Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece; Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medical College, New York, NY, USA.
First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece.
Lancet Respir Med. 2014 Jun 26. doi: 10.1016/S2213-2600(14)70125-0.
Delay of tracheostomy for roughly 2 weeks after translaryngeal intubation of critically ill patients is the presently recommended practice and is supported by findings from large trials. However, these trials were suboptimally powered to detect small but clinically important effects on mortality. We aimed to assess the mortality benefit of early versus late or no tracheostomy in critically ill patients who need mechanical ventilation.
We systematically searched PubMed, CINAHL, Embase, Web of Science, DOAJ, the Cochrane Library, references of relevant articles, scientific conference proceedings, and grey literature up to Aug 31, 2013, to identify randomised controlled trials comparing early tracheostomy (done within 1 week after translaryngeal intubation) with late (done any time after the first week of mechanical ventilation) or no tracheostomy and reporting on mortality or incidence of pneumonia in critically ill patients under mechanical ventilation. Our primary outcomes were all-cause mortality during the stay in the intensive-care unit and incidence of ventilator-associated pneumonia. We calculated pooled odds ratios (OR), pooled risk ratios (RR), and 95% CIs with a random-effects model. All but complications analyses were done on an intention-to-treat basis.
Analyses of 13 trials (2434 patients, 800 deaths) showed that all-cause mortality in the intensive-care unit was significantly lower in patients assigned to the early versus the late or no tracheostomy group (OR 0·72, 95% CI 0·53-0·98; p=0·04). This finding represents an 18% reduction in the relative risk of death, translating to a 5% absolute improvement in survival (from 65% to 70%). This result persisted when we considered only trials with a low risk of bias (663 deaths; OR 0·68, 95% CI 0·49-0·95; p=0·02; eight trials with 1934 patients). There was no evidence of a difference between the compared groups for 1-year mortality (788 deaths; RR 0·93, 95% CI 0·85-1·02; p=0·14; three trials with 1529 patients).
The synthesised evidence suggests that early tracheostomy is associated with lower mortality in the intensive-care unit than late or no tracheostomy; a finding that might question the present practice of delaying tracheostomy beyond the first week after translaryngeal intubation in mechanically ventilated patients. However, the scarcity of a beneficial effect on long-term mortality and the potential complications associated with tracheostomy need careful consideration; thus, further studies focusing on long-term outcomes are warranted.
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在接受经鼻气管插管的危重病患者中，大约 2 周后行气管切开术是目前推荐的做法，并得到了大型试验的支持。然而，这些试验的效力不足以检测到对死亡率有较小但临床意义的影响。我们旨在评估早期与晚期或无气管切开术对需要机械通气的危重病患者的死亡率的益处。
我们系统地检索了 PubMed、CINAHL、Embase、Web of Science、DOAJ、Cochrane 图书馆、相关文章的参考文献、科学会议录和灰色文献，截至 2013 年 8 月 31 日，以确定比较早期气管切开术（在经鼻气管插管后 1 周内进行）与晚期（在机械通气的第一周后任何时间进行）或无气管切开术并报告死亡率或危重病患者机械通气下肺炎发生率的随机对照试验。我们的主要结局是重症监护病房住院期间的全因死亡率和呼吸机相关性肺炎的发生率。我们使用随机效应模型计算了汇总优势比（OR）、汇总风险比（RR）和 95%置信区间（CI）。除并发症分析外，所有分析均基于意向治疗。
对 13 项试验（2434 名患者，800 例死亡）的分析表明，与晚期或无气管切开术组相比，早期气管切开术组的重症监护病房全因死亡率显著降低（OR 0.72，95%CI 0.53-0.98；p=0.04）。这一发现代表相对死亡风险降低了 18%，这意味着生存率提高了 5%（从 65%提高到 70%）。当我们仅考虑偏倚风险较低的试验时（663 例死亡；OR 0.68，95%CI 0.49-0.95；p=0.02；8 项试验，1934 名患者），这一结果仍然存在。两组间 1 年死亡率无差异（788 例死亡；RR 0.93，95%CI 0.85-1.02；p=0.14；3 项试验，1529 名患者）。
综合证据表明，与晚期或无气管切开术相比，早期气管切开术与重症监护病房死亡率降低相关；这一发现可能质疑目前在接受机械通气的患者中延迟至经鼻气管插管后第一周以上行气管切开术的做法。然而，气管切开术对长期死亡率的有益影响以及与气管切开术相关的潜在并发症需要仔细考虑；因此，有必要进行进一步关注长期结局的研究。
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