Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review

Abstract

The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.

Effect of early tracheostomy in mechanically ventilated patients

“…In our analysis, early tracheostomy did not improve 60‐day survival, which is consistent with the findings of two RCTs and a meta‐analysis . In contrast, another RCT and two meta‐analyses have shown a mortality benefit with early tracheostomy . Thus, the association between early tracheostomy and improved survival remains controversial.…”

“…7,20,21 In contrast, another RCT and two meta-analyses have shown a mortality benefit with early tracheostomy. 6,14,19 Thus, the association between early tracheostomy and improved survival remains controversial.…”

“…We used day 10 as the landmark point and for defining early tracheostomy for the following reasons: previous trials have defined early tracheostomy as that performed within 7, 10, or 14 days of admission; the median duration from intubation to tracheostomy in our study was 12 days, and we sought to investigate the effect of tracheostomy at days earlier than our current average.…”

CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway management

“…Sedated ICU patients who require prolonged intubation, often require a safer management of the airway, biasing for tracheostomy. A recent systematic review revealed how early tracheostomy, performed in the first 7 days after orotracheal intubation, is associated with a reduction of mechanical ventilation duration, mortality rate and length of stay in ICU [4]. Despite surgical tracheostomies being routinely performed in the surgeon's daily practice, the surgeon's risk of exposure to COVID-19 during this procedure is consistent.…”

CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway management

“…Regarding the most appropriate timing for such procedure, the authors outline how early tracheotomy, performed in the first 7 days from endotracheal intubation, reduced the duration of mechanical ventilation, shortened Intensive Care Unit (ICU) stay, and decreased mortality, as demonstrated in a recent systematic review of the literature [2]. However, these results are based on studies performed well before the outbreak of this epidemic and care must be taken when applying them to the current situation.…”