Abstract
Background
A recent systematic review and meta-analysis of RCTs of early vs late tracheostomy in mechanically ventilated patients suggest that early tracheostomy reduces the duration of ICU stay and mechanical ventilation, but does not reduce short-term mortality or ventilator-associated pneumonia (VAP). Meta-analysis of randomised trials is typically performed using a frequentist approach, and although reporting confidence intervals, interpretation is usually based on statistical significance. To provide a robust basis for clinical decision-making, we completed the search used from the previous review and analysed the data using Bayesian methods to estimate posterior probabilities of the effect of early tracheostomy on clinical outcomes.
Methods
The search was completed for RCTS comparing early vs late tracheostomy in the databases PubMed, EMBASE, and Cochrane library in June 2022. Effect estimates and 95% confidence intervals were calculated for the outcomes short-term mortality, VAP, duration of ICU stay, and mechanical ventilation. A Bayesian meta-analysis was performed with uninformative priors. Risk ratios (RRs) and standardised mean differences (SMDs) with 95% credible intervals were reported alongside posterior probabilities for any benefit (RRResults
Nineteen RCTs with 3508 patients were included. Comparing patients with early vs late tracheostomy, the posterior probabilities for any benefit, small benefit, and modest benefit, respectively, were: 99%, 99%, and 99% for short-term mortality; 94%, 78%, and 51% for VAP; 97%, 43%, and 1% for duration of mechanical ventilation; and 97%, 75%, and 27% and for length of ICU stay.
Conclusions
Bayesian meta-analysis suggests a high probability that early tracheostomy compared with delayed tracheostomy has at least some benefit across all clinical outcomes considered.
A recent systematic review and meta-analysis of RCTs of early vs late tracheostomy in mechanically ventilated patients suggest that early tracheostomy reduces the duration of ICU stay and mechanical ventilation, but does not reduce short-term mortality or ventilator-associated pneumonia (VAP). Meta-analysis of randomised trials is typically performed using a frequentist approach, and although reporting confidence intervals, interpretation is usually based on statistical significance. To provide a robust basis for clinical decision-making, we completed the search used from the previous review and analysed the data using Bayesian methods to estimate posterior probabilities of the effect of early tracheostomy on clinical outcomes.
Methods
The search was completed for RCTS comparing early vs late tracheostomy in the databases PubMed, EMBASE, and Cochrane library in June 2022. Effect estimates and 95% confidence intervals were calculated for the outcomes short-term mortality, VAP, duration of ICU stay, and mechanical ventilation. A Bayesian meta-analysis was performed with uninformative priors. Risk ratios (RRs) and standardised mean differences (SMDs) with 95% credible intervals were reported alongside posterior probabilities for any benefit (RRResults
Nineteen RCTs with 3508 patients were included. Comparing patients with early vs late tracheostomy, the posterior probabilities for any benefit, small benefit, and modest benefit, respectively, were: 99%, 99%, and 99% for short-term mortality; 94%, 78%, and 51% for VAP; 97%, 43%, and 1% for duration of mechanical ventilation; and 97%, 75%, and 27% and for length of ICU stay.
Conclusions
Bayesian meta-analysis suggests a high probability that early tracheostomy compared with delayed tracheostomy has at least some benefit across all clinical outcomes considered.
| Original language | English |
|---|---|
| Pages (from-to) | 693-702 |
| Number of pages | 10 |
| Journal | British Journal of Anaesthesia |
| Volume | 129 |
| Issue number | 5 |
| DOIs | |
| Publication status | Published - 23 Sept 2022 |
Bibliographical note
Funding Information:National Institute for Health and Care Research (NIHR) Doctoral Research Fellowship ( NIHR300606 to LQ) and the NIHR Applied Research Collaboration (ARC) West Midlands (to LQ). NIHR (16/136/87) using UK aid from the UK Government to support global health research and the NIHR ARC West Midlands (to RJL). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. TV is funded by the NIHR HTA (SoS, ERASER trials), MRC (CALTALYST trial), QEHB charities (acute brain injury theme) as chief investigator and MRC (Covid CNS study), i4i (LIT score in sepsis study), CDT (mechanobiology of monocyters in disease states) as co-investigator
Funding Information:
National Institute for Health and Care Research (NIHR) Doctoral Research Fellowship (NIHR300606 to LQ) and the NIHR Applied Research Collaboration (ARC) West Midlands (to LQ). NIHR (16/136/87) using UK aid from the UK Government to support global health research and the NIHR ARC West Midlands (to RJL). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. TV is funded by the NIHR HTA (SoS, ERASER trials), MRC (CALTALYST trial), QEHB charities (acute brain injury theme) as chief investigator and MRC (Covid CNS study), i4i (LIT score in sepsis study), CDT (mechanobiology of monocyters in disease states) as co-investigator
Publisher Copyright:
© 2022 The Author(s)
Keywords
- Bayesian meta-analysis
- early tracheostomy
- intensive care unit
- mechanical ventilation
- mortality
- respiratory failure
- ventilator-associated pneumonia
- Length of Stay
- Intensive Care Units
- Humans
- Critical Illness
- Pneumonia, Ventilator-Associated
- Bayes Theorem
- Respiration, Artificial/methods
- Tracheostomy/methods
ASJC Scopus subject areas
- Anesthesiology and Pain Medicine