Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis
- 2.1k Downloads
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.
KeywordsAcute 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.
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.
- 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
- 10.Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Hoboken: Wiley; 2011.Google Scholar
- 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.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.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
- 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
- 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.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). http://www.waent.org/archives/2011/Vol4-2/20111215-Tracheostomy-Intubation/late-tracheotomy.htm.
- 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
- 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.
- 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] http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014010405.
- 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
- 59.Huttner HB. WEANING-Study: Weaning by Early Versus lAte Tracheostomy iN supratentorIal iNtracerebral Bleedings 2010 https://clinicaltrials.gov/ct2/show/NCT01176214.
- 60.Daumire R. A Prospective, Randomized Trial of Early Versus Late Tracheostomy in Trauma Patients With Severe Brain Injury 2006 https://clinicaltrials.gov/ct2/show/NCT00292097.