Chest
Volume 140, Issue 6, December 2011, Pages 1456-1465
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Original Research
Critical Care
The Timing of Tracheotomy in Critically Ill Patients Undergoing Mechanical Ventilation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

https://doi.org/10.1378/chest.11-2024Get rights and content

Background

The objective of this study was to systematically review and quantitatively synthesize all randomized controlled trials (RCTs), comparing important outcomes in ventilated critically ill patients who received an early or late tracheotomy.

Methods

A systematic literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Central Register of Controlled Trials, the National Research Register, the National Health Service Trusts Clinical Trials Register, and the Medical Research Council UK database was conducted using specific search terms. Eligible studies were RCTs that compared early tracheotomy (ET) with either late tracheotomy or prolonged endotracheal intubation in critically ill adult patients.

Results

Seven trials with 1,044 patients were analyzed. ET did not significantly reduce short-term mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.13), long-term mortality (RR, 0.84; 95% CI, 0.68-1.04), or incidence of ventilator-associated pneumonia (RR, 0.94; 95% CI, 0.77-1.15) in critically ill patients. The timing of the tracheotomy was not associated with a markedly reduced duration of mechanical ventilation (MV) (weighted mean difference [WMD], −3.90 days; 95% CI, −9.71-1.91) or sedation (WMD, −7.09 days; 95% CI, −14.64-0.45), shorter stay in ICU (WMD, −6.93 days; 95% CI, −16.50-2.63) or hospital (WMD, 1.45 days; 95% CI, −5.31-8.22), or more complications (RR, 0.94; 95% CI, 0.66-1.34).

Conclusions

The present meta-analysis suggested that the timing of the tracheotomy did not significantly alter important clinical outcomes in critically ill patients. The duration of MV and sedation, as well as the long-term outcomes of ET in mechanically ventilated patients, should be evaluated in rigorously designed and adequately powered RCTs in the future.

Section snippets

Search Strategy

In reporting our results, we followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.16 Relevant articles in all languages were identified by searching PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Central Register of Controlled Trials, the National Research Register, the National Health Service Trusts Clinical Trials Register, and the Medical Research Council UK database (up to July 10, 2011). Electronic

Study Identification

The comprehensive search yielded a total of 1,212 relevant publications, and the abstracts were obtained for all citations (Fig 1). Seven RCTs with a total of 1,044 patients met the inclusion criteria.4, 14, 15, 20, 21, 22, 23 The Cohen κ statistic for agreement on study inclusion was 0.92.

Among the seven trials, three were conducted in North America,4, 14, 20 three in Europe,15, 22, 23 and one in North Africa.21 Three trials were multicenter studies.4, 15, 22 All trials were published in

Discussion

Our meta-analysis suggested that ET did not significantly reduce short- or long-term mortality or incidence of VAP in critically ill patients. In addition, the present study showed that ET was not associated with a markedly reduced duration of MV or sedation, shorter stay in ICU or hospital, or more complications.

Differences between the current meta-analysis and a previous one by Griffiths et al13 should be noted. In their meta-analysis,13 five trials with a total of 406 patients were included,

Conclusions

Our meta-analysis suggested that the timing of tracheotomy did not significantly alter important clinical outcomes in critically ill patients. A sensitive and validated formula to identify early those who need prolonged MV in the global increasing population of intubated critically ill patients is warranted. In addition, the duration of MV and sedation, as well as the long-term costs of ET in mechanically ventilated patients, should be evaluated in rigorously designed and adequately powered

Acknowledgments

Author contributions: Drs Li and Deng had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Wang: contributed to the definition of inclusion and exclusion criteria, electronic and manual search of the literature, drafting and revision of the manuscript, study design, and analysis and interpretation of the data.

Dr Wu: contributed to the definition of inclusion and exclusion criteria, electronic and manual

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    Drs Wang, Wu, and Bo contributed equally to this article. Drs Deng and Li were considered senior authors.

    Funding/Support: The authors have reported to CHEST that no funding was received for this study.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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