Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis

Abstract

Background: Patients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes.

Methods: Six databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale.

Results: Seventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale.

Conclusion: Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes.

Level of evidence: Systematic Review, level III.

Figure 1

PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Random effects meta-analysis on short-term mortality, expressed as the RR. The blue box represents the point estimate of the study result, the black horizontal line represents the 95% confidence interval of the study result, and the black diamond represents the mean point estimate and mean confidence interval of all the studies. Flanagan et al. measured mortality at admission (ICU). Galeiras et al. measured mortality during admission. Ganuza et al., Kornblith et al., Romero et al., and Wu et al., did not specify the time at which mortality was measured. Guirgis et al. measured ICU mortality. Khan et al. measured in-hospital mortality. Jeon measured in-hospital mortality. Lozano measured in-hospital mortality. ET, early tracheostomy, LT, late tracheostomy.

Figure 3

Random-effects meta-analysis on duration of MV, expressed as the MD in days. The green box represents the point estimate of the study result, the black horizontal line represents the 95% confidence interval of the study result, and the black diamond represents the mean point estimate and mean confidence interval of all the studies. MD, mean difference.

Figure 4

Random effects meta-analysis on ICU LOS, expressed as the MD in days. The green box represents the point estimate of the study result, the black horizontal line represents the 95% confidence interval of the study result, and the black diamond represents the mean point estimate and mean confidence interval of all the studies.