A Six-Day Window: Tracheostomy Timing and Short-Term Outcomes in Severe Pediatric Traumatic Brain Injury

Early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) is associated with reduced ventilator dependence and complications. However, the optimal timing of tracheostomy remains poorly defined. This study utilized a national trauma database to examine how the timing of tracheostomy is associated with critical care outcomes in children with severe TBI.

We performed a retrospective cohort study using the Trauma Quality Improvement Program (TQIP) database (2019-2023). Inclusion criteria were age <18 years, severe TBI (GCS ≤8 and AIS Head ≥3 or ICD-10 code for intracranial injury), and tracheostomy placement. We first used LOWESS curves and a series of zero-inflated negative binomial (ZINB) models across candidate cut-offs to empirically identify a timing threshold, then applied propensity score matching (PSM) to compare Early Tracheostomy (≤6 days from admission) and Late Tracheostomy (>6 days). Primary outcomes were ventilator-free and ICU-free days.

Of 15,934 children with severe TBI identified, 1,181 met the inclusion criteria and underwent tracheostomy (191 Early, 990 Late). LOWESS and ZINB analyses across candidate cut-offs identified Day 6 as an exploratory inflection point beyond which the incremental benefit of earlier tracheostomy diminished. Applying this threshold, PSM yielded a balanced cohort of 294 patients (147 pairs). The Early cohort demonstrated significantly higher median ventilator-free days (16.0 vs. 9.0, p<0.001) and ICU-free days (11.0 vs. 4.0, p<0.001). ZINB regression confirmed a higher rate of accumulating ventilator- and ICU-free days (IRR 1.47, 95% CI 1.31-1.66; IRR 1.46, 95% CI 1.27-1.67) compared with the Late cohort.

Early tracheostomy was associated with significantly reduced mechanical ventilation duration, shorter hospital stays, and a higher likelihood of home discharge. These findings suggest that tracheostomy within the first 6 days of admission is associated with improved short-term outcomes in pediatric severe TBI.