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Original Investigation
March 11, 2021

Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients: A Meta-analysis

Author Affiliations
  • 1Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia
  • 2Division of Neonatology, Department of Pediatrics, University of Texas Health–San Antonio
JAMA Otolaryngol Head Neck Surg. 2021;147(5):450-459. doi:10.1001/jamaoto.2021.0025
Key Points

Question  Is the timing of tracheostomy placement in critically ill patients associated with the rate of ventilator-associated pneumonia and duration of mechanical ventilation?

Findings  This meta-analysis assessed findings from 17 randomized clinical trials with 3145 participants and found that early tracheotomy in adults undergoing ventilator support for critical illness was associated with improved clinical outcomes.

Meaning  These findings suggest that tracheostomy placement no more than 7 days after ventilator support may lower the rates of ventilator-associated pneumonia and ventilator duration.


Importance  The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding early vs late tracheostomy placement for ventilator-associated pneumonia (VAP), ventilator days, mortality, and length of intensive care unit (ICU) hospitalization.

Objective  To compare the association of early (≤7 days) vs late tracheotomy with VAP and ventilator days in critically ill adults.

Data Sources  A search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, references of relevant articles, previous meta-analyses, and gray literature from inception to March 31, 2020, was performed.

Study Selection  Randomized clinical trials comparing early and late tracheotomy with any of our primary outcomes, VAP or ventilator days, were included.

Data Extraction and Synthesis  Two independent reviewers conducted all stages of the review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Pooled odds ratios (ORs) or the mean difference (MD) with 95% CIs were calculated using a random-effects model.

Main Outcomes and Measures  Primary outcomes included VAP and duration of mechanical ventilation. Intensive care unit days and mortality (within the first 30 days of hospitalization) constituted secondary outcomes.

Results  Seventeen unique trials with a cumulative 3145 patients (mean [SD] age range, 32.9 [12.7] to 67.9 [17.6] years) were included in this review. Individuals undergoing early tracheotomy had a decrease in the occurrence of VAP (OR, 0.59 [95% CI, 0.35-0.99]; 1894 patients) and experienced more ventilator-free days (MD, 1.74 [95% CI, 0.48-3.00] days; 1243 patients). Early tracheotomy also resulted in fewer ICU days (MD, −6.25 [95% CI, −11.22 to −1.28] days; 2042 patients). Mortality was reported for 2445 patients and was comparable between groups (OR, 0.66 [95% CI, 0.38-1.15]).

Conclusions and Relevance  Compared with late tracheotomy, early intervention was associated with lower VAP rates and shorter durations of mechanical ventilation and ICU stay, but not with reduced short-term, all-cause mortality. These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation.

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