Key messages

• For adults hospitalised with more than one life-threatening injury, evidence from a single high-quality study suggests that performing tracheostomy (creating an opening in the windpipe to help with breathing) within nine days after intubation (insertion of a breathing tube into the windpipe through the mouth or nose), compared with tracheostomy from 10 days after intubation, may have little to no effect on the number of deaths, time spent in intensive care, or the number of lung infections. However, these results are very uncertain.

• Evidence from less reliable studies, where people were not randomly assigned to treatment groups, also suggests that tracheostomy within nine days may have little to no effect on the number deaths or the number of lung infections caused by use of a breathing machine, but might reduce the length of the intensive care unit stay. These results are also very uncertain.

• We are unsure about the best timing for tracheostomy in people with more than one life-threatening injury. There is a need for well-designed studies than assign people to treatment groups at random to clarify these findings and guide decision-making.

What is a tracheostomy?

Tracheostomy is a procedure where doctors cut through the skin at the front of the neck into the trachea (windpipe) to insert a breathing tube so that air can flow in directly. Compared with a breathing tube inserted through the mouth or nose (intubation), tracheostomy can make breathing safer and more comfortable during long-term care. However, tracheostomies may lead to complications like infection or blocking of the windpipe.

Tracheostomies may be performed 'early' or 'late' during ventilation. 'Early' often means within the first nine days after intubation, and 'late' at 10 days or later.

What did we want to find out?

We wanted to find out if early tracheostomy is better than late tracheostomy in adults with more than one life-threatening injury for improving:

• the number of deaths from any cause;

• the time spent in the intensive care unit;

• quality of life;

• the number of people developing a problem in the lung;

• the number of people with unwanted effects; and

• the time from insertion to removal of the tracheostomy tube.

What did we do?

We searched for studies comparing early and late tracheostomy in adults with more than one life-threatening injury. We compared and summarised their results and rated our confidence in the evidence based on factors such as study methods and sizes.

What did we find?

We found one high-quality study with 60 people and 22 lower-quality studies with 44,811 people. In total, 16,360 people had early tracheostomy. The average age of participants was 46.7 years. The studies used different time points to define early tracheostomy, ranging from 48 hours to 10 days after intubation. We were mainly interested in evaluating tracheostomy within nine days after intubation compared with tracheostomy at 10 days or later, so our main comparison only included studies that used this definition (the high-quality study and five lower-quality studies).

Results of our main comparison

Evidence from the high-quality study suggests that early tracheostomy compared with late tracheostomy may have little to no effect on the number of deaths, the time spent in the intensive care unit, and the number of lung infections, but these results are very uncertain.

Evidence from the lower-quality studies suggests that early tracheostomy compared with late tracheostomy may have little to no effect on the number of deaths and the number of lung infections caused by the use of a breathing machine, but may reduce the time people spend in the intensive care unit. All these results are very uncertain.

No studies in our main comparison looked at quality of life, unwanted effects, or time from insertion to removal of the tracheostomy tube.

What are the limitations of the evidence?

Our confidence in the evidence for all outcomes is limited due to differences between studies and concerns about the methods they used. Because the included studies used many definitions of early tracheostomy, it was difficult to compare their results directly.

Well-designed studies with standard definitions are needed to explore the effects of different tracheostomy timings. This may help identify whether certain time frames offer greater benefits for survival, recovery, or reducing complications.

How up to date is this evidence?

The evidence is current to 15 March 2024.