Tracheostomy timing and outcome in critically ill patients with stroke: a meta-analysis and meta-regression.
Critically ill
Haemorrhagic
Ischaemic
Mechanical ventilation
Stroke
Tracheostomy
Journal
Critical care (London, England)
ISSN: 1466-609X
Titre abrégé: Crit Care
Pays: England
ID NLM: 9801902
Informations de publication
Date de publication:
01 04 2023
01 04 2023
Historique:
received:
21
02
2023
accepted:
27
03
2023
medline:
4
4
2023
entrez:
3
4
2023
pubmed:
4
4
2023
Statut:
epublish
Résumé
Stroke patients requiring mechanical ventilation often have a poor prognosis. The optimal timing of tracheostomy and its impact on mortality in stroke patients remains uncertain. We performed a systematic review and meta-analysis of tracheostomy timing and its association with reported all-cause overall mortality. Secondary outcomes were the effect of tracheostomy timing on neurological outcome (modified Rankin Scale, mRS), hospital length of stay (LOS), and intensive care unit (ICU) LOS. We searched 5 databases for entries related to acute stroke and tracheostomy from inception to 25 November 2022. We adhered to PRISMA guidance for reporting systematic reviews and meta-analyses. Selected studies included (1) ICU-admitted patients who had stroke (either acute ischaemic stroke, AIS or intracerebral haemorrhage, ICH) and received a tracheostomy (with known timing) during their stay and (2) > 20 tracheotomised. Studies primarily reporting sub-arachnoid haemorrhage (SAH) were excluded. Where this was not possible, adjusted meta-analysis and meta-regression with study-level moderators were performed. Tracheostomy timing was analysed continuously and categorically, where early (< 5 days from initiation of mechanical ventilation to tracheostomy) and late (> 10 days) timing was defined per the protocol of SETPOINT2, the largest and most recent randomised controlled trial on tracheostomy timing in stroke patients. Thirteen studies involving 17,346 patients (mean age = 59.8 years, female 44%) met the inclusion criteria. ICH, AIS, and SAH comprised 83%, 12%, and 5% of known strokes, respectively. The mean time to tracheostomy was 9.7 days. Overall reported all-cause mortality (adjusted for follow-up) was 15.7%. One in five patients had good neurological outcome (mRS 0-3; median follow-up duration was 180 days). Overall, patients were ventilated for approximately 12 days and had an ICU LOS of 16 days and a hospital LOS of 28 days. A meta-regression analysis using tracheostomy time as a continuous variable showed no statistically significant association between tracheostomy timing and mortality (β = - 0.3, 95% CI = - 2.3 to 1.74, p = 0.8). Early tracheostomy conferred no mortality benefit when compared to late tracheostomy (7.8% vs. 16.4%, p = 0.7). Tracheostomy timing was not associated with secondary outcomes (good neurological outcome, ICU LOS and hospital LOS). In this meta-analysis of over 17,000 critically ill stroke patients, the timing of tracheostomy was not associated with mortality, neurological outcomes, or ICU/hospital LOS. PROSPERO-CRD42022351732 registered on 17th of August 2022.
Sections du résumé
BACKGROUND
Stroke patients requiring mechanical ventilation often have a poor prognosis. The optimal timing of tracheostomy and its impact on mortality in stroke patients remains uncertain. We performed a systematic review and meta-analysis of tracheostomy timing and its association with reported all-cause overall mortality. Secondary outcomes were the effect of tracheostomy timing on neurological outcome (modified Rankin Scale, mRS), hospital length of stay (LOS), and intensive care unit (ICU) LOS.
METHODS
We searched 5 databases for entries related to acute stroke and tracheostomy from inception to 25 November 2022. We adhered to PRISMA guidance for reporting systematic reviews and meta-analyses. Selected studies included (1) ICU-admitted patients who had stroke (either acute ischaemic stroke, AIS or intracerebral haemorrhage, ICH) and received a tracheostomy (with known timing) during their stay and (2) > 20 tracheotomised. Studies primarily reporting sub-arachnoid haemorrhage (SAH) were excluded. Where this was not possible, adjusted meta-analysis and meta-regression with study-level moderators were performed. Tracheostomy timing was analysed continuously and categorically, where early (< 5 days from initiation of mechanical ventilation to tracheostomy) and late (> 10 days) timing was defined per the protocol of SETPOINT2, the largest and most recent randomised controlled trial on tracheostomy timing in stroke patients.
