There were no significant differences between the groups; however, there were trends to more vocal cord ulceration and subglottic inflammation in the continued intubation group. No patient was seen in this study with late vocal cord or laryngeal stenosis; there were no tracheal-innominate artery fistulae.
Seven of the patients with abnormal findings at extubation had normal 3- to 5-month postextubation laryngoscopy. Conclusion: Physician bias limited patient entry into the study. Although there were higher AIII scores in the head trauma early tracheostomy patients, there were no differences in the primary end points of ICU LOS, pneumonia, or death in any of the groups studied. Long-term endoscopic follow-up was poor, but no known late tracheal stenosis was seen.
Multicenter, randomized, prospective trial of early tracheostomy. Median critical care unit length of stay in survivors was Tracheostomy-related complications were reported for 6. Conclusions and relevance: For patients breathing with the aid of mechanical ventilation treated in adult critical care units in the United Kingdom, tracheostomy within 4 days of critical care admission was not associated with an improvement in day mortality or other important secondary outcomes.
The ability of clinicians to predict which patients required extended ventilatory support was limited. A total of nine studies [ 5 , 11 , 13 , 19 , 20 , 21 , 22 , 23 , 24 ] were selected for the systematic review Figure 1 Table 1. According to the NOS [ 16 ], the quality scores of the included studies ranged from 5 to 8. We included two randomized controlled trials [ 19 , 24 ], three observational trials [ 5 , 13 , 21 ], one cross-sectional study [ 20 ], and three retrospective cohort studies [ 11 , 22 , 23 ].
Great heterogeneity was observed in the definition of the early tracheostomy. Shibahashi et al. The cumulative z-curve crossed neither the conventional boundary for benefit nor the trial sequential futility boundary for benefit, suggesting that the current evidence was inconclusive Supplemental Figure S3.
Furthermore, we need from randomized controlled trials to assess the impact of ET on mortality. In this systematic review involving 9 studies and patients, we found that early tracheostomy, compared with late tracheostomy, might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, while an increased risk of mortality was found in the LT group.
Tracheostomy is a common procedure performed in critically ill patients. Patients with severe TBI may need prolonged MV to avoid complications such as hypoxemia and hypercapnia [ 13 ]. Robba et al. In ICU patients, tracheostomy is most commonly performed after 14 days from admission [ 27 , 28 ], and only a quarter of tracheostomies are accomplished in the first week [ 25 ].
In TBI patients, multiple factors, related to severity of neurological injury, pre- and post-hospitalization management, evolution of trauma, local medical practices, ethical and legal implications, and costs [ 5 , 25 , 29 , 30 ], play a role in the decision-making process of whether and when to perform the tracheotomy.
Literature reported a median time to tracheostomy of 9 days post-admission, probably reflecting a change in treatment goals [ 5 ] no longer aimed to manage acute intracranial emergencies, but focused on weaning from ventilator support and rehabilitation [ 5 ].
Moreover, this timing of tracheostomy also prevents the use of the procedure in patients with lesser or higher severities of injury; in the former case, patients have enough time to recover spontaneous breathing and an adequate level of consciousness, in the latter case they succumb early because of the rapid progression of the lesions [ 5 ].
This process still leads to performing tracheostomy at an earlier stage than in patients without TBI, but allows for the identification of patients who are most likely to benefit from the procedure [ 21 , 31 , 32 , 33 , 34 , 35 ].
Similarly to De Franca et al. Like other literature reports, we found that early tracheostomy may potentially reduce hospital stay, duration of mechanical ventilation and mortality rates [ 1 , 3 , 23 , 24 , 31 , 39 ].
Khalili et al. A meta-analysis by McCredie et al. While this association may suggest a benefit from an ET, patients with more severe injury may need more time to control the intracranial damage evolution and stabilize their condition, thus delaying tracheostomy, or may have a worse expected outcome, restraining the decision for the tracheostomy.
De Franca et al. We found that the LT group had an increased risk of mortality. Conversely, Lu et al. These studies showed improved outcomes for the ET groups with no survival benefit. The high mortality rate in tracheostomy patients could be related to the complications of tracheostomy e. Our results could depend on the fact that mortality in ICU is a complex outcome, taking into account different variables including age, sex, comorbidities, and the length of follow-up time.
According to this, mortality could be not driven by a single parameter like timing of tracheostomy, that is, a procedure that may allow a better management of critically ill patients. In addition, results of TSA suggested that current evidence is inconclusive and that more randomized controlled trials are necessary to assess the real impact of ET on mortality.
Despite the known advantages, there are still some controversies regarding tracheotomy in TBI. According to Cox et al.
