Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis.
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.
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, M4N 3M5, Canada. Victoria.McCredie@sunnybrook.ca.
Victoria A
VA
McCredie
Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, M4N 3M5, Canada.
Aziz S
AS
Alali
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, M4N 3M5, Canada.|Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, M4N 3M5, Canada.
Damon C
DC
Scales
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, M4N 3M5, Canada.|Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, M4N 3M5, Canada.
Neill K J
NK
Adhikari
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, M4N 3M5, Canada.|Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, M4N 3M5, Canada.
Gordon D
GD
Rubenfeld
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, M4N 3M5, Canada.|Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, M4N 3M5, Canada.|Department of Anesthesia, University of Toronto, Toronto, Canada.
Brian H
BH
Cuthbertson
Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, M4N 3M5, Canada.|Department of Surgery, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Canada.
Avery B
AB
Nathens
D001930:Brain Injuries / Q000401:mortality / Q000628:therapy*; D016638:Critical Illness / Q000628:therapy*; D006801:Humans; D014139:Tracheostomy / Q000379:methods* / Q000592:standards
Acute brain injury; Early tracheostomy; Mortality; Prolonged endotracheal intubation; Tracheostomy timing