Topical Review
Section Editors: Kyra J. Becker, MD, and Emanuela Keller, MD
Use and Timing of Tracheostomy After Severe Stroke
Julian Bösel, MD
A patient with severe ischemic or hemorrhagic stroke needs
to have a tracheostomy performed if he remains unable
to breathe and protect his airway sufficiently. This can be
caused by very different types of stroke, such as severe acute
ischemic stroke (eg, large hemispheric stroke, space-occu-
pying cerebellar stroke, basilar thrombosis, and brain stem
infarction), large or brain stem intracerebral hemorrhage and
intraventricular hemorrhage, severe cerebral venous and sinus
thrombosis, and aneurysmal subarachnoid hemorrhage. The
particular type of cerebrovascular pathology is probably less
relevant than how extensive the brain damage and its sequelae
(brain edema, secondary ischemia) are and what parts of the
brain they affect. In particular, compromise of brain regions
regulating the level of consciousness (reticular formation in
the brain stem, thalami, limbic system), breathing (respira-
tory centers in the cortex, pons, and medulla), and swallowing
(medulla and brain stem connections) may lead to the need of
a tracheostomy. There are 2 main scenarios in which tracheos-
tomy after stroke is usually considered.
The first is in a patient requiring stroke unit care with an
overall moderate stroke that affects swallowing centers of the
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brain (such as infarcts of the brain stem or the medulla oblon-
gata) causing dysphagia. In some of those cases, after sev-
eral noninvasive supportive measures have been sufficiently
applied but failed, tracheostomy may be considered to prevent
aspiration and bridge swallowing therapy. This approach to
that scenario, however, is very controversial.
The second scenario is in a patient with a stroke so severe
to demand admission to an intensive care unit (ICU) and
mechanical ventilation. There, tracheostomy will be chosen
if extubation fails or is deemed not feasible, that is, as part
of weaning from the ventilator. The need of tracheostomy,
the timing of tracheostomy, and its potential benefits versus
risks to the patient with severe stroke remain challenging and
controversial. This review will focus on the need, timing, and
safety of tracheostomy for the ICU stroke patient and will not
address details of tracheostomy techniques.
Tracheostomy in the Nonventilated Stroke
Patient
The reported incidences for dysphagia in the acute phase of
stroke range from 30% to 80%.1,2 The validity of various pro-
posed predictors remains limited.3 Posterior circulation stroke
Received May 30, 2017; final revision received July 5, 2017; accepted July 6, 2017.
From the Department of Neurology, University Hospital Heidelberg, Germany.
Correspondence to Julian Bösel, MD, FNCS, Department of Neurology, University Hospital Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg,
Germany. E-mail julian.boesel@med.uni-heidelberg.de
(Stroke. 2017;48:2638-2643. DOI: 10.1161/STROKEAHA.117.017794.)
© 2017 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
2638
is placing the patient at particular risk to develop dysphagia,
especially if pons and medulla are involved.4 A severe dys-
phagia may lead to recurrent aspiration pneumonia, which
increases morbidity and mortality. Detection of dysphagia
after stroke relies on numerous clinical and apparative tests.
A systematic review comparing 3 methods favored a simple
water swallowing test combined with pulse oximetry,5 but
endoscopic tests might be of greater value in less cooperative
patients. Screening for and treatment of dysphagia was shown
to prevent pneumonia.6 In severe dysphagia, it may not be suf-
ficient to divert nutrition by a gastric tube and to initiate swal-
lowing therapy, as some of these patients might persistently
fail to handle their saliva, demanding ongoing suctioning, and
may need a tracheostomy. However, there exist hardly any
systematic studies on tracheostomy in the non-ICU stroke
patient with dysphagia. Optimal timing, technique, and decan-
nulation management are still largely unclear. Pragmatically,
it seems reasonable to do a clinical bedside swallowing test
in any stroke patient even slightly suggestive of dysphagia,
proceed to endoscopic swallowing tests if screening is patho-
logical keeping the patient nil by mouth, place a nasogastric
tube if endoscopic tests are pathological as well and assess
penetration/aspiration. If aspiration is confirmed persistently
despite supportive measures and initiation of swallowing ther-
apy, tracheostomy may be considered. In suspected long-term
dysphagia, surgical tracheostomy (ST) may be preferable to
allow for easier and safer changing of cannulas during reha-
bilitation. Decannulation has hardly been assessed in non-ICU
dysphagic stroke patients, but indirect evidence on how to best
confirm the absence of dysphagia can probably be transferred
from ventilated patients.