RESULTS
Thirteen studies involving 17,346 patients (mean age = 59.8 years, female 44%) met the inclusion criteria. ICH, AIS, and SAH comprised 83%, 12%, and 5% of known strokes, respectively. The mean time to tracheostomy was 9.7 days. Overall reported all-cause mortality (adjusted for follow-up) was 15.7%. One in five patients had good neurological outcome (mRS 0-3; median follow-up duration was 180 days). Overall, patients were ventilated for approximately 12 days and had an ICU LOS of 16 days and a hospital LOS of 28 days. A meta-regression analysis using tracheostomy time as a continuous variable showed no statistically significant association between tracheostomy timing and mortality (β = - 0.3, 95% CI = - 2.3 to 1.74, p = 0.8). Early tracheostomy conferred no mortality benefit when compared to late tracheostomy (7.8% vs. 16.4%, p = 0.7). Tracheostomy timing was not associated with secondary outcomes (good neurological outcome, ICU LOS and hospital LOS).
CONCLUSIONS
In this meta-analysis of over 17,000 critically ill stroke patients, the timing of tracheostomy was not associated with mortality, neurological outcomes, or ICU/hospital LOS.
TRIAL REGISTRATION
PROSPERO-CRD42022351732 registered on 17th of August 2022.
Identifiants
pubmed: 37005666
doi: 10.1186/s13054-023-04417-6
pii: 10.1186/s13054-023-04417-6
pmc: PMC10068163
doi:
Types de publication
Systematic Review
Meta-Analysis
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
132Commentaires et corrections
Type : CommentIn
Type : CommentIn
Informations de copyright
© 2023. The Author(s).
Références
Lahiri S, Mayer SA, Fink ME, et al. Mechanical ventilation for acute stroke: a multi-state population-based study. Neurocrit Care. 2015;23(1):28–32. https://doi.org/10.1007/s12028-014-0082-9 .
doi: 10.1007/s12028-014-0082-9
pubmed: 25487123
Robba C, Poole D, McNett M, et al. Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med. 2020;46(12):2397–410. https://doi.org/10.1007/s00134-020-06283-0 .
doi: 10.1007/s00134-020-06283-0
pubmed: 33175276
pmcid: 7655906
Bösel J. Use and timing of tracheostomy after severe stroke. Stroke. 2017;48(9):2638–43. https://doi.org/10.1161/STROKEAHA.117.017794 .
doi: 10.1161/STROKEAHA.117.017794
pubmed: 28733479
Robba C, Bonatti G, Battaglini D, Rocco PRM, Pelosi P. Mechanical ventilation in patients with acute ischaemic stroke: from pathophysiology to clinical practice. Crit Care. 2019;23(1):388. https://doi.org/10.1186/s13054-019-2662-8 .
doi: 10.1186/s13054-019-2662-8
pubmed: 31791375
pmcid: 6889568
Pelosi P, Ferguson ND, Frutos-Vivar F, et al. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med. 2011;39(6):1482–92. https://doi.org/10.1097/CCM.0b013e31821209a8 .
doi: 10.1097/CCM.0b013e31821209a8
pubmed: 21378554
Kurtz P, Fitts V, Sumer Z, et al. How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU? Neurocrit Care. 2011;15(3):477–80. https://doi.org/10.1007/s12028-011-9539-2 .
doi: 10.1007/s12028-011-9539-2
pubmed: 21519958
Steidl C, Boesel J, Suntrup-Krueger S, et al. Tracheostomy, extubation, reintubation: airway management decisions in intubated stroke patients. Cerebrovasc Dis. 2017;44(1–2):1–9. https://doi.org/10.1159/000471892 .
doi: 10.1159/000471892
pubmed: 28395275
Bösel J, Niesen WD, Salih F, et al. Effect of early vs standard approach to tracheostomy on functional outcome at 6 months among patients with severe stroke receiving mechanical ventilation: the SETPOINT2 Randomized Clinical Trial. JAMA. 2022;327(19):1899–909. https://doi.org/10.1001/jama.2022.4798 .
