Early versus late tracheostomy in critically ill patients: an umbrella review of systematic reviews of randomised clinical trials with meta-analyses and trial sequential analysis.

Abstract

Objective: This study conducts an umbrella review of systematic reviews and meta-analyses of randomised clinical trials (RCTs) to evaluate the outcomes of early vs late tracheostomy, focusing on potential biases and the coherence of the evidence.

Data sources: Searches were conducted in the MEDLINE, Embase, Lilacs and Cochrane Library databases up to November 2024.

Study selection: Our analysis included studies meeting the following criteria: Population: patients admitted to intensive care units and receiving mechanical ventilation.

Intervention: early tracheostomy, as defined by the respective study.

Control: late tracheostomy, as defined by the respective study.

Primary outcomes: mortality and incidence of ventilator-associated pneumonia (VAP).

Study design: systematic reviews and meta-analysis of RCTs.

Data extraction: Two reviewers performed article inclusion, with consensus resolution by a third reviewer in case of disagreement. The quality of studies was assessed using the AMSTAR 2 tool. A random-effects meta-analysis was conducted with an algorithm based on the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) classification DATA SYNTHESIS: Out of 7664 articles identified, 60 articles were considered eligible for full-text reading, and 22 were included in the review. Most studies were rated as critically low quality. Our meta-analysis update with 19 RCTs showed a decrease in VAP (OR 0.65 (0.47 to 0.89), 95% CI; p=0.007) among early tracheostomy patients compared with late tracheostomy patients, but no significant difference in terms of mortality (OR 0.85 (0.70 to 1.03), 95% CI; p=0.09). A trial sequential analysis indicated that the current data are insufficient to reach a definitive conclusion.

Conclusion: In summary, despite extensive research on tracheostomy timing and its outcomes, as well as a correlation in our study between early tracheostomy and reduced VAP incidence, evidence remains weak. Besides that, no clear mortality benefits were observed. Further research using a different approach is crucial to identify the specific population that may derive benefits from early tracheostomy.