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Neurocritical Care

, Volume 26, Issue 1, pp 14–25 | Cite as

Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis

  • Victoria A. McCredieEmail author
  • Aziz S. Alali
  • Damon C. Scales
  • Neill K. J. Adhikari
  • Gordon D. Rubenfeld
  • Brian H. Cuthbertson
  • Avery B. Nathens
Original Article

Abstract

Background

The optimal timing of tracheostomy placement in acutely brain-injured patients, who generally require endotracheal intubation for airway protection rather than respiratory failure, remains uncertain. We systematically reviewed trials comparing early tracheostomy to late tracheostomy or prolonged intubation in these patients.

Methods

We searched 5 databases (from inception to April 2015) to identify randomized controlled trials comparing early tracheostomy (≤10 days of intubation) with late tracheostomy (>10 days) or prolonged intubation in acutely brain-injured patients. We contacted the principal authors of included trials to obtain subgroup data. Two reviewers extracted data and assessed risk of bias. Outcomes included long-term mortality (primary), short-term mortality, duration of mechanical ventilation, complications, and liberation from ventilation without a tracheostomy. Meta-analyses used random-effects models.

Results

Ten trials (503 patients) met selection criteria; overall study quality was moderate to good. Early tracheostomy reduced long-term mortality (risk ratio [RR] 0.57. 95 % confidence interval (CI), 0.36–0.90; p = 0.02; n = 135), although in a sensitivity analysis excluding one trial, with an unclear risk of bias, the significant finding was attenuated (RR 0.61, 95 % CI, 0.32–1.16; p = 0.13; n = 95). Early tracheostomy reduced duration of mechanical ventilation (mean difference [MD] −2.72 days, 95 % CI, −1.29 to −4.15; p = 0.0002; n = 412) and ICU length of stay (MD −2.55 days, 95 % CI, −0.50 to −4.59; p = 0.01; n = 326). However, early tracheostomy did not reduce short-term mortality (RR 1.25; 95 % CI, 0.68–2.30; p = 0.47 n = 301) and increased the probability of ever receiving a tracheostomy (RR 1.58, 95 % CI, 1.24–2.02; 0 < 0.001; n = 377).

Conclusions

Performing an early tracheostomy in acutely brain-injured patients may reduce long-term mortality, duration of mechanical ventilation, and ICU length of stay. However, waiting longer leads to fewer tracheostomy procedures and similar short-term mortality. Future research to explore the optimal timing of tracheostomy in this patient population should focus on patient-centered outcomes including patient comfort, functional outcomes, and long-term mortality.

Keywords

Acute brain injury Early tracheostomy Tracheostomy timing Prolonged endotracheal intubation Mortality 

Notes

Acknowledgments

We would like to thank Duncan Young (Adult Intensive Care Unit, John Radcliffe Hospital, University of Oxford, Oxford, England), François Blot (G. Nitenberg Intensive Care Unit, Gustave Roussy Institute, Villejuif, Paris, France), Julian Bösel (Department of Neurology, University of Heidelberg, Heidelberg, Germany), Agnes Laplanche (Service de Biostatistique et d’Epidemiologie, Gustave Roussy Institute, Villejuif, Paris, France), V. Marco Ranieri (Department of Anesthesia, University of Turin, Turin, Italy), and Akram M. Fayed (Department of Critical Care Medicine, Faculty of Medicine, University of Alexandria, Egypt) for generously providing us with additional subgroup information and clarification regarding their published trials.

Authors’ Contributions

V.A.M. contributed to the literature search, study design, data analysis, data interpretation, writing, critical revision, and final approval. A.A.A. contributed to the study design, data interpretation, critical revision, and final approval. N.K.J.A. contributed to the study design, data interpretation, critical revision, and final approval. D.C.S. contributed to data interpretation, critical revision, and final approval. G.D.R. contributed to the study design, data interpretation, critical revision, and final approval. B.H.C. contributed to the study design, data interpretation, critical revision, and final approval. A.B.N. contributed to the study design, data analysis, data interpretation, writing, critical revision, and final approval.

Funding

A.B.N. and this work were supported in part by the DeSouza Chair in Trauma Research. D.C.S. was supported by a Fellowship in Translational Health Research from the Physicians’ Services Incorporated Foundation. B.H.C. is supported by the University of Toronto, the Department of Anesthesia Merit Award. The opinions, results, and conclusions reported in this article are those of the authors. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Compliance with Ethical Standards

Conflict of Interest

The authors have no conflicts of interest to declare.

Supplementary material

12028_2016_297_MOESM1_ESM.docx (2 mb)
Supplementary material 1 (DOCX 2090 kb)

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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Victoria A. McCredie
    • 1
    Email author
  • Aziz S. Alali
    • 2
  • Damon C. Scales
    • 1
    • 2
  • Neill K. J. Adhikari
    • 1
    • 2
  • Gordon D. Rubenfeld
    • 1
    • 2
  • Brian H. Cuthbertson
    • 1
    • 2
    • 3
  • Avery B. Nathens
    • 2
    • 4
  1. 1.Department of Critical Care MedicineSunnybrook Health Sciences CentreTorontoCanada
  2. 2.Sunnybrook Research InstituteSunnybrook Health Sciences CentreTorontoCanada
  3. 3.Department of AnesthesiaUniversity of TorontoTorontoCanada
  4. 4.Department of SurgerySunnybrook Health Sciences Centre and the University of TorontoTorontoCanada

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