doi: 10.1001/jama.2022.4798
pubmed: 35506515
pmcid: 9069344
Wahlster S, Sharma M, Chu F, et al. Outcomes after tracheostomy in patients with severe acute brain injury: a systematic review and meta-analysis. Neurocrit Care. 2021;34(3):956–67. https://doi.org/10.1007/s12028-020-01109-9 .
doi: 10.1007/s12028-020-01109-9
pubmed: 33033959
Bösel J, Schiller P, Hook Y, et al. Stroke-related early tracheostomy versus prolonged orotracheal intubation in neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke. 2013;44(1):21–8. https://doi.org/10.1161/STROKEAHA.112.669895 .
doi: 10.1161/STROKEAHA.112.669895
pubmed: 23204058
Catalino MP, Lin FC, Davis N, Anderson K, Olm-Shipman C, Dedrick JJ. Early versus late tracheostomy after decompressive craniectomy for stroke. J Intensive Care. 2018;6(1):1. https://doi.org/10.1186/s40560-017-0269-1 .
doi: 10.1186/s40560-017-0269-1
pubmed: 29308208
pmcid: 5753520
Chen W, Liu F, Chen J, Ma L, Li G, You C. Timing and outcomes of tracheostomy in patients with hemorrhagic stroke. World Neurosurg. 2019;131:e606–13. https://doi.org/10.1016/j.wneu.2019.08.013 .
doi: 10.1016/j.wneu.2019.08.013
pubmed: 31408751
Küchler J, Wojak JF, Smith E, et al. Management of tracheostomized patients after poor grade subarachnoid hemorrhage: disease related and pulmonary risk factors for failed and delayed decannulation. Clin Neurol Neurosurg. 2019;184:105419. https://doi.org/10.1016/j.clineuro.2019.105419 .
doi: 10.1016/j.clineuro.2019.105419
pubmed: 31306892
Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121–2129. https://doi.org/10.1001/jama.2013.5154
Alsherbini K, Goyal N, Metter EJ, et al. Predictors for tracheostomy with external validation of the stroke-related early tracheostomy score (SETscore). Neurocrit Care. 2019;30(1):185–92. https://doi.org/10.1007/s12028-018-0596-7 .
doi: 10.1007/s12028-018-0596-7
pubmed: 30167898
Hallan DR, Simion C, Rizk E. Early versus late tracheostomy in spontaneous intracerebral hemorrhage. Cureus. 2022. https://doi.org/10.7759/cureus.24059 .
doi: 10.7759/cureus.24059
pubmed: 36439570
pmcid: 9650943
Lee YC, Kim TH, Lee JW, Oh IH, Eun YG. Comparison of complications in stroke subjects undergoing early versus standard tracheostomy. Respir Care. 2015;60(5):651–7. https://doi.org/10.4187/respcare.03652 .
doi: 10.4187/respcare.03652
pubmed: 25628452
Maier IL, Schramm K, Bähr M, Behme D, Psychogios MN, Liman J. Predictive factors for the need of tracheostomy in patients with large vessel occlusion stroke being treated with mechanical thrombectomy. Front Neurol. 2021;12:728624. https://doi.org/10.3389/fneur.2021.728624 .
doi: 10.3389/fneur.2021.728624
pubmed: 34899559
pmcid: 8660673
Rabinstein AA, Wijdicks EFM. Outcome of survivors of acute stroke who require prolonged ventilatory assistance and tracheostomy. Cerebrovasc Dis. 2004;18(4):325–31. https://doi.org/10.1159/000080771 .
doi: 10.1159/000080771
pubmed: 15359100
Schneider H, Hertel F, Kuhn M, et al. Decannulation and functional outcome after tracheostomy in patients with severe stroke (DECAST): a prospective observational study. Neurocrit Care. 2017;27(1):26–34. https://doi.org/10.1007/s12028-017-0390-y .
