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



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.


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.


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).


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.


Acute brain injury Early tracheostomy Tracheostomy timing Prolonged endotracheal intubation Mortality 



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.


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)


  1. 1.
    Alali AS, Scales DC, Fowler RA, et al. Tracheostomy timing in traumatic brain injury: a propensity-matched cohort study. J Trauma Acute Care Surg. 2014;76(1):70–6 discussion 76-78.CrossRefPubMedGoogle Scholar
  2. 2.
    Pinheiro Bdo V, Tostes Rde O, Brum CI, et al. Early versus late tracheostomy in patients with acute severe brain injury. J Bras Pneumol. 2010;36(1):84–91.CrossRefPubMedGoogle Scholar
  3. 3.
    Gandia-Martinez F, Martinez-Gil I, Andaluz-Ojeda D, et al. Analysis of early tracheostomy and its impact on development of pneumonia, use of resources and mortality in neurocritically ill patients. Neurocirugia. 2010;21(3):211–21.CrossRefPubMedGoogle Scholar
  4. 4.
    Wang HK, Lu K, Liliang PC, et al. The impact of tracheostomy timing in patients with severe head injury: an observational cohort study. Injury. 2012;43(9):1432–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Rizk EB, Patel AS, Stetter CM, et al. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care. 2011;15(3):481–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Andriolo BN, Andriolo RB, Saconato H, et al. Early versus late tracheostomy for critically ill patients. The Cochrane database of systematic reviews 2015;1:Cd007271.Google Scholar
  7. 7.
    Szakmany T, Russell P, Wilkes AR, et al. Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials. Br J Anaesth. 2015;114(3):396–405.CrossRefPubMedGoogle Scholar
  8. 8.
    Siempos II, Ntaidou TK, Filippidis FT, et al. Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med. 2015;3(2):150–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Bouderka MA, Fakhir B, Bouaggad A, et al. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. Journal of trauma. 2004;57(2):251–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Hoboken: Wiley; 2011.Google Scholar
  11. 11.
    Panic N, Leoncini E, de Belvis G, et al. Evaluation of the endorsement of the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement on the quality of published systematic review and meta-analyses. PLoS ONE. 2013;8(12):e83138.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Haynes RB, McKibbon KA, Wilczynski NL, et al. Optimal search strategies for retrieving scientifically strong studies of treatment from Medline: analytical survey. BMJ. 2005;330(7501):1179.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Wong SS, Wilczynski NL, Haynes RB. Developing optimal search strategies for detecting clinically sound treatment studies in EMBASE. J Med Libr Assoc. 2006;94(1):41–7.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Higgins JP, Altman DG, Gotzsche PC, et al. The cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Barquist ES, Amortegui J, Hallal A, et al. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. Journal of Trauma—Injury, Infection and Critical Care. 2006;60(1):91–7.CrossRefGoogle Scholar
  17. 17.
    Sugerman HJ, Wolfe L, Pasquale MD, et al. Multicenter, randomized, prospective trial of early tracheostomy. Journal of trauma. 1997;43(5):741–7.CrossRefPubMedGoogle Scholar
  18. 18.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88.CrossRefPubMedGoogle Scholar
  19. 19.
    Friedrich JO, Adhikari NK, Beyene J. Inclusion of zero total event trials in meta-analyses maintains analytic consistency and incorporates all available data. BMC Med Res Methodol. 2007;7:5.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58.CrossRefPubMedGoogle Scholar
  21. 21.
    Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Copas J, Shi JQ. Meta-analysis, funnel plots and sensitivity analysis. Biostatistics. 2000;1(3):247–62.CrossRefPubMedGoogle Scholar
  23. 23.
    Koch T, Hecker B, Hecker A, et al. Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study. Langenbecks Archives of Surgery. 2012;397(6):1001–8.CrossRefGoogle Scholar
  24. 24.
    Rodriguez JL, Steinberg SM, Luchetti FA, et al. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery. 1990;108(4):655–9.PubMedGoogle Scholar
  25. 25.
    Zheng Y, Sui F, Chen XK, et al. Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation. Chinese medical journal. 2012;125(11):1925–30.PubMedGoogle Scholar
  26. 26.
    Diaz-Prieto A, Mateu A, Gorriz M, et al. A randomized clinical trial for the timing of tracheotomy in critically ill patients: factors precluding inclusion in a single center study. Critical care (London, England) 2014;18(5):585.Google Scholar
  27. 27.
    Priyamvadha K, Rao S, Bundela Y, et al. Early versus late tracheostomy in critical brain injury: a prospective randomized study priyamvadha K, Rao S, Bundela Y, Gupta V, Dua S, Singh AK department of neurosciences, fortis hospitals, Noida, Delhi NCR, India. Brain Inj. 2012;26(4–5):504.Google Scholar
  28. 28.
    Rumbak MJ, Newton M, Truncale T, et al. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients.[Erratum appears in Crit Care Med. 2004 Dec; 32(12):2566]. Crit Care Med. 2004;32(8):1689–94.CrossRefPubMedGoogle Scholar
  29. 29.
    Saffle JR, Morris SE, Edelman L. Early tracheostomy does not improve outcome in burn patients. J Burn Care Rehabilitation. 2002;23(6):431–8.CrossRefGoogle Scholar
  30. 30.
    Trouillet JL, Luyt CE, Guiguet M, et al. Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial.[Summary for patients in Ann Intern Med. 2011 Mar 15;154(6):I-38; PMID: 21403060]. Ann Intern Med. 2011;154(6):373–83.CrossRefPubMedGoogle Scholar
  31. 31.
    El-Naggar M, Sadagopan S, Levine H, et al. Factors influencing choice between tracheostomy and prolonged translaryngeal intubation in acute respiratory failure: a prospective study. Anesth Analg. 1976;55(2):195–201.CrossRefPubMedGoogle Scholar
  32. 32.
    Dunham CM, LaMonica C. Prolonged tracheal intubation in the trauma patient. J Trauma. 1984;24(2):120–4.CrossRefPubMedGoogle Scholar
  33. 33.
    Sabouri Masih ETM, Hosseini Benham. The Effects of Early Tracheostomy on Outcomes of Patients with Severe Head Injury. Journal of Isfahan Medical School (IUMS) 2009;27(95):211-216.Google Scholar
  34. 34.
    Kiran Bylappa AM, Wilma Delphine Silvia CR, Dinesh Krishnamurthy, Mohammed Shabbir Pyarajan. A Comparative Study of Early and Late Tracheostomy in Patients Requiring Prolonged Tracheal Intubation. World Articles in Ear, Nose and Throat 2011;4(2).
  35. 35.
    Young D, Harrison DA, Cuthbertson BH, et al. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. Jama. 2013;309(20):2121–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA—J Amer Med Association. 2010;303(15):1483–9.CrossRefGoogle Scholar
  37. 37.
    Mohamed KAE, Mousa AY, ElSawy AS, et al. Early versus late percutaneous tracheostomy in critically ill adult mechanically ventilated patients. Egyptian J Chest Dis Tubercul. 2014;63(2):443–8.CrossRefGoogle Scholar
  38. 38.
    Dunham CM, Cutrona AF, Gruber BS, et al. Early tracheostomy in severe traumatic brain injury: evidence for decreased mechanical ventilation and increased hospital mortality. Int J Burns Trauma. 2014;4(1):14–24.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Bösel J, Schiller P, Hook Y, et al. Stroke-related Early Tracheostomy versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke; a journal of cerebral circulation. 2013;44(1):21-28.CrossRefGoogle Scholar
  40. 40.
    Blot F, Similowski T, Trouillet JL, et al. Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive Care Med. 2008;34(10):1779–87.CrossRefPubMedGoogle Scholar
  41. 41.
    Fayed AM, Elbadawy TH, Gamal MA, et al. Early gastrostomy and tracheostomy prevent ventilator associated pneumonia in traumatic brain injured patients. Intensive Care Med. 2012;38:S123.Google Scholar