This systematic review and meta-analysis added several novelties compared to the current literature. We included the huge study of Robba et al. Moreover, in our systematic review and meta-analysis, we carried out a sub-group analysis according to the type of the included studies RCT vs. Of note, this meta-analysis has some limitations.
First, there is the ambiguous definition of timing to differentiate an early and a late tracheostomy. Third, only published articles were reviewed, which might have contributed to a publication bias. Further studies, especially multicenter RCTs, are needed to collect more data about the different outcomes of TBI patients undergoing ET compared to those treated with LT in order to confirm the superiority of the former airway management in such a challenging clinical condition.
All authors have read and agreed to the published version of the manuscript. National Center for Biotechnology Information , U. Journal List J Clin Med v. J Clin Med. Published online Jul Rafael Badenes, Academic Editor. Author information Article notes Copyright and License information Disclaimer. Received Jul 3; Accepted Jul Associated Data Supplementary Materials jcms Abstract Introduction. Keywords: acute brain injury, early tracheostomy, late tracheostomy, tracheostomy timing, mortality, ventilatory acquired pneumonia.
Introduction Traumatic brain injury TBI is a complex disorder which can affect the central nervous system, leading to temporary or permanent physical, cognitive, and psychosocial impairments [ 1 ].
Data Extraction Two reviewers A. In addition, there is no reliable means of predicting the likely length of mechanical ventilation. The differences in tracheotomy rates between the early and late group were much larger in the predefined group of studies comparing within 4 days versus after 10 days than that comparing within 10 versus after 10 days.
Our results showed that early tracheotomy was associated with a larger number of VFDs in the group of studies comparing tracheotomy within 10 versus after 10 days.
This seems to contradict the policy that tracheotomy should be delayed until after 14 days [ 7 ], but does support several reviews that suggest that the need for tracheotomy should be assessed on a daily basis with a definite decision being taken as early as 4—7 days after endotracheal intubation [ 9 , 45 , 46 ].
As in previous meta-analyses [ 20 , 21 ], early tracheotomy was associated with a shorter duration of sedation. Some [ 47 — 49 ], but not all [ 50 ], retrospective observational studies have also reported that early tracheotomy allows a shorter duration of sedation. These differences may be related to the sedation strategies used in these studies. Our analysis has several limitations. First, there was marked heterogeneity among studies for some of the outcome measures, likely related to the diverse patient groups and characteristics and the different timings of tracheotomy, which are inherent in all systematic reviews on this topic, and the fact that respiratory management may have changed between and , the dates of publication of the included studies.
Second, early tracheotomy may be particularly beneficial in selected groups of patients, such as those with head or spinal cord injury or massive stroke [ 6 , 51 ], but our meta-analysis could not address this question. Third, adverse effects and cost-effectiveness were not assessed.
This updated meta-analysis reveals that early tracheotomy is associated with a significantly higher rate of tracheotomy and a larger number of VFDs, shorter ICU stays, shorter duration of sedation and lower long-term mortality rates than late tracheotomy. The assessment restricted to groups of studies with different time cutoffs did not provide enough information to be able to draw conclusions about differences between very early within 4 days and moderately early within 10 days tracheotomy.
Early tracheotomy was associated with significantly higher rates of tracheotomy than late tracheotomy. Early tracheotomy is associated with a larger number of VFDs, shorter ICU stays, shorter duration of sedation and lower long-term mortality rates than late tracheotomy.
In the group of studies that compared tracheotomy within 10 versus after 10 days, early tracheotomy was associated with more VFDs than late tracheotomy. West JB. The physiological challenges of the Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology. J Appl Physiol. PubMed Google Scholar. Blood gas analysis and critical care medicine. Heffner JE. Medical indications for tracheotomy. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients.
Changes in respiratory mechanics after tracheostomy. Arch Surg. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. Respir Care. Tracheostomy practice in adults with acute respiratory failure. Crit Care Med. Tracheostomy in the intensive care unit. Part 1: Indications, technique, management.
Tracheostomy in critically ill patients. Mayo Clin Proc. Epstein SK. Late complications of tracheostomy. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of critically ill adult patients. Am J Med. Consensus conference on artificial airways in patients receiving mechanical ventilation. Early versus late tracheostomy in patients who require prolonged mechanical ventilation.
Am J Crit Care. Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation.
A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation delayed tracheotomy in critically ill medical patients. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial.
Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial. Ann Intern Med. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial.
Early versus late tracheostomy in critically ill patients: a systematic review and meta-analysis. Clin Respir J. Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials.
Br J Anaesth. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 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.
0コメント