Many patients with spontaneous intracerebral hemorrhage (SDICH) require long-term mechanical breathing, and many of them also frequently have varying degrees of consciousness disruption. Early tracheostomy (TT) aims to maintain a stable airway and prevent hypoxic secondary brain damage [10, 12]. In addition to preventing complications like respiratory mucosa injury, vocal cord injury, tracheomalacia, and ventilator-associated pneumonia (VAP) that arise from prolonged intubation, TT also lessens airway resistance and increases airway compliance, which lessens the need for analgesics and tranquilizers. The possible advantages and safety of early TT in patients with intracerebral hemorrhage have been shown in a number of trials [9, 13, 14]. For example, a 60-patient randomized pilot study in cerebrovascular neurocritical care shown that early TT was safe and practicable for stroke patients, and it significantly decreased the requirement for sedation [8]. Studies that particularly address early TT in the context of SDICH are scarce, nevertheless.
In the current study, we compared patients with SDICH who had TT with those who did not, and we discovered that because of the severity of their medical condition, the patients who needed TT had a worse prognosis. Early detection of the requirement for TT in patients with SDICH can help enable earlier respiratory assistance and potentially lead to better patient outcomes [5, 15]. For patients with SDICH, standard airway management—which includes a methodical airway assessment—is essential to the whole therapeutic regimen [7, 16]. In contrast to a prior study, the Stroke-related Early TT score (SET score) was created by Silvia et al. to determine independent risk variables for predicting the necessity of early TT in stroke patients. Considering that these patients were usually unconscious, the complicated SET score made it difficult for clinical physicians to make rapid choices[15]. The TRACH Score was created by Viktor et al. to grade patients based on a combination of radiological predictors and the Glasgow Coma Score (GCS) in order to determine whether TT was necessary for SDICH patients. However, this score was not created with early TT in mind and has its own set of complications, which limits its clinical applicability[17]. Determining the necessity of TT in the early phases of therapy is therefore essential, given the possible advantages of early TT. In this work, we developed a dynamic nomogram prediction algorithm that can accurately forecast whether SDICH patients would require early TT.
The present study, Glasgow Coma Scale (GCS) as the one of model component reflects the level of consciousness in patients with spontaneous deep intracerebral hemorrhage (SDICH), a low GCS is frequently a significant independent risk factor in predicting the need for early tracheal intubation (TT) in patients with intracerebral hemorrhage (ICH) [4, 18]. These patients may experience significant neurological dysfunction and loss of consciousness due to a high blood clot load, which can lead to neurogenic pulmonary edema and consequent pulmonary ventilation difficulties. Prolonged mechanical ventilation (MV) is necessary for a significant proportion of individuals with a low GCS. Hence, in order to prevent subsequent damage to neural tissue from clot-related hypoxia, patients with SDICH and pulmonary edema need to clear their respiratory airway in order to enhance its function. Additionally, bedridden unconscious SDICH patients with a low GCS are more likely to develop hypostatic pneumonia. Severe hypoxemia results from this condition's worsening of respiratory secretions, impairment of pulmonary ventilation, and gas exchange. Because of this, the best course of action for raising blood oxygen levels is early TT [19].
Another element in the model, An high heart rate (HR) is linked to disorders connected to stress and hypoxemia, and it is used as a clinical measure of cardiopulmonary function. Numerous investigations have indicated that pulmonary dysfunction and neurogenic pulmonary edema may arise from severe brain tissue destruction [20–22]. Damage to the brain tissue causes sympathetic excitement, which raises the quantities of catecholamines in plasma. A storm-like reaction brought on by this excessive catecholamine release is characterized by fast breathing, low blood oxygen levels, and an accelerated heart rate. Furthermore, the catecholamine storm causes increased lung phagocytic and chemotactic activity, which results in the widespread death of type II pneumocytes and pulmonary edema [23]. As a result, this perpetuates the cycle of falling blood oxygen levels and rising heart rate, which eventually leads to hypoxemia and permanent alterations in the main illnesses linked to SDICH. Early therapy efforts are therefore essential to breaking this pattern.
Our study looked at a number of clinical lab indicators, such as platelets (PL) and white blood cells (WBC). There was evidence of damaged brain tissue in the form of systemic and cerebral inflammatory responses. As a result of systemic inflammation, pneumonia developed, which raised the white blood cell count in peripheral blood[24]. There are a number of options to think about. A frequent general indication of inflammatory responses is the peripheral WBC count [25]. According to Wang et al.'s research, there is a positive correlation between WBC numbers and systemic inflammatory response severity[26], This, in turn, leads to a more pronounced inflammatory response in the lungs, heightening the likelihood of early thromboembolism (TT). As a predictive factor, an elevated WBC count can be seen as an indicator for TT [27]. Subdural intracranial hemorrhage (SDICH) is characterized by endothelial injury or rupture, which exposes the collagen and fibers underlying the endothelium and activates platelets [28]. Increased catecholamine production and sympathetic hyperactivity following cerebral hemorrhage due to secondary brain tissue injury from hematomas activate PL via α2-adrenergic receptors on PL membranes. This activation raises the consumption of PL and aids in coagulation[29]. Additionally, bleeding damages brain tissue's local microvascular endothelial cells, which lowers prostaglandin-II synthesis and increases the activation of proteins that activate platelets. As a result, there are more PL in the bloodstream[30]. Particularly in critically sick patients who need TT, there is a correlation between the rise in PL and the severity of cerebral hemorrhage. Together with other factors, PL was shown in our study to be an independent risk factor for TT.
To correctly identify the SDICH patients who are most likely to need early TT and to completely reap the benefits of early TT. The SET score and the TRACH score were used in clinical therapy in several earlier research [15, 17]. These grading scales with intricate scoring schemes, however, cannot be used quickly. Using the dynamic nomogram predicted model, which takes into account the elements of GCS, WBC, PL, and HR at the time of patient admission, a device connected to the internet may be used to quickly and easily confirm the necessity for TT [31]. This approach is easily used by neurologists to assess the need of early TT for individuals with SDICH. The prognosis for these grateful individuals can be improved by preventing needless tracheotomies by detecting SDICH patients during the recovery phase and carrying out the surgery quickly. A model like this would provide prompt treatments aimed at enhancing ventilation, raising the concentration of oxygen in the damaged brain tissue, and optimizing the recovery of neurological function.
Limitation
There were a few drawbacks to our investigation, even though the retrospective data from two centers is stronger than that from a single unit. First off, the study's two locations may have limited how far the results may be applied. Both the spatial and the data heterogeneity of the two locations are somewhat different. Secondly, selection bias may have an impact on the retrospective nature. Additionally, there was selective bias due to the SDICH patients we chose, and some patients' families declined to participate in TT, which left gaps in the data. Third, not all the variables, such as nutritional status and factors that happened throughout the course of the disease, were included in our study. Since HR is one of the anticipated parameters and is very volatile due to external influences, there is a need to further improve the data's dependability. The fourth drawback is that only 45% of the patients in the training set and 55% of the patients in the test set benefited from the DCA curves derived from this study, which is slightly inadequate. This could be because there was not enough data collected, but this will be confirmed by additional data collection in the future. Finally, Thus far, the investigations have been conducted retrospectively, and the outcomes have not been confirmed prospectively. To lessen bias and validate the use of the established nomogram and its role in improving outcomes, further prospective research is needed.