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JOURNAL READING

oleh :
Ajillia Sehana Paramudita (30101206581)
Hana Rahmi Fuadah (30101306959)
Lailatus Surur (30101206660)

Pembimbing :
dr. Agus Sudarwi, Sp. THT-KL
dr. Afif Zjauhari, Sp. THT-KL

BAGIAN ILMU KESEHATAN THT-KL


RSUD dr. LOEKMONO HADI
KUDUS
JOURNAL IDENTITY

• Early versus Late Tracheostomy: A Systematic


TITLE Review and Meta-Analysis

AUTHOR • C. Carrie Liu, MD, et al.

• American Academy of Otolaryngology-Head and


PUBLISHER Neck Surgery Foundation; 6 November 2014
ABSTRACT

• To investigate improve outcome early tracheostomy vs late tracheostomy


Objective

• MEDLINE and Cochrane Center Register


Data Source

• Systematic search according PRISMA guidluene  hospital mortality, length of ICU stay, length of
mechanical ventilation, incidence of pneumonia, laryngotracheal injury, sedation use
Review • Analysis  RevMan 5 Software ( Cochrane collaboration, Oxford, England)
Methods
Result

Significant decrease in the


No significant difference
ICU length stay in early
11 studies were analized in hospital mortality (RR =
tracheostomy group (9.13
0.84, CI=95%, p= 0.11)
days, CI=95%, p=0.03)

Incidence of pneumonia, Significant defference


length of mechanical between early and late Sedation use  3 studies
ventilation, laryngotracheal tracheostomy group  reported significant
injury  analysis was not none of the studies decrease in the early
performed reported
Conclusion

Early tracheostomy
incidence of
Early tracheostomy in
pneumonia, length of
the 7 days intubation No difference in
mechanical ventilation,
 decrease ICU length hospital mortality
laryngotracheal injury,
of stay
sedation use 
Insufficient data
BACKGROUND

Tracheostomy  one of procedure in critical


care population

Indication  prolonged intubation and ventilation

Compared endotracheal intubation  tracheostomy has advantages


weaning mechanical ventilation, quicker resumtion of speech and oral
intake, more comfortable
Another advantage of tracheostomy

Lower risk laryngeal injury Granuloma and laryngeal stenosis  5% s/d 12 %

Length of endotracheal intubation higher


Laryngeal injury in endotrcheal
incidence of stenosis)
intubation 94%

More flexible tube with low pressure cuff 


improved tube management strategies, laryngeal
injury and squele less common
Optimal timing of tracheostomy in crtically illness  prolonged mechanical
ventilation is debated

Convention  tracheostomy perforemed  mechanical ventilation exeeds 14


days

Conference 1989
a. Mechanical ventilation up to 10 days  ET
b. Mechanical ventilation > 21 days  Tracheostomy

The evidence of this  limited and pathway management of the airway does
not exist
Our goal is perform a systematic review and metaanalysis of existing
literature

Investigate improved outcome in early tracheostomy compared late


tracheostomy
METHODS
INCLUSION CRITERIA
1 Randomized control trial
Critically ill patients requiring prolonged mechanical
2
ventilation
Early VS late
3
tracheostomy
Outcomes include at least one of : hospital mortality, length of
4 ICU stay, length of mechanical ventilation, incidence of
pneumonia, laryngotracheal injury, sedation use
STATISTICAL ANALYSIS

Statistical analysis measured with RevMan 5


1
software
Differences measured by RR (Relative Risk) with 95% Confidence
2
Interval
Significant p value is less than
3
0,05
I2 statistic used to quantify
4
heterogeneity
RESULT : PNEUMONIA INCIDENCE
RESULT : LENGTH OF MECHANICAL
VENTILATION
RESULT : ICU LENGTH OF STAY
RESULT : HOSPITAL MORTALITY
RESULT : SEDATION USE AND LARYNGOTRACHEAL
INJURY
Sedation use and laryngotracheal injury could only be qualitatively summarized as they were
heterogeneous and could not be combined in a quantitative analysis.

Bosel et al found a Rumbak et al also found a


Young et al23
significant decrease in significant decrease in
found a significant
the use of sedatives in sedation use, with a
decrease in the median
the early tracheostomy mean (SD) of 3.2 (0.4)
number of days
group (42%) compared days of sedation in the
of sedation use in the
with the late early tracheostomy
early tracheostomy group
tracheostomy group group compared with a
compared with the late
(62%)  (median mean (SD) of 14.1 (2.9)
tracheostomy group (5 vs
difference, 17.5 days; days of sedation in the
8 days, P < .001)
95% CI, 3.3-29.2; late tracheostomy group
P = .02). (P < .001).
RESULT : SEDATION USE AND LARYNGOTRACHEAL
INJURY
SUBGROUP ANALYSIS
DISCUSSION
Meta-analysis

Early Tracheostomy vs Late Tracheostomy

Incidence of Length of Sedation Laryngotrache


Decreased No
pneumonia mechanical Use al Injury
length of difference
was seen in ventilation
ICU stay Did not lend
hospital themselves to a
mortality meta analysis
Significant no significant
heterogencity differences in
all 3 studies the occurrence
examining this of early or late
outcome injury based on
found a the timing of
significant tracheostomy
decrease in
the early
tracheostomy
group
DISCUSSION

Previous Meta-Analysis Result


Griffith et al Did not find a significant difference in mortality or pneumonia, but
they did find a significant decrease in the duration of mechanical
ventilation and ICU length of stay.
Wang et al Did not find a significant difference in any of the outcomes, including
mortality, pneumonia, length of mechanical ventilation, and length of
ICU stay.
DISCUSSION

• Our meta-analysis also included 4 additional trials that have been reported since the Wang et
al study. Finally, we employed a more conservative and rigorous approach in the statistical
analysis and interpretation of our data. Specifically, we chose to forego pooled analyses for 2
of our outcomes due to significant heterogeneity.
DISCUSSION

In both the Griffith et al and Wang et al studies, data were combined for every outcome even
when significant heterogeneity was found (with the I2 statistic ranging from 58% to 87% in the
Griffith et al study and 0% to 98% in the Wang et al study). The following paragraph discusses
the issue of combining data in the presence of high statistical heterogeneity.
DISCUSSION

1 Heterogeneity of the data

Not have included all


A common limitation
2 randomized and quasi-
encountered in meta-analyses :
randomized trials

3 Examining the optimal timing


of tracheostomies is the
accuracy with which the length
of mechanical ventilation can
be predicted
Conclusion
When performed within 7 days, an early tracheostomy was significantly associated
with a decreased length of ICU stay. There was no difference in hospital mortality.
1
There is not enough evidence at present to support an early tracheostomy with regard
to the incidence of pneumonia or length of mechanical ventilation.

Subgroup analysis did not suggest a difference in outcomes based on the etiology of
2 critical illness or whether the early tracheostomy was performed at 2 to 3 days, 4 to 5
days, or 7 to 8 days of endotracheal intubation.