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Conflict of interest
Please cite this paper as: Meng
Meng L, Wang C, Li J and
L,Wang and Zhang
Zhang J.J. Early
Early vs
vs late
latetracheos-
tracheos- The authors have stated explicitly that there
tomy in critically
critically ill patients:
patients: aa systematic
systematic review
review and
and meta-analysis.
meta-analysis. ClinClin Respir
Respir JJ are no conflicts of interest in connection with
2015; 10:
2016; ••: ••–••. DOI:10.1111/crj.12286.
684–692. DOI:10.1111/crj.12286. this article.
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VC 2015 John Wiley & Sons Ltd
© 2015 John Wiley & Sons Ltd
Meng et al.
Tracheostomy, meta-analysis Tracheostomy, meta-analysis
Meng et al.
Table 1. Search terms and strategy on PubMed vious meta-analyses were examined as a further search
#1 (((tracheostomy) OR tracheotomy) OR tracheostomies) tool to find additional studies.
OR tracheotomies
#2 ((early) OR late) OR timing
#3 (((((Mechanical) OR Ventilation) OR Ventilator) OR
Inclusion and exclusion criteria
artificial)) OR airway Studies were eligible for the analysis if they met all of
#4 Humans[Mesh] the following inclusion criteria: (i) RCTs; (ii) there was
#5 #1 AND #2 AND #3 AND #4 no limit to the procedure of tracheostomy; (iii)
patients were assigned to the ET group or the LT group
(we defined ET as a tracheostomy that was performed
application of tracheostomy because it can be per- within 10 days after translaryngeal intubation; con-
formed by intensive care physicians at the bedside. versely, LT was performed more than 10 days after
A consensus conference recommended trans- translaryngeal intubation); (iv) studies should contain
laryngeal intubation for patients need of the artificial one of the following outcomes at least: mortality, dura-
airway up to 10 days and performing tracheostomy tion of MV, duration of sedation, length of ICU stay
after 21 days of intubation (9). But the timing of tra- and incidence of VAP.
cheostomy is still debated. Studies were excluded if they met one of the follow-
Four meta-analyses have been published in English ing exclusion reasons: (i) the studies were quasi-RCTs;
regarding the relationship between the timing of tra- (ii) ET was performed more than 10 days after
cheostomy and the prognosis of patients (10–13). All translaryngeal intubation or LT was performed within
of these meta-analyses compared early tracheostomy 10 days after translaryngeal intubation; (iii) the data
(ET) with late tracheostomy (LT) or PI to assess the were incomplete.
influence of timing of tracheostomy on the mortality, Two authors screened the search results following
the duration of MV and ICU stay and other clinical inclusion and exclusion criteria independently.
outcomes. Gomes Silva Brenda et al. (14) in 2012
excluded studies compared ET with PI and only Data extraction, quality and
reviewed studies compared ET with LT. But they only risk-of-bias assessment
enrolled three randomized controlled trials (RCTs)
and could not pool data in a meta-analysis because of For quality assessment and statistical analysis, two
clinical, methodological and statistical heterogeneity authors independently extracted the following data:
between the included studies. After Gomes Silva Bren- first author, publication year, number of patients,
da’s meta-analysis, several new RCTs have been pub- approach of tracheostomy (PDT or ST), clinical
lished concerning the comparison of the prognosis of outcome data, definition of VAP and Jadad score (17)
critically ill patients who underwent ET with LT (1, 5, of methodological quality of the study. The primary
15, 16). We undertook a systematic review and meta- outcome was mortality. The secondary outcomes were
analysis of RCTs to investigate the effects of ET vs LT incidence of VAP, duration of MV and sedation, and
on clinical outcomes in critically ill patients. length of ICU. Mortality was defined as hospital mor-
tality or mortality in 30 days.
