Original Article

Ventilator-associated pneumonia in trauma patients with open tracheotomy: Predictive factors and prognosis impact Anis Chaari, Hichem Kssibi, Wassim Zribi1, Fatma Medhioub, Hedi Chelly, Najla B. Algia, Chokri B. Hamida, Mabrouk Bahloul, MounirBouaziz Departments of Intensive Care, 1Orthopedic Surgery, Habib Bourguiba University Hospital, Sfax, Tunisia

ABSTRACT Objective: To assess the predictive factors of ventilator associated pneumonia (VAP) occurrence following open tracheotomy in trauma patients. Materials and Methods: We conducted an observational, prospective study over 15 months, between 01/08/2010 and 30/11/2011. All trauma patients (except those with cervical spine trauma), older than 15 years, undergoing open tracheotomy during their ICU stay were included. All episode of VAP following tracheotomy were recorded. Predictive factor of VAP onset were studied. Results: We included 106 patients. Mean age was 37.9 ± 15.5 years. Mean Glasgow coma Scale (GCS) was 8.5 ± 3.7 and mean Injury Severity Score (ISS) was 53.1 ± 23.8. Tracheotomy was performed for 53 patients (50%) because of prolonged ventilation whereas 83 patients (78.3%) had tracheotomy because of projected long mechanical ventilation. Tracheotomy was performed within 8.6 ± 5.3 days. Immediate complications were bleeding events (22.6%) and barotrauma (0.9%). Late complications were stomal infection (28.3%) and VAP (52.8%). In multivariate analysis, independent factors predicting VAP onset were delayed tracheotomy (OR = 0.041; CI95% [1.02-7.87]; P = 0.041) and stomal infection (OR = 3.04; CI95% [1.02-9.93]; P = 0.045).Thirty three patients died in ICU (31.1%) without significant impact of VAP on mortality. Conclusion: Late tracheotomy and stomal infection are independent factors predicting VAP onset after open tracheotomy in trauma patients. The occurrence of VAP prolongers mechanical ventilation duration and intensive care unit (ICU) length of stay (LOS) but doesn’t increase mortality. Key Words: Multiple trauma, prognosis, tracheotomy, ventilator associated pneumonia

INTRODUCTION Tracheotomy is one of the oldest and the most conducted procedures in critically ill patients.[1,2] This technique facilitates airway management and offers numerous advantages such as shortening the duration of mechanical ventilation, easier weaning from mechanical ventilation, avoiding translaryngeal complications… [3-6] Trauma patients represent a specific Address for correspondence: Dr. Anis Chaari, E-mail: [email protected] Access this article online Quick Response Code: Website: www.onlinejets.org

DOI: 10.4103/0974-2700.120364


population who can potentially benefits of these advantages. In fact, during, the first hours of trauma, mechanical ventilation is always required for severe cases because of consciousness impairment, acute respiratory failure (chest trauma, aspiration…) or uncontrolled shock.[7] Secondly, even though satisfactory weaning parameters are reached, extubation may be delayed because of the inability of these patients to protect their airway or persistent impaired level of consciousness.[8] For all these reasons, tracheotomy was proposed as an alternative modality for airway management in trauma patients and gave encouraging results concerning reduction of mechanical ventilation duration and ICU length of stay.[9,10] Several studies have even suggested a decreased incidence of ventilator-associated pneumonia (VAP) with this procedure.[9,11] However, available data in the literature dealing with this infectious complication are conflicting because of heterogeneity of studied population: Different level of trauma severity, different modalities of tracheotomy procedure (open tracheotomy versus percutaneous tracheotomy) and different delay (early versus late tracheotomy). Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013

Chaari, et al.: Ventilator-associated pneumonia in trauma patients with open tracheotomy

The aim of the present study is to identify independent factors correlated with VAP onset in severe trauma patients undergoing open tracheotomy during their ICU stay. MATERIALS AND METHODS Study design

