Tracheostomy Timing and Clinical Outcomes in Ventilated COVID-19 Patients

A Systematic Review and Meta-Analysis

Yun Ji; Yumin Fang; Baoli Cheng; Libin Li; Xiangming Fang


Crit Care. 2022;26(40) 

In This Article

Abstract and Introduction


Background: The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients' outcomes.

Methods: We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14 days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model.

Results: Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV (2098 patients; MD − 9.08 days, 95% CI − 10.91 to − 7.26 days, p < 0.01) and duration of ICU stay (1224 patients; MD − 9.41 days, 95% CI − 12.36 to − 6.46 days, p < 0.01). Mortality was reported for 2343 patients and was comparable between groups (OR 1.09, 95% CI 0.79–1.51, p = 0.59).

Conclusions: The results of this meta-analysis suggest that, compared with late tracheostomy, early tracheostomy in COVID-19 patients was associated with shorter duration of IMV and ICU stay without modifying the mortality rate. These findings may have important implications to improve ICU availability during the COVID-19 pandemic.

Trial Registration: The protocol was registered at INPLASY (INPLASY202180088).


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become one of the largest known pandemic in human history affecting more than 233 million people across the globe.[1] Although the majority of individuals experience mild symptoms, approximately 5–15% develop respiratory failure and require invasive mechanical ventilation (IMV).[2–6] Earlier reports of patients with coronavirus disease 2019 (COVID-19) on IMV described poor outcomes, with mortality rates as high as 45–74%, and 50% of patients requiring prolonged IMV (> 2 weeks).[4,7–11]

A shorter ventilator time and ICU stay were particularly valuable during the COVID-19 pandemic, when intensive care units (ICUs) had insufficient ventilator and beds.[12] Tracheostomy was considered an attractive intervention to potentially reduce the time on a ventilator, length of ICU stay, and mortality.[13,14] Nevertheless, most published guidelines in COVID-19 did not recommend performing early tracheostomy (ET) due to these early reports suggesting high mortality rates and high risk for possible virus transmission to health care workers during the tracheostomy procedure.[15–20] Unfortunately, most guidelines were published at the beginning of the pandemic without data to sustain them.

This year, several studies have attempted to investigate how ET affects COVID-19 outcomes.[21–23] However, whether ET improves COVID-19 outcomes is still controversial.[24–26] Thus, our objective was to systematically appraise the existing COVID-19 studies examining the impact of ET on the primary outcomes of duration of IMV, duration of ICU stay, and overall reported mortality and secondary outcomes of ventilator-associated pneumonia (VAP), time from tracheostomy to ventilator weaning, and duration of sedation.