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.

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.