Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis

Putensen, Christian; Theuerkauf, Nils; Guenther, Ulf; Vargas, Maria; Pelosi, Paolo

doi:10.1186/s13054-014-0544-7

Critical Care

Table 3 Characteristics of precedent meta-analyses

From: Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis

Meta-analysis	Studies included		Sum of patients	Intervention	Endpoint	Results	Conclusions	Limitations
Dulguerov and colleagues [48]	ST (1960 to 1984)	Total 4,185	• Serious complications: death, cardiopulmonary arrest, pneumothorax, pneumomediastinum, tracheoesophageal fistula, mediastinitis, sepsis, intratracheal postoperative hemorrhage, cannula obstruction and displacement, tracheal stenosis			• No OR, RR; or RD calculated	• Higher incidence of perioperative complications, perioperative death and serious cardiorespiratory events in the PT group	• Analyzes three historical cohorts
	ST (1985 to 1996)	Total 3,512	• Intermediate complications: intraoperative desaturation, lesions of the posterior tracheal wall, cannula misplacement, switch of a PT procedure to a surgical technique, aspiration, pneumonia, atelectasis, lesions of the tracheal cartilages				• Higher incidence of postoperative complications in the ST group	• Includes prospective and observational publications addressing perioperative and postoperative complications of tracheostomy
	PT	Total 1,817	• Mild complications: intraoperative hemorrhage, false passage, difficulty with tube placement, subcutaneous emphysema, postoperative wound hemorrhage, infections, delayed closure of tracheostomy tract, keloids, unaesthetic scarring					• Includes studies using different PT techniques to ST
								• Included studies comprise a variety of patient populations over a long period of time (1960 to 1996)
								• Does not follow the Cochrane Collaboration Guidelines
								• Does not distinguish between intraoperative and postoperative complications
Cheng and Fee [49]	Crofts and colleagues [31]		25/28	MDT vs. ST	Intraoperative	• No OR, RR or RD calculated	• Length of procedure is shorter in PT compared to ST	• Does not follow the Cochrane Collaboration Guidelines
	Friedman and colleagues [34]		26/27	MDT vs. ST	• Major bleeding		• Desaturation is less distinct in PT compared to ST	• Includes only four RCTs with small patient populations
	Hazard and colleagues [36]		22/24	MDT vs. ST	• Minor bleeding		• Lower incidence of minor intraoperative bleeding in PT	• No evaluation of long-term complications
	Holdgaard and colleagues [38]		30/30	MDT vs. ST	• Paratracheal insertion		• PT lower incidence of minor postoperative bleeding and infection
			Total 103/109		• Difficult insertion
					• Hypotension
					• Desaturation
					• Loss of airway
					• Length of procedure
					Postoperative:
					• Major bleeding
					• Minor bleeding
					• Pneumothorax
					• Subcutaneous emphysema
					• Aspiration
					• Atelectais
					• Mortality
Freeman and colleagues [7]	Hazard and colleagues [36]		22/24	MDT vs. ST	• Length of procedure	• Length of procedure: MD −9.8 (−7.83 to –11.85), P = NR, s	• PDT shorter length and greater ease of procedure	• Includes only five RCTs with small patient populations
	Crofts and colleagues [31]		25/28	MDT vs. ST	• Operative complications	• (All) operative complications: OR 0.73 (0.06 to 9.37), P = NR, ns	• PDT lower incidence of overall postoperative complications, intraprocedural and postprocedural bleeding and stoma infections	• No evaluation of long-term complications
	Friedman and colleagues [34]		26/27	MDT vs. ST	• Intraoperative bleeding	• Intraoperative bleeding: OR 0.15 (0.02 to 0.39), P = NR, s		• Evidence for publication bias
	Holdgaard and colleagues [38]		30/30	MDT vs. ST	• Postoperative complications	• (All) postoperative complications: OR 0.15 (0.07 to 0.29), P = NR, s
	Porter and Ivatury [42]		12/12	MDT vs. ST	• Postoperative bleeding	• Postoperative bleeding: OR 0.39 (0.18 to 0.88), P = NR, s
			Total 115/121		• Stoma infection	• Stoma infection: OR 0.02 (0.01 to 0.07), P = NR, s
					• Mortality, not differentiated	• Mortality, not differentiated: OR 0.63 (0.18 to 2.20), P = NR, ns
Delaney and colleagues [6]	Antonelli and colleagues [28]		67/72	TLT vs. ST	• Wound infection	• Wound infection OR 0.28 (0.16 to 0.49, P < 0.0005	• Compared with ST, PDT has a lower incidence of wound infections	• Does not distinguish between intraoperative and postoperative complications
	Crofts and colleagues [31]		25/28	MDT vs. ST	• Bleeding	• Bleeding OR 0.80 (0.45 to 1.41), P = 0.35	• Compared with ST, PT is not associated with a higher incidence of clinically significant bleeding, major periprocedural or long-term outcomes	• No evaluation of long-term complications
	Freeman and colleagues [33]		40/40	MDT vs. ST	• Mortality	• Mortality OR 0.79 (0.59 to 1.07), P = 0.13	• When comparing open ST performed in the OT versus PDT performed in the ICU, PDT has a lower incidence of relevant bleeding (P = 0.01) and mortality (P = 0.05)
