Early tracheostomy in severe traumatic brain injury: an umbrella systematic review

Andrade, Raul Ribeiro de; Pereira, Edla Vitória Santos; Aguiar, Igor Hudson Albuquerque e; Oliveira Neto, Olavo Barbosa de; Santos, João Gustavo Rocha Peixoto dos; Barbosa, Fabiano Timbó; Sousa-Rodrigues, Célio Fernando de

doi:10.1016/j.bjane.2026.844727

person Raul Ribeiro de Andrade ⁎

Conceptualization (Lead) · Data curation (Lead) · Formal analysis (Lead) · Investigation (Lead) · Methodology (Lead) · Project administration (Lead) · Writing-original draft (Lead)

schoolUniversidade Federal de Alagoas (UFAL), Instituto de Ciências Biológicas e da Saúde, Maceió, AL, Brazil

0000-0002-0294-1483

person Edla Vitória Santos Pereira

Data curation (Equal) · Formal analysis (Equal)

schoolUniversidade Federal de Alagoas (UFAL), Maceió, AL, Brazil

0000-0001-8622-6104

person Igor Hudson Albuquerque e Aguiar

Investigation (Equal)

schoolUniversidade Federal de Alagoas (UFAL), Maceió, AL, Brazil

0000-0001-8914-7452

person Olavo Barbosa de Oliveira Neto

Data curation (Supporting) · Formal analysis (Supporting) · Writing-review & editing (Supporting)

schoolUniversidade Federal de Alagoas (UFAL), Instituto de Ciências Biológicas e da Saúde, Maceió, AL, BrazilschoolCentro Universitário Cesmac, Faculdade de Medicina, Maceió, AL, BrazilschoolResearcher - Center for Research in Applied Morphology (CIMA) - La Frontera University - Temuco, Chile

0000-0003-1280-659X

person João Gustavo Rocha Peixoto dos Santos

Visualization (Supporting) · Writing-review & editing (Supporting)

schoolUniversidade de São Paulo (USP), São Paulo, SP, Brazil

0000-0001-8494-3556

person Fabiano Timbó Barbosa

Conceptualization (Equal) · Project administration (Equal) · Supervision (Equal) · Writing-review & editing (Equal)

schoolCentro Universitário Cesmac, Faculdade de Medicina, Maceió, AL, BrazilschoolUniversidade Federal de Alagoas (UFAL), Faculdade de Medicina, Maceió, AL, Brazil

0000-0001-6630-0629

person Célio Fernando de Sousa-Rodrigues

Formal analysis (Supporting) · Investigation (Supporting) · Methodology (Supporting) · Project administration (Supporting) · Supervision (Lead) · Writing-review & editing (Supporting)

schoolUniversidade Federal de Alagoas (UFAL), Instituto de Ciências Biológicas e da Saúde, Maceió, AL, BrazilschoolCentro Universitário Cesmac, Faculdade de Medicina, Maceió, AL, Brazil

0000-0002-1361-8139

Associate Editor:

Luiz Guilherme Villares da Costa

person⁎ Corresponding author.
E-mail address:raulrandrade.med@gmail.com (R. R. Andrade).

Conflicts of interest

The authors declare no conflicts of interest.