We used the Jadad 5-point scale to evaluate the
Materials and methods methodological quality of the included studies. The
studies were regarded to be of high quality if the Jadad
Search strategy
score was equal or higher than 3 points and low quality
To find relevant studies for this meta-analysis, a search if the score was equal or lower than 2 points.
of PubMed (Table 1), EMBASE and the Cochrane Additionally, we also assess the risk-of-bias studies
Library was carried out by two authors independently with the method recommended by a Cochrane Col-
from inception to April 2014. No limits for language, laboration tool.
gender, sample size and place of study origin were
entered for the search. Boolean operators (AND, OR,
Statistical analysis
NOT) were used to narrow and widen the search
results. The titles and the abstracts from the search Differences were expressed as relative risks (RRs) with
results were examined closely and were determined to 95% confidence intervals (CIs) for dichotomous out-
be suitable for potential inclusion into the study. In comes, and weighted mean differences (WMDs) with
addition, the references from selected articles and pre- 95% CIs for continuous outcomes. Heterogeneity was
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Table 2. Summary characteristics of the included studies
V
The
Surgical
Meng
Study/year published ICU setting approach ET group LT group Outcomes VAP definition
Mohamed et al. 2014 (5) ICU PDT Within 10 days After 10 days Not reported
et al.
①②③⑤
Young et al. 2013 (16) 70 adult general and 2 PDT/ST Within 4 days After 10 days ① Not reported
Tracheostomy,
cardiothoracic CCUs
Zheng et al. 2012 (1) Surgical ICU PDT Day 3 of MV Day 15 of MV ①②④ Using the modified CPIS.
Trouillet et al. 2011 (15) Postcardiac surgery ICU PDT Before 5 days after surgery 15 days after MV ①②③④⑤ Clinical features with positive
Terragni et al. 2010 (25) 12 ICUs PDT After 6–8 days of intubation After 13–15 days of ①② Using the modified CPIS.
intubation
Blot et al. 2008 (27) 25 Medical or surgical ICUs PDT/ST Within 4 days After 14 days of intubation ①② Clinical features with positive
BAL cultures
Barquist et al. 2006 (28) Trauma center ICU ST Before day 8 After day 28 ①②⑤ CDC criteria
Rumbak et al. 2004 (6) 3 Medical ICUs PDT Within 48 h Days 14–16 of MV ①②③④⑤ Clinical features with positive
BAL, bronchoalveolar lavage; ICU, intensive care unit; MV, mechanical ventilation; VAP, ventilator-associated pneumonia; CPIS, Clinical Pulmonary Infection Score; CDC, Centers for Disease Control
and Prevention; ET, early tracheotomy; LT, late tracheotomy; PI, prolonged intubation; PDT, percutaneous dilatational tracheostomy; ST, surgery technique; BAL, bronchoalveolar lavage.
① mortality; ② incidence of VAP; ③ duration of MV; ④ duration of sedation; ⑤ length of ICU stay.
687
© 2015 John Wiley & Sons Ltd
Meng et al.
2002 (26)
Sensitivity analyses
We performed sensitivity analyses to explore the
potential sources of heterogeneity. Exclusion of the
study by Rumbak et al. (6) resolved the heterogeneity
in duration of sedation (P for heterogeneity = 0.56;
I2 = 0%). Exclusion of the study by Rumbak et al. (6)
and Mohamed et al. (5) resolved the heterogeneity in
the length of ICU (P for heterogeneity = 0.57; I2 = 0%).
Figure 3. Risk-of-bias summary: review authors’ judgments We found that result of duration of sedation and the
about each risk-of-bias item for each included study. length of ICU stay had not been significantly changed.
688
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C 2015 John Wiley & Sons Ltd
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Meng et al.
Tracheostomy, meta-analysis Tracheostomy, meta-analysis
Meng et al.
Figure 4. Forest plot shows the comparison of the mortality between the ET group and the LT group. CI, confidence interval; df,
degrees of freedom; ET, early tracheotomy; LT, late tracheotomy; M-H, Mantel–Haenszel.
Using mortality as an endpoint, the funnel plot did not But two studies enrolled in Griffiths’ meta-analysis
suggest the significant presence of publication bias were quasi-RCTs and might produce selection bias.
(Fig. 9). The later three meta-analyses (10, 12, 13) enrolled
RCTs showed no significant difference in the mortality,
duration of MV, length of ICU and incidence of VAP.
