analysis and interpretation of data, critically revising the article, reviewed submitted version of the manuscript, and administrative/technical/material support. RD contributed to conception and design, acquisition of data, analysis and interpretation of data, critically revising the article, reviewed submitted version of the manuscript, administrative/technical/material support, and study supervision.

Source of support

No funding.

Compliance with Ethical Standards

Conflict of interest

Hormuzdiyar H. Dasenbrock, Robert F. Rudy, Kai U. Frerichs, and Rose Du have nothing to disclose; M. Ali Aziz‑Sultan received consulting honoraria from Covidien and Codman; William B. Gormley received consulting honoraria from Codman.


  1. 1.
    Young D, Harrison DA, Cuthbertson BH, Rowan K. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309:2121–9.CrossRefGoogle Scholar
  2. 2.
    Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010;303:1483–9.CrossRefGoogle Scholar
  3. 3.
    Andriolo BN, Andriolo RB, Saconato H, Atallah AN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2015;1:Cd007271.PubMedGoogle Scholar
  4. 4.
    Huang H, Li Y, Ariani F, Chen X, Lin J. Timing of tracheostomy in critically ill patients: a meta-analysis. PLoS ONE. 2014;9:e92981.CrossRefGoogle Scholar
  5. 5.
    Szakmany T, Russell P, Wilkes AR, Hall JE. Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials. Br J Anaesth. 2015;114:396–405.CrossRefGoogle Scholar
  6. 6.
    Liu CC, Livingstone D, Dixon E, Dort JC. Early versus late tracheostomy: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2015;152:219–27.CrossRefGoogle Scholar
  7. 7.
    Siempos II, Ntaidou TK, Filippidis FT, Choi AM. Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. Lancet Respirat Med. 2015;3:150–8.CrossRefGoogle Scholar
  8. 8.
    Hosokawa K, Nishimura M, Egi M, Vincent JL. Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials. Crit Care (London, England). 2015;19:424.CrossRefGoogle Scholar
  9. 9.
    Bosel J. Tracheostomy in stroke patients. Curr Treat Opt Neurol. 2014;16:274.CrossRefGoogle Scholar
  10. 10.
    Kocaeli H, Korfali E, Taskapilioglu O, Ozcan T. Analysis of intracranial pressure changes during early versus late percutaneous tracheostomy in a neuro-intensive care unit. Acta Neurochir. 2008;150:1263–7.CrossRefGoogle Scholar
  11. 11.
    Kuechler JN, Abusamha A, Ziemann S, Tronnier VM, Gliemroth J. Impact of percutaneous dilatational tracheostomy in brain injured patients. Clin Neurol Neurosurg. 2015;137:137–41.CrossRefGoogle Scholar
  12. 12.
    Kleffmann J, Pahl R, Deinsberger W, Ferbert A, Roth C. Effect of percutaneous tracheostomy on intracerebral pressure and perfusion pressure in patients with acute cerebral dysfunction (TIP Trial): an observational study. Neurocrit Care. 2012;17:85–9.CrossRefGoogle Scholar
  13. 13.
    Walcott BP, Kamel H, Castro B, Kimberly WT, Sheth KN. Tracheostomy after severe ischemic stroke: a population-based study. J Stroke Cerebrovasc Dis. 2014;23:1024–9.CrossRefGoogle Scholar
  14. 14.
    Villwock JA, Villwock MR, Deshaies EM. Tracheostomy timing affects stroke recovery. J Stroke Cerebrovasc Dis. 2014;23:1069–72.CrossRefGoogle Scholar
  15. 15.
    Cohn EC, Robertson TS, Scott SA, Finley AM, Huang R, Miles DK. Extubation failure and tracheostomy placement in children with acute neurocritical illness. Neurocrit Care. 2018;28:83–92.CrossRefGoogle Scholar
  16. 16.
    McCredie VA, Alali AS, Scales DC, et al. Effect of early versus late tracheostomy or prolonged intubation in critically ill patients with acute brain injury: a systematic review and meta-analysis. Neurocrit Care. 2017;26:14–25.CrossRefGoogle Scholar
  17. 17.
    Alali AS, Scales DC, Fowler RA, et al. Tracheostomy timing in traumatic brain injury: a propensity-matched cohort study. J Trauma Acute Care Surg. 2014;76:70–6.CrossRefGoogle Scholar
  18. 18.
    Guru PK, Singh TD, Pedavally S, Rabinstein AA, Hocker S. Predictors of extubation success in patients with posterior fossa strokes. Neurocrit Care. 2016;25:117–27.CrossRefGoogle Scholar
  19. 19.
    Schonenberger S, Al-Suwaidan F, Kieser M, Uhlmann L, Bosel J. The SETscore to predict tracheostomy need in cerebrovascular neurocritical care patients. Neurocrit Care. 2016;25:94–104.CrossRefGoogle Scholar
  20. 20.
    Lahiri S, Mayer SA, Fink ME, et al. Mechanical ventilation for acute stroke: a multi-state population-based study. Neurocrit Care. 2015;23:28–32.CrossRefGoogle Scholar
  21. 21.
