Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis

Abstract

Background The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients’ outcomes. Methods We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14 days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model. Results Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV (2098 patients; MD − 9.08 days, 95% CI − 10.91 to − 7.26 days, p < 0.01) and duration of ICU stay (1224 patients; MD − 9.41 days, 95% CI − 12.36 to − 6.46 days, p < 0.01). Mortality was reported for 2343 patients and was comparable between groups (OR 1.09, 95% CI 0.79–1.51, p = 0.59). Conclusions The results of this meta-analysis suggest that, compared with late tracheostomy, early tracheostomy in COVID-19 patients was associated with shorter duration of IMV and ICU stay without modifying the mortality rate. These findings may have important implications to improve ICU availability during the COVID-19 pandemic. Trial registration The protocol was registered at INPLASY (INPLASY202180088).

Tracheostomy outcomes in critically ill patients with COVID-19: a systematic review, meta-analysis, and meta-regression

“…Considering 47 studies for the outcome mortality, our results showed a pooled tracheostomy mortality in COVID-19 of 21.6% (95%CI=18.1-25.0), similarly to that previously reported by Ferro and co-workers 13 of 19.2% (95%CI=15.2-23.6) including 37 studies, and Ji and co-workers including 14 studies 14 , but higher than that reported by Benito and co-workers 12 of 13.1% (95%CI=8.5-18.4) including 14 studies. Ferro and co-workers reported no differences in cumulative mortality between early and late tracheostomy (RR=1.6, 95%CI=0.2-11.8) and surgical vs. percutaneous tracheostomy (RR=2.0 95%CI=0.2-20.4) 13 .…”

“…To the best of our knowledge, this is the first systematic review, meta-analysis and meta-regression in COVID-19 tracheostomized critically ill patients which reports the associations between outcomes and moderators as sources of between-study heterogeneity accounting for the effects of study duration (partial accounting for time-varying associations) and study start date (hospital strain), as well as the comparison between early vs. late at different cut-offs, and technique (surgical vs. percutaneous tracheostomy) for several outcomes, including mortality, hospital- and ICU-LOS, decannulation, duration of MV, and complications. Previous meta-analyses reported the comparison between such sub-groups of patients only for a few outcomes 12 , 13 , 14 , 24 .…”

“…Nevertheless, the potential benefits of a tracheostomy, its optimal timing and technique choice, as well as burden for patients, staff, and resources in COVID-19 have yet to be defined 11 . Few meta-analyses of tracheostomy practice in COVID-19 have been published at the beginning of pandemic 12 , 13 , 14 , but none of them was able to compare outcomes beyond mortality facing the issues around timing and technique of tracheostomy. We performed an updated systematic review and meta-analysis at the tail end of the COVID-19 pandemic to summarize and assess all published evidence regarding overall mortality in tracheostomized COVID-19 patients, also investigating tracheostomy timing and technique (surgical [open] vs. percutaneous).…”

TTCOV19: timing of tracheotomy in SARS-CoV-2-infected patients: a multicentre, single-blinded, randomized, controlled trial

“…A recent meta-analysis concerning the optimal timing of tracheotomy in COVID-19 patients concluded that early tracheotomy, defined as 14 days from intubation or less, implied reduced number of days in MV and days spent at the ICU compared to late tracheotomy (15 days after intubation or later) [ 20 ]. No RCTs were, however, available for this meta-analysis.…”

The Impact of Different Ventilatory Strategies on Clinical Outcomes in Patients with COVID-19 Pneumonia

“…Tracheostomy is considered an effective alternative to invasive MV via tracheal tube since it helps to reduce dead-space ventilation and decreases airway resistance and the risk of aspiration, as well as the need for sedation, facilitating weaning from a ventilator [ 18 ]. During the COVID-19 pandemic, there was incomplete evidence that early tracheostomy is preferable to late tracheostomy, and there is no compelling evidence that percutaneous is preferable to surgical (open) [ 5 , 19 , 20 , 21 ]. Consequently, the appropriate MV strategy for COVID-19 respiratory failure is still disputed.…”