Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation

Abstract

Objective To compare outcomes in critically ill patients undergoing artificial ventilation who received a tracheostomy early or late in their treatment. Data sources The Cochrane Central Register of Clinical Trials, Medline, Embase, CINAHL, the National Research Register, the NHS Trusts Clinical Trials Register, the Medical Research Council UK database, the NHS Research and Development Health Technology Assessment Programme, the British Heart Foundation database, citation review of relevant primary and review articles, and expert informants. Study selection Randomised and quasi-randomised controlled studies that compared early tracheostomy with either late tracheostomy or prolonged endotracheal intubation. From 15 950 articles screened, 12 were identified as "randomised or quasi-randomised" controlled trials, and five were included for data extraction. Data extraction Five studies with 406 participants were analysed. Descriptive and outcome data were extracted. The main outcome measure was mortality in hospital. The incidence of hospital acquired pneumonia, length of stay in a critical care unit, and duration of artificial ventilation were also recorded. Random effects meta-analyses were performed. Results Early tracheostomy did not significantly alter mortality (relative risk 0.79, 95% confidence interval 0.45 to 1.39). The risk of pneumonia was also unaltered by the timing of tracheostomy (0.90, 0.66 to 1.21). Early tracheostomy significantly reduced duration of artificial ventilation (weighted mean difference − 8.5 days, 95% confidence interval − 15.3 to − 1.7) and length of stay in intensive care ( − 15.3 days, − 24.6 to − 6.1). Conclusions In critically ill adult patients who require prolonged mechanical ventilation, performing a tracheostomy at an earlier stage than is currently practised may shorten the duration of artificial ventilation and length of stay in intensive care.

Clinical factors associated with weaning failure in patients requiring prolonged mechanical ventilation

“…Early tracheostomy resulted in a decreased risk of mortality and increased weaning success in some studies (36)(37)(38). In contrast, early tracheostomy did not significantly alter the mortality rate or the duration of MV in other studies (39,40). In the present study, the interval from intubation to tracheostomy did not significantly differ between the weaning success and failure groups (a median day of 16 days vs. 15 days; P=0.725).…”

The Ventilator Discontinuation Process: An Expanding Evidence BaseDiscussion

“…67,68 Their conclusion was that, despite considerable methodologic heterogeneity, an early tracheostomy strategy was associated with trends in favor of early tracheostomy in mortality (49% vs 64%) and pneumonia (12% vs 22%), as well as a significant reduction in time on ventilator in favor of early tracheostomy (7 d vs 17 d).…”

Tracheostomy: Epidemiology, Indications, Timing, Technique, and OutcomesDiscussion

“…However, all of these studies demonstrated either benefit or null effect for early tracheostomy, and none demonstrated detrimental effects. 50 There were major differences in the specific tracheostomy timing (early vs late) and the patient populations (medical critically ill, surgical critically ill, burn injury, head injury subjects) in these 4 studies, and no standard ventilator weaning protocol was used, making ventilator duration and ICU stay outcomes vulnerable to clinical practices in these ICUs.…”