Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials

Abstract

IntroductionThe optimal timing of tracheotomy in critically ill patients remains a topic of debate. We performed a systematic review to clarify the potential benefits of early versus late tracheotomy.MethodsWe searched PubMed and CENTRAL for randomized controlled trials that compared outcomes in patients managed with early and late tracheotomy. A random-effects meta-analysis, combining data from three a priori-defined categories of timing of tracheotomy (within 4 versus after 10 days, within 4 versus after 5 days, within 10 versus after 10 days), was performed to estimate the weighted mean difference (WMD) or odds ratio (OR).ResultsOf the 142 studies identified in the search, 12, including a total of 2,689 patients, met the inclusion criteria. The tracheotomy rate was significantly higher with early than with late tracheotomy (87 % versus 53 %, OR 16.1 (5.7-45.7); p <0.01). Early tracheotomy was associated with more ventilator-free days (WMD 2.12 (0.94, 3.30), p <0.01), a shorter ICU stay (WMD -5.14 (-9.99, -0.28), p = 0.04), a shorter duration of sedation (WMD -5.07 (-10.03, -0.10), p <0.05) and reduced long-term mortality (OR 0.83 (0.69-0.99), p = 0.04) than late tracheotomy.ConclusionsThis updated meta-analysis reveals that early tracheotomy is associated with higher tracheotomy rates and better outcomes, including more ventilator-free days, shorter ICU stays, less sedation, and reduced long-term mortality, compared to late tracheotomy.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-1138-8) contains supplementary material, which is available to authorized users.

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.…”

“…Based on this result, if the groups were comparable, tracheostomy could have been avoided for half of the patients undergoing early tracheostomy (≤4 days). Similarly, a meta‐analysis of 12 randomized controlled trials (RCTs) showed a much higher tracheostomy rate in patients undergoing early tracheostomy (87% vs. 53%) . In these trials, the patients may have been excessively treated and exposed to the complications related to this surgery.…”

Elective Tracheotomy Practices in Turkey

“…Krishnan et al defined early tracheotomy as performing tracheotomy between 1 st and 7 th days of MV [16]. Although it was shown that there was no enough evidence for advantages of early tracheotomy in some studies, Hosokawa et al concluded that early tracheotomy was associated with higher rate of tracheotomy, shorter ICU stay, shorter sedation of duration and lower long-term mortality rate [26–28]. In the present survey, we found that ET was commonly performed in 2 nd and 3 rd week and early tracheotomy (in 1 st week) was being performed by only 3% of all ICUs (Tables 2 and 7).…”

Percutaneous tracheostomy: a comprehensive review

“…Although, two more recent analyses suggest superiority of early tracheostomy (43,44), the timing of tracheostomy is dependent mostly on individual and institutional practice.…”