This prospective observational study was conducted over 15  months, between 01/08/2010 and 30/11/2011 in our medical surgical intensive care unit (HabibBourguiba University Hospital – Sfax – Tunisia). Our study was approved by our local ethic board. Patients

All trauma patients older than 15 years and undergoing open tracheotomy during their ICU stay were eligible for our study. We excluded patients meeting at least one of the following criteria: • Patients who developed VAP prior to tracheotomy. • Tracheotomy performed for urgent airway management. • Patients with cervical spine trauma. • Patients who undergone percutaneous tracheotomy. During the study period, 386 adult trauma patients were admitted in our ICU. All of them were ventilated either on the scene of the accident or at their arrival to our emergency department. During their ICU stay, 106 (27.5%) needed tracheotomy and were included in our study. For each included patient, the following data were recorded on admission: • Demographic parameters: Age, sex, previous medical history. • Clinical parameters: Blood pressure, heart rate, respiratory rate, neurological state (the consciousness was judged by the Glasgow Coma Scale (GCS)[12] calculated on the scene of the accident before sedation infusion, localization signs, motor deficiency…). • Exhaustive chart of trauma lesions were obtained by imaging test. All our patients had undergone cranial, thoracic, abdominal and pelvic computed tomography. The trauma severity was assessed by the Injury Severity Score (ISS).[13] • The clinical severity was assessed by the Simplified Acute Physiology Score (SAPS II)[14] and the Sequential Organ Failure Assessment (SOFA) score.[15] • Therapeutic measures (mechanical ventilation, sedation, surgery, osmotherapy). Ventilation and weaning modalities

Patients were kept under sedation and mechanical ventilation for at least 48 hours. Sedation withdrawal was decided if intracranial hypertension was controlled and if the patients had a good level of consciousness, a positive end expiratory pressure (PEEP) of 5 cm H2O and 50% of oxygen. Then, A T-piece test is tried and extubation is performed within 1 hour if the test is successful. However, the trial was stopped if the patient developed a respiratory rate >30 per minute, SpO2 48 hours) pulmonary infiltrates with at least two of the following criteria: Fever >38°C or hypothermia 12000/mm 3 or 7 days





Bleeding events





Delay of weaning from MV after tracheotomy





Successful Oral feeding after tracheotomy





Stomal infection





MV: Mechanical ventilation

intubation in terms of VAP incidence.[20,28] However, Lesnik et al.[9] reported in a retrospective study including 101 patients with blunt and multiple organ trauma, that early tracheostomy significantly reduces the incidence of VAP when compared to prolonged endotracheal intubation. The same conclusions were highlighted by Kluger et al. [11] who retrospectively studied 118 cases of trauma patients requiring tracheostomy during their ICU stay: Early tracheostomy was associated with a significant reduction of VAP incidence. Similarly, Rodriuez et al.[29] found in their prospective randomized trial, a significantly decreased frequency of VAP in patients who underwent early tracheostomy (within 5 days of intubation). 249

Chaari, et al.: Ventilator-associated pneumonia in trauma patients with open tracheotomy

In our study, multivariate analysis shows also that delayed tracheotomy (> 7 days regarding the initiation of mechanical ventilation) was an independent factor predicting VAP onset (OR = 0.041; CI95% [1.02-7.87]; P = 0.041). Several hypotheses can be advanced to explain reduced VAP incidence with early tracheotomy: First, tracheotomy can reduce mechanical ventilation duration which represents the main risk factor for VAP onset.[9,10,20,30] Second, this procedure facilitates nursing care which may avoid secretions pooling above the endotracheal cuff and aspiration through the vocal cords, kept open by the tube.[6] Third, tracheotomy is associated with less endotracheal damage such as ulcerations and edema which may causes repetitive aspiration episodes[31] and finally, tracheotomized patients have the opportunity to have an oral nutrition sooner than intubated patients which reduce the need of orogastric tubes used for enteral feeding.



van Heurn LW, Brink PR. The history of percutaneous tracheotomy. J Laryngol Otol 1996;110:723-6.