Tracheostomy in the Ventilated Stroke Patient
Use of Tracheostomy
The prognosis of stroke patients requiring ICU management
and mechanical ventilation was suggested to be generally poor
by past retrospective studies with reported mortality rates rang-
ing between 40% and 80%. These and similar studies, how-
ever, had been conducted before new options to reduce these
stroke patients’ morbidity and mortality (such as by thrombec-
tomy or decompressive surgery) were demonstrated. Because
the most frequent extracerebral complications of neurological
DOI: 10.1161/STROKEAHA.117.017794

ICU patients are respiratory,7 measures to improve airway
and ventilation management have the potential to improve
outcome. Although tracheostomy in the general ICU is per-
formed in about 10% to 15% of patients, the rate in ICU stroke
patients ranges between 15% and 45%.7–9 It is quite custom-
ary to estimate chances of extubation at the end of the first
week of ventilation and proceed to tracheostomy if this is
not deemed feasible for the following week. Practices, how-
ever, vary greatly between centers and how to decide on the
need of tracheostomy is hardly standardized for general ICU
patients,10 and even less so for stroke ICU patients. Accepted
advantages of a short tracheal cannula compared with a long
orotracheal tube are improved oral hygiene and nursing mea-
sures, avoidance of lesions to pharynx and larynx, less need
for sedation, and a higher patient comfort.11 Other meaningful
benefits of tracheostomy, such as reduction of ventilatory dead
space and thus of work of breathing, improved patient safety,
faster weaning and shorter ventilation duration, reduced ICU
length of stay (LOS), lower risk of ventilator-associated pneu-
monia or even lower mortality, and improved outcome, have
been suggested by studies of varying sizes and numbers but
have largely remained controversial until today.10
Need of Tracheostomy
Clinical judgment of prolonged ventilation and hence need of
tracheostomy seems to be a great challenge in the non-neuro-
logical ICU population. In the largest randomized tracheos-
tomy trial, the TracMan trial, the rate of patients deemed to
be ventilated long term who actually needed a tracheostomy
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was 50%.12 Accepted indications for tracheostomy in the
general ICU are long-term ventilation because of prolonged
respiratory failure, demand to protect the airway in increased
risk of aspiration or functional/mechanical obstruction, pro-
longed demand of suctioning of tracheal secretions, and a
dysphagia. In 2 retrospective studies, predictors for the need
of tracheostomy were investigated in ICU patients with
supratentorial intracerebral hemorrhage. Independent pre-
dictors were low Glasgow Coma Scale, presence of chronic
obstructive pulmonary disease, volume and thalamic location
of the intracerebral hemorrhage, midline shift, presence of
intraventricular blood and hydrocephalus.13,14 Some of these
parameters have been combined to form the Tracheostomy
prediction score (the TRACH score) with a reported posi-
tive predictive value of 95% and a negative one of 83%.14
That score awaits, however, prospective validation. Qureshi
et al15 have retrospectively assessed predictors of tracheos-
tomy in patients with (mainly vascular) infratentorial lesions
and found brain stem dysfunction, a low Glasgow Coma
Scale and additional supratentorial lesions to either predict
tracheostomy or alternatively death. At this author’s own
institution, a score to predict tracheostomy need after severe
stroke (the SETscore; Table 1) has recently been validated in
a single-center cohort of 75 severely afflicted stroke patients
and predicted tracheostomy need with a sensitivity of 64%
and a specificity of 86%.16 The score has also been proven
useful as a screening tool in our randomized pilot trial on
early tracheostomy in stroke.17,18 Our decision to perform a
tracheostomy is currently based on the score combined with
the judgment of an experienced neurointensivist.
Bösel  Tracheostomy After Stroke  2639
Put simply, stroke patients who can not be timely and safely
extubated should be considered for a tracheostomy. How to
judge extubation success, however, is challenging and contro-
versial. In a recent study of our own, extubation failure in 98
ICU stroke patients was found in 37%, and classical respira-
tory weaning criteria as well as level of consciousness were
not reliably predicting this, but rather criteria more closely
related to airway safety and secretion handling.9 In a retro-
spective study in 37 patients middle cerebral artery infarction,
Wendell et al19 found a Glasgow Coma Scale score of >8 to
be associated with extubation success, but none of the other
classical extubation criteria. Although coma on its own should
certainly not be regarded as an indication for tracheostomy, if
there are several arguments to doubt extubation success (no
cough effectiveness, high quantity of secretions, high vis-
cosity of secretions, etc), tracheostomy might be the better
option, as both extubation delay and extubation failure worsen
the prognosis of the ICU patient.20
An often proposed reason to proceed to tracheostomy
in ICU stroke patients is to facilitate respirator weaning.
Discontinuous methods of weaning, that is, those involving
extended spontaneous breathing trials and as such wake-up
trials, can compromise intracranial pressure balance and oxy-
genation in brain-injured patients.21,22 It may hence be more
adequate to apply a continuous way of weaning (such as grad-
ually reduced pressure support ventilation) to a stroke patient
after tracheostomy at higher comfort but less sedation, who is
then able to better participate in the weaning process. In a ret-
rospective subgroup analysis of 129 patients of a mixed ICU,
the 31 neurological/neurosurgical patients were the fastest to
be weaned from the ventilator after tracheostomy compared
with other subgroups.23
Timing of Tracheostomy
Optimal timing of tracheostomy in non-neurological ICU
patients has remained unclear. A recent meta-analysis of
randomized clinical trials comparing early with late (<> 7
days from intubation) tracheostomy in mixed ICU popula-
tions showed neutral results, except for a reduced incidence
of ventilator-associated pneumonia.24 The largest randomized
clinical trial to date, the UK TracMan trial on tracheostomy
at day 4 versus day 10 (or more) in 909 mixed ICU patients,
demonstrated safety between early and late tracheostomy, but
no other relevant benefit of early tracheostomy than less seda-
tion need.12 A common recommendation is to estimate need
of prolonged (>14 days) ventilation after 7 days of ventilation
and proceed to tracheostomy in that case.10 Quite likely, recent
randomized clinical trials were underpowered to show ben-
efits in mixed populations, and it could be more relevant (and
rewarding) to investigate the matter in special ICU subgroups.
A recent meta-analysis of studies of early versus late
tracheostomy in patients with acute brain injury suggested
reductions in long-term mortality, duration of mechanical
ventilation, and ICU LOS.25 Early tracheostomy in stroke
ICU patients has hardly been investigated prospectively.
Although burdened with high mortality and morbidity, 25%
long-term ventilated survivors of ischemic or hemorrhagic
stroke who had received tracheostomy had a favorable out-
come in a retrospective study of 97 patients.26 The same
 2640  Stroke  September 2017
Table 1. SETscore to Estimate Tracheostomy Need After
Severe Stroke
Area of Assessment Situation
Neurological function Dysphagia
Observed aspiration
GCS on admission <10
Neurological lesion Brain stem
Space-occupying
cerebellar
Ischemic infarct >2/3
MCA territory
ICH volume > 25 mL
Diffuse lesion
Hydrocephalus
Extracerebral organ (Neuro)surgical
function/procedure intervention
Additional respiratory
disease
PaO2/FiO2 <150
APS (of APACHEII) >20
LIS score of >1
Sepsis
Score >8 in combination with estimate of experienced neurointensivist
suggests prolonged ventilation and tracheostomy need.16 APACHEII indicates
Acute Physiology and Chronic Health Evaluation II; APS, Acute Physiology Score;
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FiO2, fraction of inspired oxygen; GCS, Glasgow Coma Scale; ICH, intracerebral
hemorrhage; LIS, Lung Injury Score; MCA, middle cerebral artery; and PaO2,
partial arterial pressure of oxygen.
