Review paper|Articles in Press

Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis

  • Wagner Malago Tavares
    Department of Research of IPSPAC, Instituto Paulista de Saúde para Alta Complexidade, 215 - Al. Terracota, Room 407, Cerâmica, São Caetano do Sul, SP, 09531-190, Brazil

    Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar Avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil
    Search for articles by this author
  • Sabrina Araujo de França
    Corresponding author at: IPSPAC - Instituto Paulista de Saúde para a Alta Complexidade, 215 - Al. Terracota, Room 407, Cerâmica, São Caetano do Sul, SP, 09531-190, Brazil.
    Department of Research of IPSPAC, Instituto Paulista de Saúde para Alta Complexidade, 215 - Al. Terracota, Room 407, Cerâmica, São Caetano do Sul, SP, 09531-190, Brazil
    Search for articles by this author
  • Wellingson Silva Paiva
    Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar Avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil
    Search for articles by this author
  • Manoel Jacobsen Teixeira
    Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar Avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil
    Search for articles by this author
Published:February 10, 2023DOI:



      We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies.

      Data sources

      Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted.

      Review methods

      Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS.


      The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: −4.40 days [95% CI, −8.28, −0.53] p = 0.03), and shorter ICU (MD: −6.93 days [95% CI, −8.75, −5.11] p < 0.00001) and hospital LOS (MD: −7.05 days [95% CI, −8.27, −5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference.


      Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Australian Critical Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ward Jane
        Oxygen delivery and demand.
        Surgery. 2006; 24: 354-360
        • Barrett K.E.
        • Barman S.M.
        • Boitanon S.
        • Brooks H.L.
        Circulation through special regions.
        in: Barrett K.E. Barman S.M. Boitano S. Brooks H.L. Ganong's Review of Medical Physiology. 24th ed. McGraw-Hill Companies, 2012: 601-617
        • Maggia Christophe
        • Doyle Senan
        • Forbes Florence
        • Heck Olivier
        • Troprès Irène
        • Berthet Corentin
        • et al.
        Assessment of tissue injury in severe brain trauma.
        in: Crimi Alessandro Menze Bjoern Maier Oskar Reyes Mauricio Handels Heinz BT - brainlesion: glioma, multiple sclerosis, stroke and traumatic brain injuries. Springer International Publishing, Cham2016: 57-68
        • Xi Guohua
        • Keep Richard F.
        • Hoff Julian T.
        Mechanisms of brain injury after intracerebral haemorrhage.
        Lancet Neurol. 2006; 5: 53-63
        • Carney Nancy
        • Totten Annette M.
        • O'Reilly Cindy
        • Ullman Jamie S.
        • Hawryluk Gregory W.J.
        • Bell Michael J.
        • et al.
        Guidelines for the management of severe traumatic brain injury.
        Neurosurgery. 2017; 80: 6-15
        • Powers William J.
        • Rabinstein Alejandro A.
        • Ackerson Teri
        • Adeoye Opeolu M.
        • Bambakidis Nicholas C.
        • Becker Kyra
        • et al.
        Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke a guideline for healthcare professionals from the American Heart Association/American Stroke A.
        Stroke. 2019; 50: E344-E418
        • Wolkewitz Martin
        • Palomar-Martinez Mercedes
        • Alvarez-Lerma Francisco
        • Olaechea-Astigarraga Pedro
        • Schumacher Martin
        Analyzing the impact of duration of ventilation, hospitalization, and ventilation episodes on the risk of pneumonia.
        Infect Control Hosp Epidemiol. 2019; 40: 301-306
        • Kaier Klaus
        • Heister Thomas
        • Motschall Edith
        • Hehn Philip
        • Bluhmki Tobias
        • Wolkewitz Martin
        Impact of mechanical ventilation on the daily costs of ICU care: a systematic review and meta regression.
        Epidemiol Infect. 2019; 147 (e314): e314
        • Moher David
        • Liberati Alessandro
        • Tetzlaff Jennifer
        • Altman Douglas G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151: 264
        • de Franca Sabrina A.
        • Tavares Wagner
        • Paiva Wellingson
        • Teixeira Manoel
        Early tracheostomy versus late tracheostomy in severe trauma brain injury or stroke: a systematic review and meta-analysis.
        PROSPERO. 2021; (Available at:)CRD42021242866
        • Wells G.A.
        • Brodsky L.
        • O'Connell D.
        • Shea B.
        • Henry D.
        • Mayank S.
        • et al.
        An evaluation of the Newcastle Ottawa Scale: an assessment tool for evaluating the quality of non-randomized studies.
        in: XI International Cochrane Colloquium B. Abstract. 2003: 26
        • Higgins J.P.T.
        • Savović J.
        • Page M.J.
        • Elbers R.G.
        • Sterne J.A.C.
        Chapter 8: assessing risk of bias in a randomized trial.
        in: Higgins J.P.T. Thomas J. Chandler J. Cumpston M. Li T. Page M.J. Cochrane Handbook for Systematic Reviews of Interventions version 6.1. 2020 (updated Sept. 2020). Cochrane
      1. U.S. Department of the Treasury. Treasury reporting rates of exchange - historical rates. Available at Accessed November 22, 2020, n.d.