	Friedman and colleagues [34]		26/27	MDT vs. ST
	Gysin and colleagues [35]		35/35	MDT vs. ST
	Hazard and colleagues [36]		22/24	MDT vs. ST
	Heikkinen and colleagues [37]		30/26	GWDF vs. ST
	Holdgaard and colleagues [38]		30/30	MDT vs. ST
	Ahn and colleagues [50]		NA/NA	MDT vs. ST
	Massick and colleagues [51]		50/50	MDT vs. ST
	Melloni and colleagues [40]		25/25	MDT vs. ST
	Porter and Ivatury [42]		12/12	MDT vs. ST
	Raine and colleagues [52]		50/50	GWDF vs. ST
	Silvester and colleagues [43]		100/100	MDT vs. ST
	Sustic and colleagues [44]		8/8	GWDF vs. ST
	Tabaee and colleagues [45]		29/14	SSDT vs. ST
	Wu and colleagues [47]		41/42	MDT vs. ST
			Total 590/583	MDT vs. ST
Higgins and Punthakee [8]	Antonelli and colleagues [28]		67/72	TLT vs. ST	• Minor hemorrhage	• Minor hemorrhage OR 1.09 (0.61 to 1.97), P = 0.77	• PDT higher incidence of false passage and accidental decannulation	• Does not distinguish between intraoperative and postoperative complications
	Crofts and colleagues [31]		25/28	MDT vs. ST	• Major hemorrhage	• Major hemorrhage OR 0.60 (0.28 to 1.26), P = 0.17	• PDT lower incidence of wound infection and unfavorable scarring	• Evidence for publication bias
	Freeman and colleagues [33]		40/40	MDT vs. ST	• False passage	• False passage OR 2.70 (0.89 to 8.22), P = 0.008	• PDT performed faster and with more cost-effectiveness	• Heterogeneous definition of study outcomes, in particular concerning bleeding and wound infection
	Friedman and colleagues [34]		26/27	MDT vs. ST	• Wound infection	• Wound infection OR 0.37 (0.22 to 0.62), P = 0.0002	• Overall complications did not differ between groups (P = 0.05)
	Gysin and colleagues [35]		35/35	MDT vs. ST	• Unfavorable scar	• Unfavorable scar OR 0.44 (0.23 to 0.83), P = 0.01	• When comparing open TT performed in the OT vs. PDT performed in the ICU, PDT has a lower overall complication rate (P = 0.01)
	Hazard and colleagues [36]		22/24	MDT vs. ST	• Decannulation/dislodgement	• Decannulation/obstruction OR 2.79 (1.29 to 6.03), P = 0.009
	Heikkinen and colleagues [37]		30/26	GWDF vs. ST	• Subglottic stenosis	• Subglottic stenosis OR 0.59 (0.27 to 1.29), P = 0.19
	Holdgaard and colleagues [38]		30/30	MDT vs. ST	• Mortality	• Mortality OR 0.70 (0.24 to 2.01), P = 0.50
	Massick and colleagues [51]		50/50	MDT vs. ST
	Melloni and colleagues [40]		25/25	MDT vs. ST
	Porter and Ivatury [42]		12/12	MDT vs. ST
	Raine and colleagues [52]		50/50	GWDF vs. ST
	Sustic and colleagues [44]		8/8	GWDF vs. ST
	Tabaee and colleagues [45]		29/14	SSDT vs. ST
	Wu and colleagues [47]		41/42	MDT vs. ST
			Total 490/483
Cabrini and colleagues [15]	Anon and colleagues [27]		27/26	SSDT vs. GWDF	• Conversion to other method	• Conversion to other method	• SSDT lower incidence of mild complications than BDT and GWDF	• Only few studies, comparing different PT techniques; in particular those comparing TLT, BDT and RDT
	Ambesh and colleagues [26]		30/30	SSDT vs. GWDF	• Any mild complication	• TLT vs. GWDF RD = 23% (11 to 36%), P = 0.0002	• SSDT lower frequency of failure than RDT	• Does not distinguish between intraoperative and postoperative complications
	Birbicer and colleagues [53]		50/50	MDT vs. RDT	• Any severe complication	• SSDT vs. RDT RD = 17% (4 to 30%), P = 0.01	• GWDF lower incidence of severe complications and frequency of failure than TLT
	Byhahn and colleagues [12]		25/25	MDT vs. SSDT		• Any mild complication	• No differences between MDT and SSDT
	Byhahn and colleagues [29]		35/35	SSDT vs. RDT		• SSDT vs. BDT RD = 40% (22 to 58%), P < 0.0001	• MDT lower incidence of mild complications than GWDF, same incidence of severe complications and conversion rate
	Cantais and colleagues [54]		47/53	TLT vs. GWDF		• SSDT vs. GWDF RD = 19% (5 to 33%), P = 0.008
	Cianchi and colleagues [30]		35/35	SSDT vs. BDT		• Any severe complication
	Johnson and colleagues [55]		25/25	MDT vs. SSDT		• TLT vs. GWDF RD = 30% (16 to 44%), P < 0.0001
	Kaiser and colleagues [39]		48/42	MDT vs. GWDF
	Nates and colleagues [41]		52/48	MDT vs. GWDF
	Stocchetti and colleagues [56]		10/10	MDT vs. TLT
	van Heurn and colleagues [46]		63/64	MDT vs. GWDF
	Yurtseven and colleagues [57]		22/45	MDT vs. GWDF/RDT
			Total 469/488

BDT, balloon dilatation tracheotomy; GWDF, guide wire dilatation forceps; MD, weighted mean difference; MDT, multiple dilatation tracheotomy; NA, not available; NR, not reported; ns, not significant; OR, odds ratio; OT, operating theatre; RCT, randomized controlled trial; RD, risk difference; RDT, rotational dilatation tracheotomy; RR, relative risk; s, significant; SSDT, single-step dilatation tracheotomy; ST, surgical tracheotomy; PT, percutaneous tracheotomy; TLT, translaryngeal tracheostomy; TT, tracheostomy; PDT, percutaneous dilatation tracheotomy.

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