  42. 42.
    Garner JS, Jarvis WR, Emori TG, et al. CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988;16(3):128–40.CrossRefPubMedGoogle Scholar
  43. 43.
    Hospital-acquired pneumonia in adults. Diagnosis, assessment of severity initial antimicrobial therapy and preventive strategies a consensus statement American Thoracic Society November 1995. Amer J Resp Criti Care Med. 1996;153(5):1711–25.CrossRefGoogle Scholar
  44. 44.
    Guidelines for the management of adults with hospital-acquired. ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.CrossRefGoogle Scholar
  45. 45.
    Griffiths J, Barber VS, Morgan L, et al. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005;330(7502):1243.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Scales DC. The implications of a tracheostomy for discharge destination. Am J Respir Crit Care Med. 2015;192(4):404–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Scales DC, Cuthbertson BH. Percutaneous dilatational tracheostomy: mostly safe, but do benefits outweigh risks? Criti care. 2014;18(2):117.CrossRefGoogle Scholar
  48. 48.
    Simon M, Metschke M, Braune SA, et al. Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. Criti care. 2013;17(5):258.CrossRefGoogle Scholar
  49. 49.
    Huang H, Li Y, Ariani F, et al. Timing of tracheostomy in critically ill patients: a meta-analysis. PLoS ONE. 2014;9(3):e92981.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Meng L, Wang C, Li J, et al. Early vs late tracheostomy in critically ill patients: a systematic review and meta-analysis. Clin Respir J. 2015. 1–6. doi: 10.1111/crj.12286.
  51. 51.
    Hosokawa K, Nishimura M, Egi M, et al. Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials. Critical care. 2015;19:424.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Unroe M, Kahn JM, Carson SS, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med. 2010;153(3):167–75.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Arling G, Ofner S, Reeves MJ, et al. Care trajectories of veterans in the 12 Months after hospitalization for acute ischemic stroke. Circ Cardiovasc Qual Outcomes. 2015;8(6 Suppl 3):S131–40.CrossRefPubMedGoogle Scholar
  54. 54.
    Mehta AB, Syeda SN, Bajpayee L, et al. Trends in tracheostomy for mechanically ventilated patients in the United States, 1993–2012. Am J Respir Crit Care Med. 2015;192(4):446–54.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Kahn JM, Benson NM, Appleby D, et al. Long-term acute care hospital utilization after critical illness. JAMA. 2010;303(22):2253–9.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    McCredie V, Alali A, Scales D, et al. Timing of tracheostomy in critically-ill acutely brain injured patients: a systematic review and meta-analysis, CRD42014010405. 2014 [cited 2015 December]
  57. 57.
    Hopewell S, McDonald S, Clarke M, et al. Grey literature in meta-analyses of randomized trials of health care interventions. Cochrane Database Syst Rev. 2007;(2):Mr000010.Google Scholar
  58. 58.
    Saatman KE, Duhaime AC, Bullock R, et al. Classification of traumatic brain injury for targeted therapies. J Neurotrauma. 2008;25(7):719–38.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Huttner HB. WEANING-Study: Weaning by Early Versus lAte Tracheostomy iN supratentorIal iNtracerebral Bleedings 2010
  60. 60.
    Daumire R. A Prospective, Randomized Trial of Early Versus Late Tracheostomy in Trauma Patients With Severe Brain Injury 2006
  61. 61.
    Inthout J, Ioannidis JP, Borm GF. Obtaining evidence by a single well-powered trial or several modestly powered trials. Statistical methods in medical research. 2016;25(2):538–52.CrossRefPubMedGoogle Scholar
  62. 62.
    Cappelleri JC, Ioannidis JP, Schmid CH, et al. Large trials vs meta-analysis of smaller trials: how do their results compare? JAMA. 1996;276(16):1332–8.CrossRefPubMedGoogle Scholar

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

Personalised recommendations