Tracheostomy timing does not affect outcomes in critically ill patients with stroke: Study

"Our findings suggested that GCS (Glasgow Coma Score) on admission and stroke type are better predictors of outcome than time to tracheostomy," the researchers wrote. "Clinical outcomes in critically ill stroke patients depend on a multifactorial array of variables, only one of which is the tracheostomy timing."

Patients with stroke needing mechanical ventilation are at high risk of poor neurological outcomes and death. In these patients, tracheostomy is often considered, especially when weaning from mechanical ventilation and extubation is delayed or difficult. The optimal tracheostomy timing and its impact on mortality in these patients remain uncertain.

Therefore, Lavienraj Premraj, Griffith University School of Medicine, Gold Coast, Queensland, Australia, and colleagues performed a systematic review and meta-analysis of tracheostomy timing and its association with reported all-cause mortality. Secondary outcomes included the effects of tracheostomy timing on hospital LOS, ICU LOS, and neurological outcomes (modified Rankin Scale, mRS).

For this purpose, the researchers searched five databases for acute stroke and tracheostomy entries from inception to 25 November 2022. They adhered to PRISM guidance for reporting meta-analyses and systematic reviews. Selected studies included ICU-admitted patients with stroke [either intracerebral haemorrhage (ICH) or acute ischemic stroke (AIS)] and received a tracheostomy (with known timing) during their stay and (2) > 20 tracheotomized. It excluded studies primarily reporting sub-arachnoid haemorrhage (SAH). Where this was impossible, they performed an adjusted meta-analysis and meta-regression with study-level moderators.

There was a continuous and categorical analysis of the tracheostomy timing, where early (< 5 days from initiation of mechanical ventilation to tracheostomy) and late (> ten days) timing was defined per the protocol of SETPOINT2, the most recent and most extensive randomized controlled trial on tracheostomy timing in stroke patients.

The inclusion criteria were met by thirteen studies comprising 17,346 patients (mean age = 59.8 years, female 44%).

The study led to the following findings:

• ICH, SAH, and AIS comprised 83%, 5%, and 12% of general strokes, respectively. The mean time for tracheostomy was 9.7 days.
• Overall reported all-cause mortality (adjusted for follow-up) was 15.7%.
• One in five patients had good neurological outcomes (mRS 0–3; median follow-up duration was 180 days).
• Patients were ventilated for approximately 12 days and had an ICU LOS of 16 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).
• Early tracheostomy conferred no mortality benefit compared to late tracheostomy (7.8% versus 16.4%).
• Tracheostomy timing was not associated with secondary outcomes (good neurological outcome, ICU LOS and hospital LOS).

Based on the findings, the authors recommend clinical decisions around tracheostomy be based on patient characteristics, prognosis and neurological status, risk–benefit ratio, patient comfort and requests of caregivers and patients.

Reference:

Premraj, L., Camarda, C., White, N. et al. Tracheostomy timing and outcome in critically ill patients with stroke: a meta-analysis and meta-regression. Crit Care 27, 132 (2023). https://doi.org/10.1186/s13054-023-04417-6