What is the purpose of the I-trach (Intubation-Tracheostomy) score in airway management?

I-Trach Score: Purpose and Clinical Application

The I-Trach score does not exist as a validated clinical tool in airway management—you may be confusing it with other established scoring systems used to predict tracheostomy needs or intubation difficulty.

Established Scoring Systems for Airway Management

TRACH Score (for Intracerebral Hemorrhage)

The TRACH score predicts the need for tracheostomy in mechanically ventilated patients with supratentorial spontaneous intracerebral hemorrhage. 1

• Formula: TRACH score = 3 + (1 × RScale) - (0.5 × GCS) 1
• RScale components (radiological findings): 1
  • Thalamic location of hemorrhage (L): 2 points
  • Hydrocephalus (H): 1.5 points
  • Septum pellucidum shift (S): 3 points
• Performance characteristics: Sensitivity 94%, positive predictive value 83%, negative predictive value 95%, ROC 0.92 1
• Clinical utility: Allows early identification of patients requiring tracheostomy, potentially reducing ICU length of stay and hospitalization costs 1

TRACHY Score (for Head and Neck Cancer)

The TRACHY score guides airway management decisions in head and neck cancer surgery requiring flap reconstruction. 2

• Components: 2
  • T: T staging of tumor
  • R: Reconstruction type
  • A: Anatomy of tumor
  • C: Coexisting conditions
  • H: History of previous head and neck cancer treatment
  • Y: lateralitY (bilateral neck dissection)
• Threshold: Score ≥4 predicts tracheostomy need 2
• Performance: Sensitivity 91.4%, specificity 90.8%, positive predictive value 90.9%, negative predictive value 88.2% 2
• Mean scores: Intubated patients 2.1, primary tracheostomy 5.7, late tracheostomy 4.6 2

CASST Criterion (Clinical Assessment Scoring System for Tracheostomy)

The CASST criterion provides objective criteria to predict pre-operatively the need for tracheostomy in head and neck malignancies. 3

• Factors analyzed: Age, previous surgery, extent of surgery, trismus, extent of mandibular resection and reconstruction 3
• Threshold: Score ≥7 indicates need for tracheostomy 3
• Performance: Sensitivity 95.5%, negative predictive value 99.3% 3
• Clinical impact: Reduces post-operative complications and contributes to safer treatment 3

Intubation Difficulty Prediction

IDS (Intubation Difficulty Scale)

The IDS defines difficult intubation using 7 variables, with a score ≥5 indicating difficult intubation 4

Best predictors of difficult intubation (IDS ≥5): 4

• Total airway score >6: Odds ratio 13.57
• Upper lip bite test (ULBT) class III: Odds ratio 12.48
• Head and neck movement <90°: Odds ratio 3.11

Key Principles from DAS Guidelines

For tracheostomy emergencies, the Difficult Airway Society emphasizes: 5

• Oxygenation takes priority over immediately securing the airway definitively
• Early assistance from trained multi-disciplinary team members is critical
• Separate algorithms are needed for patients with patent upper airway (green algorithm) versus laryngectomy (red algorithm) 5

Critical Timing Considerations

• Surgical tracheostomy: Stoma matures sufficiently for safe tube exchange after 3 days 6
• Percutaneous tracheostomy: Dilated tissues recoil if tube displaced, making re-insertion more difficult in first 7-10 days 6
• Bedhead signs documenting airway status and emergency contacts must be completed as part of theatre sign-out 6

Common Pitfalls to Avoid

• Do not confuse tracheostomy prediction scores (TRACH, TRACHY, CASST) with intubation difficulty scores (IDS, MACOCHA) 2, 1, 3, 4
• Never assume a percutaneous tracheostomy stoma will remain patent like a surgical one—they behave differently in emergencies 6
• Always document whether upper airway is patent or not (laryngectomy), as this fundamentally changes emergency management 5