title: Airway management following repair of cervical tracheal injuries: A retrospective, multicenter study.
abstract: BACKGROUND
  Optimal airway management following repair of cervical tracheal injuries is unknown. This study aimed to determine the optimal airway strategy following cervical tracheal injury repair.
  
  
  METHODS
  Patients with cervical tracheal injuries admitted from January 2000 to January 2014 at seven US Level I trauma centers were identified. Patients were grouped depending on postoperative airway management: immediate or early extubation (≤24 hours, EXT), prolonged intubation (>24 hours, INT), and immediate tracheostomy (TRACH). Following univariate analysis, a multivariate model was then developed to evaluate for surgical site infection (SSI) and intensive care unit-free and ventilator-free days, comparing INT and TRACH with EXT as the reference.
  
  
  RESULTS
  A total of 120 cervical tracheal injuries were treated at seven Level I trauma centers. Ten patients were excluded for incomplete data, and seven died within 24 hours of admission, leaving 103 patients included in the study. Patients were grouped based on airway management: 40 (39%) in the EXT, 30 (29%) in the INT, and 33 (32%) in the TRACH group. There were no differences in demographics or injury mechanism. The INT and TRACH groups were more severely injured than the EXT group (median Injury Severity Score [ISS]: INT, 25; TRACH, 17 vs. EXT, 16; p < 0.01). Despite a higher SSI rate (TRACH, 21% vs. INT, 13% vs. EXT, 2%; p = 0.11), the TRACH group had a lower mortality rate (TRACH, 0% vs. INT, 13% vs. EXT, 0%, p < 0.01) and more ventilator-free days compared with the INT cohort. On multivariate analysis, tracheostomy was associated with an increased risk in the odds of SSI (odds ratio, 9.56; 95% confidence interval, 1.35-67.95) compared with both EXT and INT, while INT was associated with fewer ventilator-free days (correlation coefficient, -9.24; 95% confidence interval, -12.30 to -6.18) compared with both EXT and TRACH.
  
  
  CONCLUSIONS
  In patients with a cervical tracheal injury, immediate or early extubation was common and safe. However, among those with more severe injuries, immediate tracheostomy versus prolonged intubation presents a risk-benefit decision. Immediate tracheostomy is associated with increased risk of SSI, while prolonged intubation is associated with higher risk of mortality and fewer ventilator-free days.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: From the University of Texas Medical School at Houston (J.A.H., E.A.T., B.A.C., J.B.H.), Houston, Texas; The University of Maryland School of Medicine (J.B.), Baltimore, Maryland; The University of Southern California Keck School of Medicine (E.D., K.I.), Los Angeles, California; The Vanderbilt University School of Medicine (M.A.V., O.G.), Nashville, Tennessee; The Johns Hopkins University School of Medicine (L.M.K., E.R.H.), Baltimore, Maryland; The University of Tennessee College of Medicine (C.R.E., J.A.W.), Memphis, Tennessee; and The University of Cincinnati College of Medicine (M.D.G., B.RH.R.), Cincinnati, Ohio.
authors.forename: John A
authors.initials: JA
authors.lastname: Harvin
authors.forename: Ethan A
authors.initials: EA
authors.lastname: Taub
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Jason
authors.initials: J
authors.lastname: Brocker
authors.forename: Deborah M
authors.initials: DM
authors.lastname: Stein
authors.forename: Evren
authors.initials: E
authors.lastname: Dilektasli
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Michael A
authors.initials: MA
authors.lastname: Vella
authors.forename: Oscar
authors.initials: O
authors.lastname: Guillamondegui
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Kodadek
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.forename: Cory R
authors.initials: CR
authors.lastname: Evans
authors.forename: Jordan A
authors.initials: JA
authors.lastname: Weinberg
authors.forename: Michael D
authors.initials: MD
authors.lastname: Goodman
authors.forename: Bryce R H
authors.initials: BR
authors.lastname: Robinson
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
mesh_terms: D000293:Adolescent; D000328:Adult; D058109:Airway Management / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods; D008297:Male; D008875:Middle Aged; D019838:Neck Injuries / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D012121:Respiration, Artificial / Q000379:methods*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014132:Trachea / Q000293:injuries*; D014139:Tracheostomy / Q000379:methods*; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult