**7. Conclusion**

*Advancement and New Understanding in Brain Injury*

room and staff [88, 103, 104].

procedures risks [94, 109, 110].

admission [111–116].

costs [113, 117].

**6. The benefits of tracheostomy on TBI**

ment of the surgical techniques, instruments and cannulas.

open surgical (OST) or percutaneous dilatory (PDT) techniques.

During the Second World War, TQT grown relevance in chest trauma patients [93] and since then, it is expanding its role in airway management, as well improve-

Prolonged/impractical intubation, ventilation support for weaning, pulmonary hygiene management and airway protection are main indications for TQT placement [86–88, 94]. Patients can benefit from tracheostomy that is performed by

Patient's individual aspects assist the medical team to decide whether to use PDT or OST. PDT is recommended for patients who can hyperextend the neck, tolerate hypercarbia and hypoxemia, and present at least 1-cm distance between the inferior cricoid cartilage and the suprasternal notch (in case of needed re-intubated after accidental extubation) [86–88]. PDT relative contraindications are emergency airway access, anatomical incompatibility, coagulopathies, higher levels for support oxygenation (e.g. positive end-expiratory pressure ≥ 10 mm Hg or fraction of inspired oxygen ≥0.7), and infection at insertion site surroundings [86–88]. Studies were carried out to establish advantages and preferences between techniques. A Cochrane review did not find statistical difference for mortality and serious life-threatening adverse events between techniques [95]. However, PDT presented significantly reduced rate for wound infections/stomatitis and unfavorable scaring. Other systematic reviews and meta-analysis confirmed the same result trend: no difference in mortality and life-threatening complications [96–100]. Significant positive outcomes for PDT was cited as less infection rate [97–100] and less procedure time [96, 100–102]. Besides these results, OST could also impact hospital expenditures, since the procedure can require an operatory

A multidisciplinary team collaborates in patient's care for adequate communication, ventilation and oxygenation [104]. The presence of a TQT may promote greater airway security, assisting in patient's mobilization and engagement to physical therapies [88]. Likewise, TQT allows sedation reduction or cessation, reduction of laryngeal lesions, assist in weaning protocol and improve oral nutrition and communication [105–107]. Mentioned risks are tracheal stenosis, tracheomalacia and hemorrhage [108]. However, TQT benefits overcome

Over the past decade, extensive research has been done concerning TQT timing for optimal results in patient's care, and an oscillation of a cut out day to consider TQT as an early procedure (ET) is perceived. Literature reveals authors acceptation of TQT as an early procedure, as those ones performed between 2 and 12 days after

A systematic review and meta-analysis [115] revealed that ET, in severe TBI patients, is associated with shorter length of mechanical ventilation and intensive care unit (ICU) and hospital stay. Likewise, decreased risk of ventilator associated pneumonia was found. Complementary literature comparing early and late tracheostomy (LT) populations demonstrated lower ICU stay [113, 117–120], lower hospital stay [117, 120], lower rates for pneumonia [113, 117, 119, 120] and lower

Healthcare cost management has increasing its role as part of patient's care plan. Given an aging population and rising medical comorbidities, expertise in resource allocation is crucial. Herrit and colleagues [121] demonstrated the average weighted cost of ET (≤4 days) patients in ICU is \$4316 less when compared with

**160**

Overall, ET could contribute to lower exposure to secondary insults and nosocomial adverse events, rising patient's early rehabilitation and discharge rates, and improve hospital/staff resources management. Establishment of guidelines for further homogenous approaches to better assist severe TBI patients and improve second injury control is concerned.