    Rizk EB, Patel AS, Stetter CM, Chinchilli VM, Cockroft KM. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care. 2011;15:481–9.CrossRefGoogle Scholar
  22. 22.
    Anderson CD, Bartscher JF, Scripko PD, et al. Neurologic examination and extubation outcome in the neurocritical care unit. Neurocrit Care. 2011;15:490–7.CrossRefGoogle Scholar
  23. 23.
    Szeder V, Ortega-Gutierrez S, Ziai W, Torbey MT. The TRACH score: clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage. Neurocrit Care. 2010;13:40–6.CrossRefGoogle Scholar
  24. 24.
    Vidotto MC, Sogame LC, Calciolari CC, Nascimento OA, Jardim JR. The prediction of extubation success of postoperative neurosurgical patients using frequency-tidal volume ratios. Neurocrit Care. 2008;9:83–9.CrossRefGoogle Scholar
  25. 25.
    Catalino MP, Lin FC, Davis N, Anderson K, Olm-Shipman C, Dedrick Jordan J. Early versus late tracheostomy after decompressive craniectomy for stroke. J Intensive Care. 2018;6:1.CrossRefGoogle Scholar
  26. 26.
    Steidl C, Boesel J, Suntrup-Krueger S, et al. Tracheostomy, extubation, reintubation: airway management decisions in intubated stroke patients. Cerebrovasc Dis (Basel, Switzerland). 2017;44:1–9.CrossRefGoogle Scholar
  27. 27.
    Lu Q, Xie Y, Qi X, Li X, Yang S, Wang Y. Is early tracheostomy better for severe traumatic brain injury? A meta-analysis. World Neurosurg. 2018;112:e324–30.CrossRefGoogle Scholar
  28. 28.
    McCredie VA, Ferguson ND, Pinto RL, et al. Airway management strategies for brain-injured patients meeting standard criteria to consider extubation. A prospective cohort study. Ann Am Thorac Soc. 2017;14:85–93.CrossRefGoogle Scholar
  29. 29.
    Bosel J, Schiller P, Hook Y, et al. Stroke-related early tracheostomy versus prolonged orotracheal intubation in neurocritical care trial (SETPOINT): a randomized pilot trial. Stroke. 2013;44:21–8.CrossRefGoogle Scholar
  30. 30.
    Gessler F, Mutlak H, Lamb S, et al. The impact of tracheostomy timing on clinical outcome and adverse events in poor-grade subarachnoid hemorrhage. Crit Care Med. 2015;43:2429–38.CrossRefGoogle Scholar
  31. 31.
    Lazaridis C, DeSantis SM, McLawhorn M, Krishna V. Liberation of neurosurgical patients from mechanical ventilation and tracheostomy in neurocritical care. J Crit Care. 2012;27:417.e1-8.CrossRefGoogle Scholar
  32. 32.
    Wolf S. Tracheostomy in poor-grade subarachnoid hemorrhage: if deemed necessary, you may want to perform it early. Crit Care Med. 2015;43:2514–5.CrossRefGoogle Scholar
  33. 33.
    Barker FG 2nd, Amin-Hanjani S, Butler WE, Ogilvy CS, Carter BS. In-hospital mortality and morbidity after surgical treatment of unruptured intracranial aneurysms in the United States, 1996–2000: the effect of hospital and surgeon volume. Neurosurgery. 2003;52:995–1007.PubMedGoogle Scholar
  34. 34.
    Hoh BL, Chi YY, Lawson MF, Mocco J, Barker FG 2nd. Length of stay and total hospital charges of clipping versus coiling for ruptured and unruptured adult cerebral aneurysms in the Nationwide Inpatient Sample database 2002 to 2006. Stroke. 2010;41:337–42.CrossRefGoogle Scholar
  35. 35.
    Kshettry VR, Rosenbaum BP, Seicean A, Kelly ML, Schiltz NK, Weil RJ. Incidence and risk factors associated with in-hospital venous thromboembolism after aneurysmal subarachnoid hemorrhage. J Clin Neurosci. 2014;21:282–6.CrossRefGoogle Scholar
  36. 36.
    Veeravagu A, Chen YR, Ludwig C, et al. Acute lung injury in patients with subarachnoid hemorrhage: a nationwide inpatient sample study. World Neurosurg. 2014;82:e235–41.CrossRefGoogle Scholar
  37. 37.
    Washington CW, Derdeyn CP, Dacey RG Jr, Dhar R, Zipfel GJ. Analysis of subarachnoid hemorrhage using the Nationwide Inpatient Sample: the NIS-SAH Severity Score and Outcome Measure. J Neurosurg. 2014;121:482–9.CrossRefGoogle Scholar
  38. 38.
    Khatri R, Tariq N, Vazquez G, Suri MF, Ezzeddine MA, Qureshi AI. Outcomes after nontraumatic subarachnoid hemorrhage at hospitals offering angioplasty for cerebral vasospasm: a national level analysis in the United States. Neurocrit Care. 2011;15:34–41.CrossRefGoogle Scholar
  39. 39.
    Nuno M, Patil CG, Lyden P, Drazin D. The effect of transfer and hospital volume in subarachnoid hemorrhage patients. Neurocrit Care. 2012;17:312–23.CrossRefGoogle Scholar
  40. 40.
    George BP, Schneider EB, Hwang DY. Consequences of the nationwide inpatient sample redesign for studies examining between-hospital practice variation. Crit Care Med. 2016;44:e1261.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA

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