From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas.
Department of Life Science, University of Toronto, Toronto, Ontario, Canada.
Anesth Analg. 2021 Feb 1;132(2):384-394. doi: 10.1213/ANE.0000000000005212.
Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy.
We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD).
Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24-3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, -19.18 to -7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, -24.33 to -12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32-1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted.
Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term outcomes of tracheostomy timing following acute SCI.
急性创伤性脊髓损伤 (SCI) 常导致呼吸功能障碍，继而出现肺部功能障碍、感染风险增加和死亡等并发症。目前，对于急性 SCI 患者，气管切开术的最佳时机仍不清楚。本系统评价和荟萃分析旨在评估 SCI 患者气管切开术的最佳时机，并评估早期与晚期气管切开术的潜在获益。
我们检索了 Medline、PubMed、Embase、Cochrane 中心、Cochrane 系统评价数据库和 PsycINFO 以获取已发表的研究。我们纳入了接受早期或晚期气管切开术并比较结局的成人 SCI 患者的研究。此外，排除了同时伴有创伤性脑损伤的研究。两名评审员独立提取数据并将其复制到 R 软件中进行分析。采用随机效应荟萃分析来估计汇总优势比 (OR) 或均数差值 (MD)。
共有 8 项研究，总计 1220 例患者符合纳入标准。早期和晚期气管切开术组的平均年龄和性别相似。大多数研究在损伤或气管插管后 7 天内进行早期气管切开术。颈段 SCI 患者行早期气管切开术的可能性是胸段 SCI 患者的两倍 (OR = 2.13；95%置信区间 [CI]，1.24-3.64；P =.006)。与晚期气管切开术相比，早期气管切开术可使重症监护病房 (ICU) 住院时间缩短 13 天 (95% CI，-19.18 至 -7.00；P =.001)，机械通气时间缩短 18.30 天 (95% CI，-24.33 至 -12.28；P =.001)。尽管与晚期气管切开术相比，早期气管切开术的院内死亡率较低，但结果无统计学意义 (OR = 0.56；95% CI，0.32-1.01；P =.054)。在亚组分析中，早期气管切开术组的死亡率显著降低 (OR = 0.27；P =.006)。最后，早期和晚期气管切开术组的肺炎发生率无差异。
基于现有数据，与晚期气管切开术相比，损伤或气管插管后 7 天内进行早期气管切开术的患者颈段 SCI 发生率更高、ICU 住院时间更短、机械通气时间更短。早期气管切开术可能降低院内死亡率风险。然而，由于研究质量和现有临床数据不足，难以得出明确的结论。需要开展更大规模的前瞻性试验，以充分评估急性 SCI 后气管切开术时机对短期和长期结局的影响。
