During the study period, 2,516 patients were admitted to the trauma center. Blunt mechanisms (motor vehicle crashes, falls, etc) were most frequent cause for hospital admission. There were 405 patients who were intubated or arrived intubated.
Twenty-four patients were reintubated 27 times for 19 planned, 5 self-extubations, and 3 unplanned extu-bations (Table 2). All patients were intubated orotracheally. There were 8 women and 16 men, with a mean age of 37 years (range, 14 to 80 years). Mean Injury Severity Score (ISS) was 20, and the mean Glasgow Coma Scale (GCS) at hospital admission was 11. Length of intubation ranged from 6 h to 9 days, with a mean of 3.6 days. No patient suffered direct laryngeal trauma, and there were no head and neck bums or smoke inhalation injuries.
Reasons for initial intubation were altered senso-rium , airway safety after pain control maneuvers , respiratory distress , or respiratory arrest . Seven were intubated in the field, 14 in the admitting area, 1 at a transferring facility, and 2 in the operating theater.
Extubation occurred in 19 instances when the specific criteria (sensorium, control of infectious processes, respiratoiy parameters [negative inspiratory force, spontaneous tidal volumes, FVC, rate]) were achieved in a controlled environment. In five instances, the patient was able to dislodge the tube prior to meeting such criteria, and three times the endotracheal tube was dislodged from extraneous forces (ventilator tubing caught in bed rail when patient rolled for nursing care, dislodged during suctioning and displaced during bed-to-bed transfer). Quality assurance review found only one planned extubation requiring reintubation to be deemed inappropriate due to inadequate parameters; all five self-extubations were un-preventable (all patients were restrained and sedated at the time), and the three unplanned extubations were all preventable.
Reasons for intubation were respiratory distress/inability to clear secretions (14 times in 11 patients), stridor (9 times in 8 patients), declining sensorium (3 times in 3 patients), and urgent reoperation (once in 1 patient). One patient was reintubated a second time for stridor after having tolerated breathing around a deflated cuff, and one patient with a low cervical spinal cord injury was reintubated three times for respiratory distress, each time achieving the criteria for extubation, and with hopes of self-sufficient respiration. Overall reintubation rate was 7%. Time to reintubation averaged 11.6 h, with a range from 0.1 to 72 h.
Two patients in the reintubated group died, for a mortality rate of 8%, 1 from a withdrawal of care at 7 days after family request, and 1 of pseudomonal sepsis with multiple organ system dysfunction at 8 months postinjury. The mortality rate for the intubated patient cohort was 16% (65/405), and the mortality rate for the trauma center over the study time period was 224 of 2,516, or 6.5%, including those who were dead at the time of admission. Death rate among reintubated patients and all intubated patient cohort was significant at a p value <0.1 but greater than p<0.05 (x2 with Yates’ correction).
Of the 405 patients intubated prior to ICU admission, 123 (30%) had tracheostomy performed for prolonged ventilatory support or airway protection. Fifteen of 24 patients reintubated underwent tracheostomy (62%). These tracheostomy rates are significantly different by x2 analysis (p<0.01).
Dividing the reintubated group into stridor and nonstridor patients revealed that 7 of 8 (87%) patients with stridor required surgical airways, while 8 of 16 (50%) with other causes had tracheostomy. Comparing the group which suffered stridor to the other causes for reintubation revealed no significant differences in age, site or reason for intubation, tube size, ISS, GCS, or length of time intubated. There was a significant difference for time to reintubation between these groups (p<0.002, Mann-Whitney test); these data are in Table 3.
Pulmonary complications developed during the course of hospitalization in 14 patients who were reintubated (51%), and included 7 cases of pneumonia (21% of all reintubated patients), 6 cases of atelectasis, and 1 pleural effusion. The stridorous group developed pneumonia in 2 (25%) and atelectasis in 2 (25%), while the nonstridorous group had 5 cases of pneumonia (30%), 4 of atelectasis (25%), and a pleural effusion (6%).
Table 2—Study Population
Not Intubated [excluded] Extubated/Died
Reintubated [27 events] Self-extubated
Planned , Unplanned
Table 3—Data Comparison of Reintubated Stridor vs Nonstridor Patients
|Time intubated, d||4.5||3.6||0.072|
|Time to reintubation, h||0.3||18.1||0.002*|