        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Contr Clin Trials. 1986; 7: 177-188
      2. Higgins Julian PT, Green Sally. 9.5 heterogeneity. Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0. n.d.

        • Hozo Stela Pudar
        • Djulbegovic Benjamin
        • Hozo Iztok
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Res Methodol. 2005; 5: 13
        • Villwock Jennifer A.
        • Villwock Mark R.
        • Deshaies Eric M.
        Tracheostomy timing affects stroke recovery.
        J Stroke Cerebrovasc Dis. 2014; 23: 1069-1072
        • American College of Surgeons
        Tracheostomy. Am. Coll. Surg. Trauma qual. Improv. Progr. Guidel. Best Pract. Manag.
        Trauma. brain Inj. 2015; : 15-16
        • De Leyn Paul
        • Bedert Lieven
        • Delcroix Marion
        • Depuydt Pieter
        • Lauwers Geert
        • Sokolov Youri
        • et al.
        Tracheotomy: clinical review and guidelines.
        Eur J Cardio Thorac Surg. 2007; : 412-421
        • Cheung Nora H.
        • Napolitano Lena M.
        Tracheostomy: epidemiology, indications, timing, technique, and outcomes.
        Respir Care. 2014; 59 (LP): 895-919
        • Brass Patrick
        • Hellmich Martin
        • Ladra Angelika
        • Ladra Jürgen
        • Wrzosek Anna
        Percutaneous techniques versus surgical techniques for tracheostomy.
        Cochrane Database Syst Rev. 2016; 7: CD008045
        • Putensen Christian
        • Theuerkauf Nils
        • Guenther Ulf
        • Vargas Maria
        • Pelosi Paolo
        Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis.
        Crit Care. 2014; 18: 544
        • Plummer A.L.
        • Gracey D.R.
        Consensus conference on artificial airways in patients receiving mechanical ventilation.
        Chest. 1989; 96: 178-180
        • Liang Meng
        • Wang Chunmei
        • Li Jianxin
        • Zhang Jian
        Early vs late tracheostomy in critically ill patients: a systematic review and meta-analysis.
        Clin Res J. 2016; 10: 684-692
        • Carrie Liu C.
        • Devon Livingstone
        • Dixon Elijah
        • Dort Joseph C.
        Early versus late tracheostomy: a systematic review and meta-analysis.
        Otolaryngol Neck Surg Off J Am Acad Otolaryngol Neck Surg. 2015; 152: 219-227
        • Szakmany T.
        • Russell P.
        • Wilkes A.R.
        • Hall J.E.
        Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials.
        Br J Anaesth. 2015; 114: 396-405
        • de Franca Sabrina Araujo
        • Tavares Wagner M.
        • Salinet Angela S.M.
        • Paiva Wellingson S.
        • Teixeira Manoel J.
        Early tracheostomy in stroke patients: a meta-analysis and comparison with late tracheostomy.
        Clin Neurol Neurosurg. 2021; 203106554
        • de Franca Sabrina Araujo
        • Tavares Wagner M.
        • Salinet Angela S.M.
        • Paiva Wellingson S.
        • Teixeira Manoel J.
        Early tracheostomy in severe traumatic brain injury patients: a meta-analysis and comparison with late tracheostomy.
        Crit Care Med. 2020; 48: e325-e331
        • Wang Hao Kuang
        • Lu Kang
        • Chou Liliang Po
        • Wang Kuo Wei
        • Chen Han Jung
        • Chen Tai Been
        • et al.
        The impact of tracheostomy timing in patients with severe head injury: an observational cohort study.
        Injury. 2012; 43: 1432-1436
        • Alsherbini Khalid
        • Goyal Nitin
        • Metter E Jeffrey
        • Pandhi Abhi
        • Tsivgoulis Georgios
        • Huffstatler Tracy
        • et al.
        Predictors for tracheostomy with external balidation of the stroke-related early tracheostomy score (SETscore).
        Neurocritical Care. 2019; 30: 185-192
        • Chen Wei
        • Liu Fujun
        • Chen Jing
        • Ma Lu
        • Li Guoping
        • You Chao
        Timing and outcomes of tracheostomy in patients with hemorrhagic stroke.
        World Neurosurg. 2019; 131: e606-e613
        • Richardson Marty
        • Garner Paul
        • Donegan Sarah
        Interpretation of subgroup analyses in systematic reviews: a tutorial.
        Clin Epidemiol Glob Heal. 2019; 7: 192-198
        • Zolfaghari Parjam S.