To the best of our knowledge, there is no previous study which aimed to identify independent factors predicting VAP onset in trauma patients undergoing tracheotomy during their ICU stay. In the multivariate analysis, our study shows that independent factors predicting VAP onset after tracheotomy were delayed tracheotomy and stomal infection. We hypothesize that stomal infection results mainly from secretions pooling above the endotracheal cuff. The risk of stomal infection could be also enhanced by bleeding events following tracheotomy. In fact, our univariate analysis revealed that these events were significantly higher in VAP (+) group. In a systematic review including 17 randomized controlled trials comparing percutaneous dialatationaltracheostmoy (PDT) and surgical tracheosotmy (ST), Delaney et al. reported that that PDT was associated to a significant reduction of wound infection and bleeding events regarding patients who underwent ST in the operating theatre.[32] Thus, causality relation between both complications is highly suspected. The higher incidence of VAP in patients with stomal infection may be explained by oropharyngeal colonization with virulent microorganisms which can secondly invade airways and disseminate through the lungs.


Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330:1243.


Whited RE. A prospective study of laryngotrachealsequelae in long-term intubation. Laryngoscope 1984;94:367-77.


Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76.


Diehl JL, El Atrous S, Touchard D, Lemaire F, Brochard L. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J RespirCrit Care Med 1999;159:383-8.


Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004;32:1689-94.


Ross BJ, Barker DE, Russell WL, Burns RP. Prediction of long-term ventilatory support in trauma patients. Am Surg 1996;62:19-25.


Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J RespirCrit Care Med 2000;161:1530-6.


Lesnik I, Rappaport W, Fulginiti J, Witzke D. The role of early tracheostomy in blunt, multiple organ trauma. Am Surg 1992;58:346-9.

Previous studies reported that early weaning from mechanical ventilation was a major advantage that can be reached with tracheotomy.[9,10,20,28] In our study, patients who didn’t develop ventilator associated pneumonia were weaned faster than those who developed nosocomial pneumonia (5.9 ± 6.9 days Vs 10.8 ± 12.5 days; P = 0.037). This is not surprising as similar conclusions were found in trauma patients who were ventilated with endotracheal intubation.[33] As a consequence, the onset of VAP was also associated with longer ICU LOS (31.9 ± 18.5 days Vs 23.3 ± 12.5 days; P = 0.01). These findings are particularly important. In fact, previous studies highlighted that early tracheotomy in trauma patients improves resource utilization with reduced mechanical ventilation duration and ICU LOS.[10] Our study suggests that theses benefices seem to be lost with the occurrence of ventilator associated pneumonia. 250

Our study shows that late tracheotomy and stomal infections are independent factors predicting VAP onset in tracheotomized patients. VAP occurrence is associated with significantly longer mechanical ventilation and ICU LOS. These findings should incite physicians to avoid such complication by identifying patients who would need prolonged ventilation and thus, may benefit of early tracheotomy. Stomal infection should be prevented by multiple local aseptic cares. Secretions pooling above the canula cuff should be also avoided by repetitive suctioning. REFERENCES

10. Arabi Y, Haddad S, Shirawi N, Al Shimemeri A. Early tracheostomy in intensive care trauma patients improves resource utilization: A cohort study and literature review. Crit Care 2004;8:R347-52. 11. Kluger Y, Paul DB, Lucke J, Cox P, Colella JJ, Townsend RN, et al. Early tracheostomy in trauma patients. Eur J Emerg Med 1996;3:95-101. 12. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: A practical scale. Lancet 1974;13:81-4. 13. Greenspan L, McLellan BA, Greig H. Abbreviated Injury Scale and Injury Severity Score: A scoring chart. J Trauma 1985;25:60-4. 14. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993;270:2957-63. 15. Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med 1998;26:1793-800. Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013

Chaari, et al.: Ventilator-associated pneumonia in trauma patients with open tracheotomy

