Boni Aline, Tonietto Tiago Antonio, Rihl Marcos Frata, Viana Marina Verçoza
Medical Science Post-Graduate Program, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
Department of Intensive Care, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
BMJ Open Respir Res. 2025 Apr 5;12(1):e002434. doi: 10.1136/bmjresp-2024-002434.
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.
Searches were conducted in the MEDLINE, Embase, Lilacs and Cochrane Library databases up to November 2024.
Our analysis included studies meeting the following criteria: Population: patients admitted to intensive care units and receiving mechanical ventilation.
early tracheostomy, as defined by the respective study.
late tracheostomy, as defined by the respective study.
mortality and incidence of ventilator-associated pneumonia (VAP).
systematic reviews and meta-analysis of RCTs.
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.
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.
本研究对随机临床试验（RCT）的系统评价和荟萃分析进行了一项伞形综述，以评估早期与晚期气管切开术的结果，重点关注潜在偏倚和证据的一致性。
截至2024年11月，在MEDLINE、Embase、Lilacs和Cochrane图书馆数据库中进行了检索。
我们的分析纳入了符合以下标准的研究：人群：入住重症监护病房并接受机械通气的患者。
各研究定义的早期气管切开术。
各研究定义的晚期气管切开术。
死亡率和呼吸机相关性肺炎（VAP）的发生率。
RCT的系统评价和荟萃分析。
两名审阅者进行文章纳入，如有分歧则由第三名审阅者达成共识解决。使用AMSTAR 2工具评估研究质量。基于推荐分级、评估、制定和评价（GRADE）分类的算法进行随机效应荟萃分析。
在识别出的7664篇文章中，60篇文章被认为有资格进行全文阅读，22篇被纳入综述。大多数研究被评为质量极低。我们对19项RCT的荟萃分析更新显示，与晚期气管切开术患者相比，早期气管切开术患者的VAP有所降低（OR 0.65（0.47至0.89），95%CI；p=0.007），但在死亡率方面无显著差异（OR 0.85（0.70至1.03），95%CI；p=0.09）。一项试验序贯分析表明，目前的数据不足以得出明确结论。
总之，尽管对气管切开术时机及其结果进行了广泛研究，且我们的研究发现早期气管切开术与降低VAP发生率之间存在相关性，但证据仍然薄弱。此外，未观察到明显的死亡率获益。采用不同方法进行进一步研究对于确定可能从早期气管切开术中获益的特定人群至关重要。