        • Wyncoll Duncan L.A.
        The tracheal tube: gateway to ventilator-associated pneumonia.
        Crit Care. 2011; 15: 310
        • Salkind Neil
        Eyeball estimation.
        Encycl Meas Stat. 2007; 1: 335-336
        • Eyal Zimlichman
        • Henderson Daniel
        • Orly Tamir
        • Calvin Franz
        • Song Peter
        • Yamin Cyrus K.
        • et al.
        Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system.
        JAMA Intern Med. 2013; 173: 2039-2046
        • Zheng Yue
        • Sui Feng
        • Chen Xiu-Kai
        • Zhang Gui-Chen
        • Wang Xiao-Wen
        • Zhao Song
        • et al.
        Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation.
        Chin Med J (Engl). 2012; 125: 1925-1930
        • Koch Tillo
        • Hecker Birgit
        • Hecker Andreas
        • Brenck Florian
        • Preuß Matthias
        • Schmelzer Thorsten
        • et al.
        Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study.
        Langenbeck's Arch Surg. 2012; 397: 1001-1008
        • Jeon Young-Tae
        • Hwang Jung-Won
        • Lim Young-Jin
        • Lee Sue-Young
        • Woo Koung-In
        • Park Hee-Pyoung
        Effect of tracheostomy timing on clinical outcome in neurosurgical patients: early versus late tracheostomy.
        J Neurosurg Anesthesiol. 2014; 26: 22-26
        • Pier Paolo Terragni
        • Massimo Antonelli
        • Roberto Fumagalli
        • Chiara Faggiano
        • Maurizio Berardino
        • Franco Bobbio Pallavicini
        • et al.
        Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial.
        JAMA. 2010; 303: 1483-1489
        • Estebanez Roque Keroulay
        • Teresa Tonini
        • Prates Melo Enirtes Caetano
        Adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study.
        Cad Saúde Pública. 2016; 32: 1-15
        • Forster Alan J.
        • Kwadwo Kyeremanteng
        • Hooper Jon
        • Shojania Kaveh G.
        • Walraven Carl van
        The impact of adverse events in the intensive care unit on hospital mortality and length of stay.
        BMC Health Serv Res. 2008; 8: 259
        • Schreiber Martin A.
        • Aoki Noriaki
        • Scott Bradford G.
        • Robert Beck J.
        Determinants of mortality in patients with severe blunt head injury.
        Arch Surg. 2002; 137: 285-290
        • Biodun Ogungbo
        • Kumar Vinod
        • Barbara Gregson
        • Mendelow Alexander D.
        Mortality risk after head injury.
        J Am Coll Surg. 2004; 852–3 (; author reply 853)
        • Catalino Michael P.
        • Lin Feng-Chang
        • Davis Nathan
        • Anderson Keith
        • Olm-Shipman Casey
        • Dedrick Jordan J.
        Early versus late tracheostomy after decompressive craniectomy for stroke.
        J Intensive Care. 2018; 6: 1
        • Julian Bösel
        • Petra Schiller
        • Hook Yvonne
        • Michaela Andes
        • Jan-Oliver Neumann
        • Sven Poli
        • et al.
        Stroke-related early tracheostomy versus prolonged orotracheal intubation in neurocritical care trial (SETPOINT).
        Stroke. 2013; 44: 21-28
        • Gandía-Martínez F.
        • Martínez-Gil I.
        • Andaluz-Ojeda D.
        • Bobillo de Lamo F.
        • Parra-Morais L.
        • Díez-Gutiérrez F.
        Análisis de la traqueotomía precoz y su impacto sobre la incidencia de neumonía, consumo de recursos y mortalidad en pacientes neurocríticos.
        Neurocirugia (Astur). 2010; 21: 211-221
        • Gandjour Afschin
        How many intensive care beds are justifiable for hospital pandemic Preparedness? A cost-effectiveness analysis for COVID-19 in Germany.
        Appl Health Econ Health Pol. 2021; 19: 181-190
        • Meixensberger J.
        • Jaeger M.
        • Väth A.
        • Dings J.
        • Kunze E.
        • Roosen K.
        Brain tissue oxygen guided treatment supplementing ICP/CPP therapy after traumatic brain injury.
        J Neurol Neurosurg & Amp; Psychiatry. 2003; 74 (LP – 764): 760
        • Young Duncan
        • Harrison David A.
        • Cuthbertson Brian H.
        • Rowan Kathy
        Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial.
        JAMA, J Am Med Assoc. 2013; 309: 2121-2129