Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients: A Meta-analysis

Abstract

Importance: The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding early vs late tracheostomy placement for ventilator-associated pneumonia (VAP), ventilator days, mortality, and length of intensive care unit (ICU) hospitalization.

Objective: To compare the association of early (≤7 days) vs late tracheotomy with VAP and ventilator days in critically ill adults.

Data sources: A search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, references of relevant articles, previous meta-analyses, and gray literature from inception to March 31, 2020, was performed.

Study selection: Randomized clinical trials comparing early and late tracheotomy with any of our primary outcomes, VAP or ventilator days, were included.

Data extraction and synthesis: Two independent reviewers conducted all stages of the review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Pooled odds ratios (ORs) or the mean difference (MD) with 95% CIs were calculated using a random-effects model.

Main outcomes and measures: Primary outcomes included VAP and duration of mechanical ventilation. Intensive care unit days and mortality (within the first 30 days of hospitalization) constituted secondary outcomes.

Results: Seventeen unique trials with a cumulative 3145 patients (mean [SD] age range, 32.9 [12.7] to 67.9 [17.6] years) were included in this review. Individuals undergoing early tracheotomy had a decrease in the occurrence of VAP (OR, 0.59 [95% CI, 0.35-0.99]; 1894 patients) and experienced more ventilator-free days (MD, 1.74 [95% CI, 0.48-3.00] days; 1243 patients). Early tracheotomy also resulted in fewer ICU days (MD, -6.25 [95% CI, -11.22 to -1.28] days; 2042 patients). Mortality was reported for 2445 patients and was comparable between groups (OR, 0.66 [95% CI, 0.38-1.15]).

Conclusions and relevance: Compared with late tracheotomy, early intervention was associated with lower VAP rates and shorter durations of mechanical ventilation and ICU stay, but not with reduced short-term, all-cause mortality. These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Moreira reported receiving grants from the Parker B. Francis Foundation and the National Heart, Lung, and Blood Institute outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. PRISMA Flow Diagram

Figure 2.. Association of Early Tracheotomy With Ventilator-Associated Pneumonia

Forest plots demonstrate pooled odds ratios (ORs) and 95% CI with a random-effects model. The vertical dashed line represents the point estimate of the overall effect (as it meets with the middle of the diamond).

Figure 3.. Association of Early Tracheotomy With Duration of Mechanical Ventilation and Ventilator-Free Days

Forest plots demonstrating pooled mean differences (MDs) in days and 95% CIs with a random-effects model. NA indicates not applicable; pts, patients. The vertical dashed line represents the point estimate of the overall effect (as it meets with the middle of the diamond).

Figure 4.. Mortality Outcome in Early vs Late Tracheotomy

Forest plots demonstrating pooled odds ratios (ORs) and 95% CIs with a random-effects model. The vertical dashed line represents the point estimate of the overall effect (as it meets with the middle of the diamond).