National Trends in Open vs Percutaneous Tracheostomy Among U.S. Hospitalizations for COPD Exacerbation, 2016-2022

Background National utilization and short-term outcomes of open surgical tracheostomy (OST) versus percutaneous dilatational tracheostomy (PDT) in adults hospitalized for COPD exacerbation are uncertain. Methods Adult hospitalizations not coded as elective, with a primary diagnosis of COPD exacerbation and tracheostomy, in the U.S. National Inpatient Sample (2016-2022) were classified as OST or PDT using ICD-10-PCS approach codes. Utilization trends, in-hospital mortality, length of stay (LOS), and inflation-adjusted charges were compared using survey-weighted multivariable models and inverse probability of treatment weighting (IPTW), with further adjustment for timing, coded severity, and pandemic period. Results Of an estimated 2,970 hospitalizations (594 sampled), 36.5% involved PDT. Annual volumes declined for PDT (215 to 115; P-trend=0.023) and OST (480 to 165; P-trend=0.003). In-hospital mortality was 13.5% (PDT 14.3% vs OST 13.0%; P=0.662). Mortality was higher in 2020-2022 than in 2016-2019 among OST hospitalizations (21.3% vs 10.2%; P=0.006) but not among PDT hospitalizations (18.3% vs 12.7%; P=0.29); annual trends did not differ significantly between approaches (P for interaction=0.061). After adjustment, PDT was not associated with mortality (RR, 1.06; 95% CI, 0.68-1.66), LOS (-0.63 days; 95% CI, -4.19 to 2.94), or charges (ratio, 0.98; 95% CI, 0.85-1.12); estimates were consistent with IPTW, timing and severity adjustment, exclusion of 2020, and within both periods. Conclusions Both OST and PDT volumes declined. No significant association was detected between approach and short-term outcomes, although estimates were imprecise. The mortality increase within OST hospitalizations, concentrated in the pandemic period, warrants cautious interpretation given potential changes in case mix, treatment selection, pandemic-related practice, and unmeasured severity.