study suggested earlier tracheostomy to be associated with
shorter ICU LOS, as was likewise demonstrated in another
retrospective study on 69 ventilated stroke patients with
(mainly vascular) infratentorial lesions.15 A retrospective
analysis of >13 000 stroke patients from the US Nationwide
Inpatient Sample suggested reduced ventilation-associated
pneumonia, LOS,and costs with early tracheostomy.27 In the
only randomized clinical trial on the question of early tra-
cheostomy in stroke ICU patients to date, the single-center
pilot study, SETPOINT (Stroke-Related Early Tracheostomy
Versus Prolonged Intubation), we randomized 60 ventilated
patients with severe intracerebral hemorrhage, subarachnoid
hemorrhage, or acute ischemic stroke to either early tracheos-
tomy (within 3 days from intubation) or prolonged intubation
(weaning and extubation or, if not successful, tracheostomy
between days 7 and 14). Early tracheostomy was feasible,
safe, and resulted in less sedation and a more patient-domi-
nated ventilation. The primary end point ICU LOS, however,
was identical between the groups, as were many other sec-
ondary end points. ICU mortality was significantly lower in
the early tracheostomy group, but this should not be over-
estimated in such a small trial.18 The results of SETPOINT
are tried to be confirmed and extended in the ongoing larger
multicenter trial SETPOINT2, that will hopefully help to
judge the efficacy of early tracheostomy application in the
ICU patient with severe stroke.28
Safety of Tracheostomy
Percutaneous dilational tracheostomy (PDT) is the tech-
Points nique currently favored over traditional ST (open) in many
ICUs worldwide. Details of ST and PDT as well as details of
4
periprocedural measures have been nicely summarized and
3 illustrated in a review by Durbin29; both approaches have
3 been compared in meta-analyses and PDT found advanta-
geous, particularly with regard to fewer overall complica-
4
tions, reduced wound infection, inflammation, unfavorable
3 scarring, and higher cost-effectiveness, and a trend toward
reduced relevant bleeding.30,31 The following have been con-
4 traindications against PDT (and may lead to choice of ST
instead), some of which are now regarded relative: gross
4 anatomic distortion of the neck, previous neck surgery,
3
burns, radiotherapy, instable or rigid cervical spine, tracheal
distortion, stenosis or malacia, upper airway tumor or ste-
4 nosis, morbid obesity, large thyroid gland or vessels in the
2 intervention territory, relevant oxygenation compromise,
hemodynamic instability, high demand of vasopressors,
3 coagulopathy, increased intracranial pressure, emergency
situation, very difficult airway, expected (re)intubation prob-
2 lems, and need for permanent tracheostoma. Bronchoscopy
guidance and ultrasound orientation can help to make trache-
4
ostomy safer.32
2 Overall, PDT can be considered a very safe ICU proce-
3 dure with a rate of procedure-related complications of 3% to
4%.33,34 In a 6-year prospective follow-up study of 572 PDTs,
Dempsey et al34 reported only 3% early and 0.7% late compli-
cations. However, 2 patients (0.35%) died because of bleed-
ing from injury of the brachiocephalic truncus.34 Death from
tracheostomy was further investigated in a systematic review
of published lethal cases and the incidence of such complica-
tions calculated to be <0.2%, of these hemorrhage 38%, airway
complications 29.6%, tracheal perforation 15.5%, and pneu-
mothorax 5.6%.35 Particular care has to be taken when chang-
ing the cannula after PDT is necessary within the first 2 weeks.
Complications in ICU stroke patients do not differ between
early and late tracheostomy.36 Studies have demonstrated that
PDT in ICU stroke patients can be performed quickly and
safely at the bedside by neurointensivists.18,37 In essence, total
complication rate is low, more frequent complications are of
minor relevance, and very rare complications can be severe.
After completed ventilator weaning after tracheostomy, a
stroke patient can be decannulated as soon as his ability to
swallow and handle his saliva is reestablished. Clinical swal-
lowing evaluation in patients after tracheostomy can be unre-
liable and both lead to inadequately early decannulation in
dysphagic patients and (more often) unnecessarily delayed
decannulation. Endoscopic bedside tests have proven valu-
able to detect or exclude dysphagia in stroke patients after
ventilation and tracheostomy, even if the patient is not fully
cooperative. In a recent prospective study in 100 such stroke
patients, >80% more patients could be successfully decan-
nulated than by relying on clinical swallowing evaluation
alone.38 In another study, about 60% formerly ventilated
stroke patients were decannulated after 1 year, which was
associated with better functional outcome than if not decan-
nulated.39 Relevant studies on tracheostomy in stroke patients
are listed in Table 2.
