ArticlesEffect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis
Introduction
A substantial proportion (up to a third) of patients who receive mechanical ventilation for more than 48 h undergo tracheostomy.1, 2 Perceived benefits of tracheostomy include airway security, enhanced patient comfort, and easier weaning from mechanical ventilation, but the procedure is not risk free. Thus, patients who need mechanical ventilation often undergo translaryngeal intubation for an initial period of time, after which a tracheostomy is undertaken. However, optimum timing for the placement of a tracheostomy remains a challenging question.
In the past few years, investigators of large trials addressed this question and reported that timing of tracheostomy might not affect clinical outcomes.3, 4, 5 Accordingly, most experts support the wait-and-see strategy—ie, the delay of tracheostomy placement until day 106 or even day 157, 8 of mechanical ventilation. However, even the largest and most recent of the above mentioned contributions did not achieve its intended sample size.3 Because of the potentially modest benefits of early tracheostomy and the methodological challenges to design and undertake such trials (eg, recruitment rates), any one trial might be unlikely to provide convincing evidence of the effectiveness of the intervention. A carefully done meta-analysis of trials could address this issue;9 it could restrict the likelihood of type II error by increasing sample size, and uncover the benefit (if any) of the intervention. We did a systematic review and meta-analysis to investigate whether early tracheostomy has any benefit compared with late or no tracheostomy in terms of mortality and pneumonia in critically ill patients who need mechanical ventilation.
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Search strategy and selection criteria
We undertook the systematic review and meta-analysis in accordance with recommendations of the Cochrane Handbook for Systematic Reviews of Interventions.10 We reported the systematic review and the meta-analysis in accordance with the PRISMA Statement.11 The review protocol is available online.
We systematically searched PubMed, CINAHL, Embase, Web of Science, Directory of Open Access Journals, and the Cochrane Central Register of Controlled Trials from database inception to Aug 31, 2013. We
Results
Figure 1 shows the flow diagram for study selection. We included 16 trials3, 4, 5, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 in the systematic review. One of these trials27 was a conference abstract that mentioned significant difference in mortality (but not in pneumonia) in favour of early versus late tracheostomy; however, it was not included in the meta-analysis because it did not provide specific numbers and we could not contact its investigators.27 Thus, 15 trials were included in
Discussion
The synthesised evidence suggests that early, compared with late or no, tracheostomy is not significantly associated with lower mortality in the intensive-care unit, but might be associated with lower incidence of ventilator-associated pneumonia.
Our finding for intensive-care-unit mortality is in line with those of recent trials in which early tracheostomy offered no survival benefit compared with postponing tracheostomy for at least 10 days after the start of mechanical ventilation.3, 4, 5
References (47)
- et al.
The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta–analysis of randomized controlled trials
Chest
(2011) - et al.
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
Lancet
(2009) - et al.
Attributable mortality of ventilator-associated pneumonia: a meta-analysis of individual patient data from randomised prevention studies
Lancet Infect Dis
(2013) - et al.
Beyond pneumonia: improving care for ventilated patients
Lancet Infect Dis
(2013) - et al.
Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis
Lancet
(2013) - et al.
Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993–2002
Crit Care Med
(2004) - et al.
Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?
Crit Care Med
(2007) - et al.
Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial
JAMA
(2013) - et al.
Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial
Ann Intern Med
(2011) - et al.
Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial
JAMA
(2010)
When should a mechanically ventilated patient undergo tracheostomy?
JAMA
Tracheostomy practice in adults with acute respiratory failure
Crit Care Med
What's new with tracheostomy?
Intensive Care Med
Obtaining evidence by a single well–powered trial or several modestly powered trials
Stat Methods Med Res
Cochrane handbook for systematic reviews of interventions (version 5.1.0)
Preferred reporting items for systematic reviews and meta–analyses: the PRISMA statement
Ann Intern Med
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
BMJ
Measuring inconsistency in meta–analyses
BMJ
Stroke–related early tracheostomy versus prolonged orotracheal intubation in neurocritical care trial (SETPOINT): a randomized pilot trial
Stroke
Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study
Langenbecks Arch Surg
Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation
Chin Med J
A comparative study of early and late tracheostomy in patients requiring prolonged tracheal intubation
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