Merola Raffaele, Iacovazzo Carmine, Troise Stefania, Marra Annachiara, Formichella Antonella, Servillo Giuseppe, Vargas Maria
Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy.
Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy.
Life (Basel). 2024 Sep 14;14(9):1165. doi: 10.3390/life14091165.
The ideal timing for tracheostomy in critically ill patients is still debated. This systematic review and meta-analysis examined whether early tracheostomy improves clinical outcomes compared to late tracheostomy or prolonged intubation in critically ill patients on mechanical ventilation. We conducted a comprehensive search of randomized controlled trials (RCTs) assessing the risk of clinical outcomes in intensive care unit (ICU) patients who underwent early (within 7-10 days of intubation) versus late tracheostomy or prolonged intubation. Databases searched included PubMed, Embase, and the Cochrane Library up to June 2023. The primary outcome evaluated was mortality, while secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), ICU length of stay, and duration of mechanical ventilation. No language restriction was applied. Eligible studies were RCTs comparing early to late tracheostomy or prolonged intubation in critically ill patients that reported on mortality. The risk of bias was evaluated using the Cochrane Risk of Bias Tool for RCTs, and evidence certainty was assessed via the GRADE approach. This systematic review and meta-analysis included 19 RCTs, covering 3586 critically ill patients. Early tracheostomy modestly decreased mortality compared to the control (RR -0.1511 [95% CI: -0.2951 to -0.0070], = 0.0398). It also reduced ICU length of stay (SMD -0.6237 [95% CI: -0.9526 to -0.2948], = 0.0002) and the duration of mechanical ventilation compared to late tracheostomy (SMD -0.3887 [95% CI: -0.7726 to -0.0048], = 0.0472). However, early tracheostomy did not significantly reduce the duration of mechanical ventilation compared to prolonged intubation (SMD -0.1192 [95% CI: -0.2986 to 0.0601], = 0.1927) or affect VAP incidence (RR -0.0986 [95% CI: -0.2272 to 0.0299], = 0.1327). Trial sequential analysis (TSA) for each outcome indicated that additional trials are needed for conclusive evidence. Early tracheostomy appears to offer some benefits across all considered clinical outcomes when compared to late tracheostomy and prolonged intubation.
危重症患者气管切开的理想时机仍存在争议。本系统评价和荟萃分析探讨了与延迟气管切开或机械通气的危重症患者长时间插管相比，早期气管切开是否能改善临床结局。我们全面检索了评估接受早期（插管后7 - 10天内）与延迟气管切开或长时间插管的重症监护病房（ICU）患者临床结局风险的随机对照试验（RCT）。检索的数据库包括截至2023年6月的PubMed、Embase和Cochrane图书馆。评估的主要结局是死亡率，次要结局包括呼吸机相关性肺炎（VAP）的发生率、ICU住院时间和机械通气时间。不设语言限制。符合条件的研究是比较危重症患者早期与延迟气管切开或长时间插管并报告死亡率的RCT。使用Cochrane随机对照试验偏倚风险工具评估偏倚风险，并通过GRADE方法评估证据确定性。本系统评价和荟萃分析纳入了19项RCT，涵盖3586例危重症患者。与对照组相比，早期气管切开适度降低了死亡率（RR -0.1511 [95% CI： -0.2951至 -0.0070]，P = 0.0398）。与延迟气管切开相比，它还缩短了ICU住院时间（SMD -0.6237 [95% CI： -0.9526至 -0.2948]，P = 0.0002）和机械通气时间（SMD -0.3887 [95% CI： -0.7726至 -0.0048]，P = 0.0472）。然而，与长时间插管相比，早期气管切开并未显著缩短机械通气时间（SMD -0.1192 [95% CI： -0.2986至0.0601]，P = 0.1927），也未影响VAP发生率（RR -0.0986 [95% CI： -0.2272至0.0299]，P = 0.1327）。每个结局指标的试验序贯分析（TSA）表明，需要更多试验才能得出确凿证据。与延迟气管切开和长时间插管相比，早期气管切开似乎在所有考虑到的临床结局方面都有一些益处。