Discussion
We excluded the studies that compared ET with PI and
There have been four meta-analyses published in included the newest study published by Mohamed
English to elaborate the relationship between the et al. to further compare the ET with LT.
timing of tracheostomy and the prognosis of patients With advances and improvements in critical care
(10–13). All of these meta-analyses compared ET with medicine, more patients survived the initial episodes of
LT or PI to assess the influence of timing of tracheos- critical illness, such as acute respiratory failure, trauma
tomy on the mortality, the duration of MV and ICU and extensive surgeries, and required prolonged MV.
stay and other clinical outcomes. The meta-analysis, So, there were more patient in need of tracheostomy to
published by Griffiths et al. (11), showed that ET could replace the translaryngeal intubation in the ICU. There
reduce the duration of MV and the length of ICU stay. was no consistency about timing of the tracheotomy.
Figure 5. Forest plot shows the comparison of incidence of ventilator-associated pneumonia between the ET group and the LT
group. CI, confidence interval; df, degrees of freedom; ET, early tracheotomy; LT, late tracheotomy; M-H, Mantel–Haenszel.
Figure 6. Forest plot shows the comparison of duration of mechanical ventilation between the ET group and the LT group. CI,
confidence interval; df, degrees of freedom; ET, early tracheotomy; LT, late tracheotomy; M-H, Mantel–Haenszel.
In a nationwide survey in 455 German ICUs, Kluge VAP, duration of MV and length of ICU stay. Signifi-
et al. (29) found that 68.2% of tracheostomies were cant heterogeneity was observed among these studies,
performed during the second week of MV and 21.7% except the pooled analysis of mortality. The heteroge-
of tracheostomies were performed during the first neity could be caused by differences in several aspects.
week. An international utilization review in 412 The inclusion and exclusion criteria differed across
medical-surgical ICUs, Esteban et al. (30) reported that the studies. Only one study (26) described the method
tracheostomies were performed at a median period of to predict which patient would require prolonged
11 days after intubation. Thus, we defined ET as tra- ventilation, and such formula applicable to the general
cheotomy performed within 10 days after intubation in population had yet to be produced and validated. A
our meta-analysis. sensitive and validated formula to identify early those
We investigated the influence of important clinical who need prolonged MV is warranted in the future. In
outcomes in critically ill patients who received ET or the study of Rumbak et al. (6), the patients were moved
LT during their treatment. Meta-analysis showed that out of intensive care once the airway was secured and
ET did not significantly reduce mortality, incidence of the patients were hemodynamically stable. This study
Figure 7. Forest plot shows the comparison of duration of sedation between the ET group and the LT group. CI, confidence interval;
df, degrees of freedom; ET, early tracheotomy; LT, late tracheotomy; M-H, Mantel–Haenszel.
Figure 8. Forest plot shows the comparison of length of ICU stay between the ET group and the LT group. CI, confidence interval;
df, degrees of freedom; ET, early tracheotomy; LT, late tracheotomy; M-H, Mantel–Haenszel.
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Meng et al.
Tracheostomy, meta-analysis Tracheostomy, meta-analysis
Meng et al.
attributed to the heterogeneity in the analysis of mor- scores of two studies (5, 6) were 2, and there was con-
tality and length of ICU stay. The definition of pneu- siderable heterogeneity in our outcomes described
monia was different across the included studies. Two above.
studies adopted the Centers for Disease Control and
Prevention criteria, three studies defined pneumonia
based on clinical features with positive cultures of pul- Conclusion
monary secretion samples and other two studies used
the simplified Clinical Pulmonary Infection Score In summary, our meta-analysis suggested that trache-
(CPIS) to diagnose pneumonia if CPIS was larger than ostomy, performed within 10 days after translaryngeal
6 (Table 2). The difference of definition might attrib- intubation in critically ill patients, might be able to
ute to the heterogeneity in the analysis of incidence of reduce the duration of sedation. But compared with
VAP. A unified diagnosis of pneumonia should be LT, ET did not reduce mortality, incidence of VAP,
designed in future RCTs. Our meta-analysis indicated duration of MV and length of ICU stay.
that ET could reduce the duration of sedation. This
result might be related to the advantages of tracheos-
tomy such as improved patient comfort. But there were References
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