doi: 10.1007/s12028-017-0390-y
pubmed: 28324263
Shen Y, Cao Q, Zhuo H, Hu M, Chen S. Early versus late tracheostomy in stroke patients: a retrospective analysis. Neuropsychiatr Dis Treat. 2022;18:2713–23. https://doi.org/10.2147/NDT.S388062 .
doi: 10.2147/NDT.S388062
pubmed: 36419859
pmcid: 9677992
Villwock JA, Villwock MR, Deshaies EM. Tracheostomy Timing Affects Stroke Recovery. J Stroke Cerebrovasc Dis. 2014;23(5):1069–72. https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.09.008 .
doi: 10.1016/j.jstrokecerebrovasdis.2013.09.008
pubmed: 24555919
Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. Published online March 29, 2021:n71. https://doi.org/10.1136/bmj.n71 .
Krishnan K, Elliot SC, Mallick A. The current practice of tracheostomy in the United Kingdom: a postal survey. Anaesthesia. 2005;60(4):360–4. https://doi.org/10.1111/j.1365-2044.2004.04106.x .
doi: 10.1111/j.1365-2044.2004.04106.x
pubmed: 15766339
Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123(3):A12-13.
doi: 10.7326/ACPJC-1995-123-3-A12
pubmed: 7582737
Ottawa Hospital Research Institute. Accessed September 13, 2022. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp .
Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. https://doi.org/10.1136/bmj.l4898 .
doi: 10.1136/bmj.l4898
pubmed: 31462531
Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5(1):13. https://doi.org/10.1186/1471-2288-5-13 .
doi: 10.1186/1471-2288-5-13
pubmed: 15840177
pmcid: 1097734
Weir CJ, Butcher I, Assi V, et al. Dealing with missing standard deviation and mean values in meta-analysis of continuous outcomes: a systematic review. BMC Med Res Methodol. 2018;18(1):25. https://doi.org/10.1186/s12874-018-0483-0 .
doi: 10.1186/s12874-018-0483-0
pubmed: 29514597
pmcid: 5842611
Furukawa TA, Barbui C, Cipriani A, Brambilla P, Watanabe N. Imputing missing standard deviations in meta-analyses can provide accurate results. J Clin Epidemiol. 2006;59(1):7–10. https://doi.org/10.1016/j.jclinepi.2005.06.006 .
doi: 10.1016/j.jclinepi.2005.06.006
pubmed: 16360555
Battaglini D, Premraj L, White N, et al. Tracheostomy outcomes in critically ill COVID-19 patients: a systematic review, meta-analysis, and meta-regression. Br J Anaesth. 2022. https://doi.org/10.1016/j.bja.2022.07.032 .
doi: 10.1016/j.bja.2022.07.032
pubmed: 36182551
pmcid: 9345907
IntHout J, Ioannidis JP, Borm GF. The Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis is straightforward and considerably outperforms the standard DerSimonian–Laird method. BMC Med Res Methodol. 2014;14(1):25. https://doi.org/10.1186/1471-2288-14-25 .
doi: 10.1186/1471-2288-14-25
pubmed: 24548571
pmcid: 4015721
Viechtbauer W. Conducting Meta-Analyses in R with the metafor Package. J Stat Softw. 2010. https://doi.org/10.18637/jss.v036.i03 .
doi: 10.18637/jss.v036.i03
MuMIn.pdf. Accessed September 2, 2022. https://cran.r-project.org/web/packages/MuMIn/MuMIn.pdf .
Cinar O, Umbanhowar J, Hoeksema JD, Viechtbauer W. Using information-theoretic approaches for model selection in meta-analysis. Res Synth Methods. 2021;12(4):537–56. https://doi.org/10.1002/jrsm.1489 .
doi: 10.1002/jrsm.1489
pubmed: 33932323
pmcid: 8359854
McCann MR, Hatton KW, Vsevolozhskaya OA, Fraser JF. Earlier tracheostomy and percutaneous endoscopic gastrostomy in patients with hemorrhagic stroke: associated factors and effects on hospitalization. J Neurosurg. 2020;132(1):87–93. https://doi.org/10.3171/2018.7.JNS181345 .
