Griffith University School of Medicine, Gold Coast, Queensland, Australia.
Critical Care Research Group, The Prince Charles Hospital, Chermside, Queensland, Australia.
Crit Care. 2023 Apr 1;27(1):132. doi: 10.1186/s13054-023-04417-6.
Stroke patients requiring mechanical ventilation often have a poor prognosis. The optimal timing of tracheostomy and its impact on mortality in stroke patients remains uncertain. We performed a systematic review and meta-analysis of tracheostomy timing and its association with reported all-cause overall mortality. Secondary outcomes were the effect of tracheostomy timing on neurological outcome (modified Rankin Scale, mRS), hospital length of stay (LOS), and intensive care unit (ICU) LOS.
We searched 5 databases for entries related to acute stroke and tracheostomy from inception to 25 November 2022. We adhered to PRISMA guidance for reporting systematic reviews and meta-analyses. Selected studies included (1) ICU-admitted patients who had stroke (either acute ischaemic stroke, AIS or intracerebral haemorrhage, ICH) and received a tracheostomy (with known timing) during their stay and (2) > 20 tracheotomised. Studies primarily reporting sub-arachnoid haemorrhage (SAH) were excluded. Where this was not possible, adjusted meta-analysis and meta-regression with study-level moderators were performed. Tracheostomy timing was analysed continuously and categorically, where early (< 5 days from initiation of mechanical ventilation to tracheostomy) and late (> 10 days) timing was defined per the protocol of SETPOINT2, the largest and most recent randomised controlled trial on tracheostomy timing in stroke patients.
Thirteen studies involving 17,346 patients (mean age = 59.8 years, female 44%) met the inclusion criteria. ICH, AIS, and SAH comprised 83%, 12%, and 5% of known strokes, respectively. The mean time to tracheostomy was 9.7 days. Overall reported all-cause mortality (adjusted for follow-up) was 15.7%. One in five patients had good neurological outcome (mRS 0-3; median follow-up duration was 180 days). Overall, patients were ventilated for approximately 12 days and had an ICU LOS of 16 days and a hospital LOS of 28 days. A meta-regression analysis using tracheostomy time as a continuous variable showed no statistically significant association between tracheostomy timing and mortality (β = - 0.3, 95% CI = - 2.3 to 1.74, p = 0.8). Early tracheostomy conferred no mortality benefit when compared to late tracheostomy (7.8% vs. 16.4%, p = 0.7). Tracheostomy timing was not associated with secondary outcomes (good neurological outcome, ICU LOS and hospital LOS).
In this meta-analysis of over 17,000 critically ill stroke patients, the timing of tracheostomy was not associated with mortality, neurological outcomes, or ICU/hospital LOS.
PROSPERO-CRD42022351732 registered on 17th of August 2022.
需要机械通气的中风患者预后通常较差。中风患者气管切开术的最佳时机及其对死亡率的影响仍不确定。我们进行了一项系统评价和荟萃分析，探讨了气管切开术的时机及其与报告的全因总死亡率之间的关系。次要结局是气管切开术时机对神经功能结局（改良 Rankin 量表，mRS）、住院时间（LOS）和重症监护病房（ICU） LOS 的影响。
我们从成立到 2022 年 11 月 25 日在 5 个数据库中搜索与急性中风和气管切开术相关的条目。我们遵循 PRISMA 指南报告系统评价和荟萃分析。纳入的研究包括（1）入住 ICU 的中风患者（急性缺血性中风，AIS 或颅内出血，ICH），并在入住期间接受了气管切开术（已知时机）；（2）气管切开术患者>20 例。主要报告蛛网膜下腔出血（SAH）的研究被排除在外。如果不可能，将进行调整后的荟萃分析和基于研究水平的调节因素的荟萃回归分析。气管切开术时机连续和分类分析，SETPOINT2 协议中定义早期（机械通气开始至气管切开术的时间<5 天）和晚期（>10 天），SETPOINT2 是最大和最新的中风患者气管切开术时机的随机对照试验。
13 项研究涉及 17346 例患者（平均年龄 59.8 岁，女性 44%）符合纳入标准。ICH、AIS 和 SAH 分别占已知中风的 83%、12%和 5%。气管切开术的平均时间为 9.7 天。总体报告的全因死亡率（随访调整后）为 15.7%。五分之一的患者有良好的神经功能结局（mRS 0-3；中位随访时间为 180 天）。总体而言，患者接受通气治疗约 12 天，ICU LOS 为 16 天，医院 LOS 为 28 天。使用气管切开术时间作为连续变量的荟萃回归分析显示，气管切开术时机与死亡率之间无统计学显著关联（β=-0.3，95%CI=-2.3 至 1.74，p=0.8）。与晚期气管切开术相比，早期气管切开术并没有带来死亡率的获益（7.8% vs. 16.4%，p=0.7）。气管切开术时机与次要结局（良好的神经功能结局、ICU LOS 和医院 LOS）无关。
在这项对 17000 多名重症中风患者的荟萃分析中，气管切开术的时机与死亡率、神经功能结局或 ICU/医院 LOS 无关。
PROSPERO-CRD42022351732 于 2022 年 8 月 17 日注册。
Zotero 插件