 Bösel  Tracheostomy After Stroke  2641

Table 2. Relevant Studies on Tracheostomy in ICU Stroke Patients

Investigator and Year n Study Population Study Design Main Findings
Early tracheostomy
 Qureshi et al15 2000 69 Infratentorial lesions, Retrospective Reduced ICU LOS, ventilation
including 56 with stroke duration in early tracheostomy
 Rabinstein and Wijdicks26 97 AIS, ICH, SAH survivors after Retrospective Reduced ICU LOS, ventilation
2004 prolonged intubation and duration in early tracheostomy
tracheostomy
 Bösel et al18 2013 60 AIS, ICH, SAH Prospective randomized Safety, feasibility, reduced
sedation need, and lower
mortality in early tracheostomy
 Villwock et al27 2014 13 165 AIS, ICH, SAH Retrospective Reduced incidence of VAP,
LOS, and hospital costs in early
tracheostomy
 Lee et al36 2015 95 AIS, ICH, SAH Retrospective No significant difference
between early and late
tracheostomy
Predictors of tracheostomy need
 Huttner et al13 2006 392 Supratentorial ICH Retrospective Predictors of tracheostomy
need: COPD, hematoma
volume, ganglionic location,
hydrocephalus
 Szeder et al14 2010 150 Supratentorial ICH Retrospective Predictors of tracheostomy
need: GCS, septum pellucidum
shift, thalamic location,
hydrocephalus (TRACH score)
 Schönenberger et al16 2016 75 AIS, ICH, SAH Prospective observational SETscore > 8 predicts
prolonged ICU stay, ventilation
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time, and tracheostomy need

 Steidl et al9 2017 185 AIS, ICH, SAH Prospective observational Primary tracheostomy more
likely in ICH, low GCS,
neurosurgery need, obesity,
and those intubated for loss of
protective reflexes
Decannulation
 Warnecke et al38 2013 100 Mixed neurocritical, including Prospective observational Earlier and safe decannulation
68 with stroke by FEES
 Schneider et al39 2017 53 AIS, ICH, SAH Prospective observational Decannulation achieved in 59%
at 1 y, associated with better
functional outcome
AIS indicates acute ischemic stroke; COPD, chronic obstructive pulmonary disease; FEES, Flexible Endoscopic Evaluation of Swallowing; GCS, Glasgow Coma Scale;
ICH, intracerebral hemorrhage; ICU, intensive care unit; LOS, length of stay; SAH, subarachnoid hemorrhage; TRACH, Tracheostomy prediction score; and VAP, ventilator-
associated pneumonia.

Summary
Patients with severe ischemic and hemorrhagic strokes may
require tracheostomy in the course of their disease. This may be
a reasonable consideration in stroke unit patients whose deficits
include a severe dysphagia posing such risk of aspiration as can-
not be sufficiently counteracted by tube feeding and swallowing
therapy alone, after adequate noninvasive supportive measures
have been applied and complications such as aspiration pneumo-
nia occurred or been judged threatening. More often, tracheos-
tomy is performed in stroke patients so severely afflicted that they
require ICU treatment and mechanical ventilation. In these, long-
term ventilation and prolonged insufficient airway protection
are the main indications for tracheostomy. Accepted advantages
are less pharyngeal and laryngeal lesions than with prolonged
orotracheal intubation, better oral hygiene and nursing care, and
higher patient comfort. Optimal timing of tracheostomy is still
unclear, in general as in stroke ICU patients. Potential benefits
of early tracheostomy concerning ventilation duration and LOS,
respirator weaning, airway safety, rate of pneumonia and other
complications, outcome, and mortality have not been sufficiently
established in patients with severe stroke. A single randomized
pilot trial on early tracheostomy in 60 ventilated patients with
severe hemorrhagic and ischemic stroke (SETPOINT) dem-
onstrated feasibility, safety. and less need of sedation, whereas
data on functional clinical outcome remain limited. About the
technique, bedside PDT should be preferred over ST because of
 2642  Stroke  September 2017
several reported advantages. As procedural risk is low, and early
tracheostomy does not seem to worsen the clinical course of the
ventilated stroke patient, it may be reasonable to assess ventila-
tion need at the end of the first week of intensive care and con-
sider tracheostomy if an extubation attempt failed or is judged
not to be feasible. Reliable prediction of prolonged ventilation
need and outcome benefits of early tracheostomy, however, await
further clarification. Decannulation of stroke patients after dis-
continued ventilation has to follow reliable confirmation of swal-
lowing ability, as by endoscopy.
Disclosures
The author has been and is principal investigator of the SETPOINT
and SETPOINT2 trials on early tracheostomy after severe stroke.
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KEY WORDS: intracerebral hemorrhage ◼ neurocritical care ◼ stroke
◼ subarachnoid hemorrhage ◼ tracheostomy ◼ tracheotomy ◼ weaning