doi: 10.3171/2018.7.JNS181345
Siempos II, Ntaidou TK, Filippidis FT, Choi AMK. Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med. 2015;3(2):150–8. https://doi.org/10.1016/S2213-2600(15)00007-7 .
doi: 10.1016/S2213-2600(15)00007-7
pubmed: 25680911
Deng H, Fang Q, Chen K, Zhang X. Early versus late tracheotomy in ICU patients: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2021;100(3):e24329. https://doi.org/10.1097/MD.0000000000024329 .
doi: 10.1097/MD.0000000000024329
pubmed: 33546065
da Cruz VM, Demarzo SE, Sobrinho JBB, Amato MBP, Kowalski LP, Deheinzelin D. Effects of tracheotomy on respiratory mechanics in spontaneously breathing patients. Eur Respir J. 2002;20(1):112–7. https://doi.org/10.1183/09031936.02.01342001 .
doi: 10.1183/09031936.02.01342001
Villalba D, Feld V, Leiva V, et al. Effect of tracheostomy tube on work of breathing: Comparison of pre- and post-decannulation. Int J Crit Illn Inj Sci. 2016;6(3):98. https://doi.org/10.4103/2229-5151.190651 .
doi: 10.4103/2229-5151.190651
pubmed: 27722109
pmcid: 5051063
Kleffmann J, Pahl R, Deinsberger W, Ferbert A, Roth C. Effect of percutaneous tracheostomy on intracerebral pressure and perfusion pressure in patients with acute cerebral dysfunction (TIP Trial): an observational study. Neurocrit Care. 2012. https://doi.org/10.1007/s12028-012-9709-x .
doi: 10.1007/s12028-012-9709-x
pubmed: 22539153
Kocaeli H, Korfali E, Taşkapilioğlu O, Ozcan T. Analysis of intracranial pressure changes during early versus late percutaneous tracheostomy in a neuro-intensive care unit. Acta Neurochir (Wien). 2008;150(12):1263–1267; discussion 1267. https://doi.org/10.1007/s00701-008-0153-9
Dasenbrock HH, Rudy RF, Gormley WB, Frerichs KU, Aziz-Sultan MA, Du R. The timing of tracheostomy and outcomes after aneurysmal subarachnoid hemorrhage: a nationwide inpatient sample analysis. Neurocrit Care. 2018;29(3):326–35. https://doi.org/10.1007/s12028-018-0619-4 .
doi: 10.1007/s12028-018-0619-4
pubmed: 30298335
Chang YM, Lee TH, Liao CC, Huang YH. Characterization of tracheotomized patients after spontaneous subarachnoid hemorrhage. Medicine (Baltimore). 2020;99(28):e21057. https://doi.org/10.1097/MD.0000000000021057 .
doi: 10.1097/MD.0000000000021057
pubmed: 32664119
pmcid: 7360272
Walcott BP, Kamel H, Castro B, Kimberly WT, Sheth KN. Tracheostomy following severe ischemic stroke: a population based study. J Stroke Cerebrovasc Dis Off J Natl Stroke Assoc. 2014;23(5):1024–9. https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.08.019 .
doi: 10.1016/j.jstrokecerebrovasdis.2013.08.019
Szeder V, Ortega-Gutierrez S, Ziai W, Torbey MT. The TRACH score: clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage. Neurocrit Care. 2010;13(1):40–6. https://doi.org/10.1007/s12028-010-9346-1 .
doi: 10.1007/s12028-010-9346-1
pubmed: 20393814
Schönenberger S, Al-Suwaidan F, Kieser M, Uhlmann L, Bösel J. The SETscore to predict tracheostomy need in cerebrovascular neurocritical care patients. Neurocrit Care. 2016;25(1):94–104. https://doi.org/10.1007/s12028-015-0235-5 .
doi: 10.1007/s12028-015-0235-5
pubmed: 26842719
Rass V, Ianosi BA, Lindlbauer M, et al. Factors associated with prolonged mechanical ventilation in patients with subarachnoid haemorrhage—the RAISE Score. Crit Care Med. 2022;50(1):103–13. https://doi.org/10.1097/CCM.0000000000005189 .
doi: 10.1097/CCM.0000000000005189
pubmed: 34259444