Early tracheostomy doesn't improve outcomes ... much (Meta-analysis, CHEST) - PulmCCM
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Jan 082012
 

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A 2005 meta-analysis of 5 studies (n=406) concluded that early tracheostomy reduced need for mechanical ventilation and ICU days. But then a 2006 randomized trial in trauma patients found no benefit to early trach, and an underpowered 2008 RCT also found no benefit.

In a new meta-analysis and systematic review of 7 trials (n=1,044), Fei Wang et al take a fresh look including the new data, and conclude that early tracheostomy doesn’t improve clinical outcomes in critically ill patients:

  • Short-term mortality, relative risk 0.86 (95% CI 0.65 – 1.13)
  • Long-term mortality, RR 0.84 (CI 0.68 – 1.04)
  • Incidence of VAP, RR 0.94 (CI 0.77 – 1.15)

They further concluded that early trach’s did not “markedly” improve other important outcomes, noting that those getting early tracheostomy had:

  • 4 more ventilator-free days (CI -9 days to +2 days)
  • 7 fewer days of sedation (-15 days to +0.5 days)
  • 7 fewer ICU days (-17 to +3 days)
  • 1.45 fewer days in the hospital (-5 to +8 days)

Although these do look like markedly good trends, the wide confidence intervals preclude a definite conclusion of benefit in this analysis. (It’s commonly accepted that trach’s are more comfortable than endotracheal intubati0n, and reduce need for sedation; these trends validate that belief, to me.)

A week’s less time in an ICU would be great — unless of course that week is your first week in the LTAC your ICU team shipped you to. In at least one of the included trials, such a transfer reduced the number of ICU days counted, contaminating this statistic. (Since weaning rates in LTACs are ~30-50% and 1 year mortality ~50-70% [ref], transfer to one should in no way be construed as a good outcome or successful weaning).

Authors recommend — you guessed it — an adequately powered randomized controlled trial to answer the question “when to trach?” more definitively.

chest journal review review articles randomized controlled trials mechanical ventilation review interventional pulmonology critical care review  Early tracheostomy doesnt improve outcomes ... much (Meta analysis, CHEST)Clinical Takeaway: Early tracheotomy reduces need for sedation, and there’s a suggestion (but no good proof) early trachs reduce time on the ventilator. However, in almost every randomized trial, a large proportion of early tracheotomies were unnecessary or futile (because many patients in the late-trach groups weaned from the ventilator or died before “needing” a tracheotomy).

If you consider tracheotomy a safe, benign procedure that enhances patient comfort and ICU throughput with minimal risk, trach early and often. If you consider tracheotomy rather brutal, believe its real-world risks are understated, or just feel that even low-risk procedures should be avoided where possible, wait to trach. And if you care what the lawyers are saying about it, read this. 

Wang F et al. The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials.  CHEST 2011; ePub September 22, 2011.

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  One Response to “Early tracheostomy doesn’t improve outcomes … much (Meta-analysis, CHEST)”

  1. Just wondering when on earth the large UK TracMan study is going to be published….only a brief summary of the results so far. Just because it’s likely to be negative, doesn’t mean don’t publish it!
    Sigh…..

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