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.

Fig 1

Process of study selection of randomised controlled trials

Fig 2

Random effects meta-analysis of relative risk (95% confidence interval) of mortality with early compared with late tracheostomy

Fig 3

Random effects meta-analysis of relative risk (95% confidence interval) of hospital acquired pneumonia with early compared with late tracheostomy

Fig 4

Random effects meta-analysis of weighted mean difference (95% confidence interval) of duration of ventilation in days

Fig 5

Random effects meta-analysis of weighted mean difference (95% confidence interval) of length of stay in the critical care unit in days