16. B e r n a r d G R , A r t i g a s A , B r i g h a m K L , C a r l e t J, Fa l ke K , Hudson  L, et al. The American-European Consensus Conference on ARDS.  Definitions, mechanisms, relevant outcomes, and clinical  trial  coordination.Am J  RespirCrit Care Med 1994;149 (3 Pt 1):818-24. 17. Bonten MJ, Kollef MH, Hall JB. Risk factors for ventilator-associated pneumonia: From epidemiology to patient management. Clin Infect Dis 2004;38:1141-9. 18. Pearson WS, Ovalle F Jr, Faul M, Sasser SM. A review of traumatic brain injury trauma center visits meeting physiologic criteria from The American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention Field Triage Guidelines. Prehosp Emerg Care 2012;1:323-8. 19. Shirawi N, Arabi Y. Bench-to-bedside review: Early tracheostomy in critically ill trauma patients. Crit Care 2006;10:201. 20. Bouderka MA, Fakhir B, Bouaggad A, Hmamouchi B, Hamoudi D, Harti A. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma 2004;57:251-4. 21. Mascia L, Corno E, Terragni PP, Stather D, Ferguson ND. Pro/ con  clinical debate: Tracheostomy is ideal for withdrawal of mechanical  ventilation in severe neurological impairment. Crit Care 2004;8:327-30. 22. Ryan DW, Kilner AJ. Another death after percutaneous dilational tracheostomy. Br J Anaesth 2003;91:925-6. 23. Kallel H, Chelly H, Bahloul M, Ksibi H, Dammak H, Chaari A, et al. The effect of ventilator-associated pneumonia on the prognosis of head trauma patients. J Trauma 2005;59:705-10.

patients receiving selective digestive decontamination. Intensive Care Med 2005;31:64-70. 26. Roquilly A, Mahe PJ, Seguin P, Guitton C, Floch H, Tellier AC, et al. Hydrocortisone therapy for patients with multiple trauma: The randomized controlled HYPOLYTE study. JAMA 2011;305:1201-9. 27. Polk HC Jr. Factors influencing the risk of infection after trauma. Am J Surg 1993;165(2A Suppl):2S-7S. 28. Sugerman HJ, Wolfe L, Pasquale MD, Rogers FB, O’Malley KF, Knudson M, et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma 1997;43:741-7. 29. Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery 1990;108:655-9. 30. D’Amelio LF, Hammond JS, Spain DA, Sutyak JP. Tracheostomy and percutaneous endoscopic gastrostomy in the management of the headinjured trauma patient. Am Surg 1994;60:180-5. 31. Santos PM, Afrassiabi A, Weymuller EA. Risk factors associated with prolonged intubation and laryngeal injury. Otolaryngol Head Neck Surg 1994;111:453-9. 32. Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: A systematic review and meta-analysis. Crit Care 2006;10:R55. 33. Tejada Artigas A, Bello Dronda S, ChacónVallés E, Muñoz Marco  J, VilluendasUsón MC, Figueras P, et al. Risk factors for nosocomial pneumonia in critically ill trauma patients. Crit Care Med 2001;29:304-9.

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How to cite this article: Chaari A, Kssibi H, Zribi W, Medhioub F, Chelly H, Algia NB, et al. Ventilator-associated pneumonia in trauma patients with open tracheotomy: Predictive factors and prognosis impact. J Emerg Trauma Shock 2013;6:246-51.

25. Leone M, Delliaux S, Bourgoin A, Albanèse J, Garnier F, Boyadjiev I, et al. Risk factors for late-onset ventilator-associated pneumonia in trauma

Received: 30.08.12. Accepted: 16.09.12. Source of Support: Nil. Conflict of Interest: None declared.

Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013


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Ventilator-associated pneumonia in trauma patients with open tracheotomy: Predictive factors and prognosis impact.

To assess the predictive factors of ventilator associated pneumonia (VAP) occurrence following open tracheotomy in trauma patients...
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