Early versus Late Percutaneous Tracheostomy in Ventilated Stroke Patients in Indonesia: Pneumonia, Ventilator Liberation and Mortality in a Retrospective Cohort

Abstract

Background: The timing of percutaneous dilatational tracheostomy (PDT) in ventilated stroke patients is debated, and observational comparisons are prone to guarantee-time bias.

Objective: To compare outcomes after early (≤7 days from intubation) and late (>7 days) PDT, reporting only effects the data can identify.

Methods: Retrospective cohort of all 70 adults with acute stroke ventilated for more than 48 h who underwent bedside PDT at a tertiary hospital in Malang, Indonesia, in 2024 (early n=34; late n=36). Group-level counts were analyzed with exact tests; because only group-level data were available, covariate adjustment was replaced by bounds analyses across all datasets compatible with the observed margins.

Results: Ventilator-associated pneumonia (VAP) occurred in 20.6% after early and 44.4% after late PDT (risk difference −23.9 percentage points, 95% CI −42.8 to −1.8; Fisher p=0.043; exact odds ratio 95% CI 0.10–1.04); the fragility index was 1 and Holm-adjusted p 0.217. Liberation by discharge (50.0% vs 41.7%; p=0.632) and in-hospital death (50.0% vs 58.3%; p=0.632) did not differ, and procedural complications were rare. Cumulative liberation equaled survival in both groups, and time-to-liberation effects were not identifiable because exposure was defined by the day of the procedure.

Conclusion: Early PDT was associated with less VAP but not with liberation or survival; the VAP association is fragile and may reflect reverse causation. Patient-level timing data are needed before early PDT is recommended for respiratory benefit.