Key messages

• For adults hospitalized with COVID-19 on mechanical ventilators, performing an early tracheostomy (where doctors cut through the skin into the trachea (windpipe) to insert a breathing tube) before 10 days after starting ventilation, may have little or no effect on deaths and the time patients spend on a ventilator compared with late tracheostomy, performed 10 days or more after starting ventilation.

• We are uncertain whether early tracheostomy improves or worsens patients’ condition or shortens their intensive care unit stay.

• Researchers should agree on key outcomes to be used in COVID-19 research; future research should focus on well‐designed studies with robust methods. We could then draw stronger conclusions about the best timing for tracheostomy in critically ill COVID-19 patients.

What is a tracheostomy?

A tracheostomy is a procedure where doctors cut through the skin into the trachea (windpipe) to insert a breathing tube. Breathing then takes place completely through this tube. Tracheostomies are performed on patients who require long-term ventilation in order to make ventilation easier and provide a safe airway access directly to the trachea. Compared to a breathing tube through the mouth, a tracheostomy tube offers less resistance to airflow. This can help to reduce the work of breathing and make weaning from mechanical ventilation easier. However, tracheostomies can also lead to complications. There is a risk of infection at the tracheostomy site. Prolonged placement of a tracheostomy tube can lead to obstruction of the windpipe. This can obstruct the flow of air and lead to breathing difficulties.

Tracheostomies may be performed 'early' or 'late' during ventilation. 'Early' is often defined as during the first 10 days of ventilation and 'late' as 10 days or more after ventilation started.

What is the link between tracheostomy and COVID‐19?

Most patients with severe COVID-19 need help with breathing. In some cases, this means long-term mechanical ventilation, so tracheostomy may be advised. In these patients, a tracheostomy can be associated with serious complications for both the patient and the caregiver. Patients with COVID-19 already have a higher risk of additional infections because their immune system is weakened. The tracheostomy can bring an additional risk of infection. These patients often have a higher risk of bleeding. Bleeding complications can happen during a tracheostomy. Doctors and nursing staff are at increased risk of becoming infected with the virus during the procedure.

To date, there are no universal recommendations for the best time to perform a tracheostomy for these patients.

What did we want to find out?

We wanted to find out the effects of early tracheostomy in very ill COVID‐19 patients on:

• death from any cause;

• whether patients got better after treatment, measured by how long they spent on a ventilator;

• whether patients' condition worsened so that they developed unwanted effects, such as lung infections; and

• how long they stayed in the intensive care unit.

What did we do?

We searched for studies that investigated the performance of early tracheostomy compared to late tracheostomy in hospitalized adults with COVID‐19.

We compared and summarized their results, and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found 1 good-quality study with 150 people, and 24 lower-quality studies with 6372 people. Patients’ average age was 62 years. Studies took place around the world, mainly in high- and upper-middle-income countries. All studies compared early with late tracheostomy but defined early and late differently. Early tracheostomy was defined at 7, 10, 12, 14 and 21 days after the start of mechanical ventilation. We selected up to 10 days for early tracheostomy and after 10 days as late. This was the time used by the good-quality study and in 6 of the other studies.

Main results

We found the following results from 1 study with 150 people.

Deaths: early tracheostomy may result in little to no difference to deaths from any cause. Of 1000 people, 67 fewer die when a tracheostomy is performed early.

Did patients get better with early tracheostomy? Early tracheostomy may result in little to no effect on how long patients spend on a ventilator.

Did patients get worse with early tracheostomy? Early tracheostomy may result in little to no difference in the number of patients:

• with any unwanted effect; or

• with ventilator-related lung infections.

How long did patients have to stay in the intensive care unit? Early tracheostomy may result in little benefit to no difference in the length of time patients spend in the intensive care unit.

What are the limitations of the evidence?

Our confidence in the evidence is very limited, because we found only 1 good-quality study with few participants. The other, less robust studies, performed tracheostomies at very different time points and measured and reported their results inconsistently.

How up to date is this evidence?

The evidence is up-to-date to 14 June 2022.

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