Outcome	Meta-analysis	Selected primary studies	Results
Mortality	McCredie et al. (2017)¹⁴	RCT Sugerman et al. (1997)¹⁸ Bouderka et al. (2004)¹⁹ Dunhan et al. (2014)²⁰ Barquist et al. 2006³²	RCT: RR = 1.2 [0.44, 3.30], I² = 37%
	Lu et al. (2018)¹⁵	RCT Sugerman et al. (1997)¹⁸ Bouderka et al. (2004)¹⁹ Dunhan et al. (2014)²⁰	RCT: OR = 2.58 [0.96, 6.96], I² = 0%
	Lu et al. (2018)¹⁵	Observational Siddiqui et al. (2015)²² Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷ Wang et al. (2012)²⁸	Cohort: OR = 1.15 [0.81, 1.63], I² = 0%
	Franca et al. (2020)¹⁶	RCT Dunhan et al. (2014)²⁰	RCT and Cohort: Risk = 0.03 [-0.02, 0.07], I² = 69%
	Franca et al. (2020)¹⁶	Observational Shibahashi et al. (2017)²¹ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	RCT and Cohort: Risk = 0.03 [-0.02, 0.07], I² = 69%
	Marra et al. (2021)¹⁷	RCT Sugerman et al. (1997)¹⁸ Dunhan et al. (2014)¹⁹	RCT: OR = 3.154 [0.456, 21.695], I² = 0%
	Marra et al. (2021)¹⁷	Observational Shibahashi et al. (2017)²¹ Robba et al. (2020)²³ Kahlili et al. (2017)²⁴ Rizk et al. (2011)²⁵ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	Cohort: OR 1.505 [0.993, 2.279], I²: 49.435%
VAP	McCredie et al. (2017)¹⁴	RCT Sugerman et al. (1997)¹⁸ Bouderka et al. (2004)¹⁹ Dunhan et al. (2014)²⁰ Barquist et al. (2006)³² Blot et al. (2008) Fayed et al. (2012)	RR = 0.89 [0.65, 1.21], I² = 54%
	Lu et al. (2018)¹⁵	RCT Sugerman et al. (1997)¹⁸ Bouderka et al. (2004)¹⁹ Dunhan et al. (2014)²⁰	RCT: OR = 0.89 [0.47, 1.68], I² = 0%
	Lu et al. (2018)¹⁵	Observational Siddiqui et al. (2015)²² Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷ Wang et al. (2012)²⁸	Cohort: OR = 0.62 [0.51, 0.77], I² = 0%
	Franca et al. (2020)¹⁶	RCT Dunhan et al. (2014)²⁰	RCT and Cohort: RR = 0.78 [0.70, 0.88], I² = 0%
	Franca et al. (2020)¹⁶	Observational Shibahashi et al. (2017)²¹ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	RCT and Cohort: RR = 0.78 [0.70, 0.88], I² = 0%
	Marra et al. (2021)¹⁷	Observational Shibahashi et al. (2017)²¹ Robba et al. (2020)²³ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷ Wang et al. (2012)²⁸	Cohort: OR = 0.623 [0.518, 0.750], I² = 0%
Time in MV	McCredie et al. (2017)¹⁴	RCT Sugerman et al. (1997)¹⁸ Bouderka et al. (2004)¹⁹ Dunhan et al. (2014)²⁰ Barquist et al. (2006)³² Blot et al. (2008) (NO TBI) Terragni et al. (2010) (NO TBI) Fayed et al. (2012) (NO TBI) Bösel et al. (2013) (NO TBI) Youngi et al. (2021) (NO TBI)	MD = -2.72 [-4.15, -2.19], I² = 0%
	Lu et al. (2018)¹⁵	RCT Bouderka et al. (2004)¹⁹ Dunhan et al. (2014)²⁰	RCT and Cohort: MD = -4.92 [-6.82, -3.02], I² = 51%
	Lu et al. (2018)¹⁵	Observational Siddiqui et al. (2015)²² Robba et al. (2020)²³ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷ Wang et al. (2012)²⁸	RCT and Cohort: MD = -4.92 [-6.82, -3.02], I² = 51%
	Franca et al. (2020)¹⁶	RCT Dunhan et al. (2014)²⁰	RCT and Cohort: MD = -4.15 [-6.30, -1.99], I² = 85%
	Franca et al. (2020)¹⁶	Observational Shibahashi et al. (2017)²¹ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	RCT and Cohort: MD = -4.15 [-6.30, -1.99], I² = 85%
	Marra et al. (2021)¹⁷	RCT Dunhan et al. (2014)²⁰	RCT and Cohort: MD = -4.866 [-6.981, -2.751], I² = 93.203%
	Marra et al. (2021)¹⁷	Observational Shibahashi et al. (2017)²¹ Robba et al. (2020)²³ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	RCT and Cohort: MD = -4.866 [-6.981, -2.751], I² = 93.203%
LOS (ICU)	McCredie et al. (2017)¹⁴	RCT Sugerman et al. (1997)¹⁸ Blot et al. (2008) (NO TBI) Terragni et al. (2010) (NO TBI) Bösel et al. (2013) (NO TBI) Youngi et al. (2021) (NO TBI)	MD = -2.55 [-4.59, -0.50], I² = 0%
	Lu et al. (2018)¹⁵	RCT Sugerman et al. (1997)¹⁸ Bouderka et al. (2004)¹⁹ Dunhan et al. (2014)²⁰	RCT and Cohorts: MD = -3.08 [-3.75, -2.41], I² = 38%
	Lu et al. (2018)¹⁵	Cohorts Siddiqui et al. (2015)²² Kahlili et al. (2017)²⁴ Ahmed, Kuo et al. (2007)²⁷ Wang et al. (2012)²⁸	RCT and Cohorts: MD = -3.08 [-3.75, -2.41], I² = 38%
	Franca et al. (2020)¹⁶	Cohorts Shibahashi et al. (2017)²¹ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	Cohorts: MD = -5.87 [-8.74, -3.00], I² = 83%
	Marra et al. (2021)¹⁷	Cohorts Shibahashi et al. (2017)²¹ Robba et al. (2020)²³ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	Cohorts: MD = -5.96 [-7.99, -3.92], I² = 88.661%
LOS (Hospital)	Lu et al. (2018)¹⁵	Cohorts Siddiqui et al. (2015)²² Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷ Wang et al. (2012)²⁸	Cohorts: MD = -4.79 [-8.63, -0.94]; I² = 59%
	Franca et al. (2020)¹⁶	Cohorts Shibahashi et al. (2017)²¹ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶	Cohorts: MD = -6.68 [-8.03, -5.32]; I² = 0%
	Marra et al. (2021)¹⁷	Cohorts Shibahashi et al. (2017)²¹ Robba et al. (2020)²³ Kahlili et al. (2017)²⁴ Alali et al. (2014)²⁶ Ahmed, Kuo et al. (2007)²⁷	Cohorts: MD = -6.97 [-8.25, -5.68]; I² = 0%

Outcome	Study	ET group	LT/PI group	Day of ET	N° of participants (studies)	Certainty of the evidence (GRADE)	Meta-analysis
Mortality	RCT
	Bouderka et al. (2004)¹⁹	12/31	7/31	5‒6 days	153 (3 RCTs)	⨁⨁◯◯ Lowa	RR = 1.86 [0.90, 3.84], I² = 0%
	Dunhan et al. (2014)²⁰	0/15	0/9	3‒5 days
	Surgerman et al. (1997)¹⁸	5/35	1/32	3‒5 days
	Cohorts
	Ahmed & Kuo et al. (2007)²⁷	4/27	1/28	≤ 7 days	5043 (7 Cohorts)	⨁◯◯◯ Very Lowa	RR = 1.32 [0.89, 1.96], I² = 56%
	Alali et al. (2014)²⁶	48/571	39/571	≤ 8 days
	Shibahashi et al. (2017)²¹	1/40	4/51	≤ 72 hours
	Rizk et al. (2011)²⁵	238/1577	111/1527	≤ 7 days
	Wang et al. (2012)²⁸	2/16	4/50	≤ 7 days
	Siddiqui et al. (2015)²²	4/49	9/51	≤ 7 days
	Khalili et al. (2017)²⁴	10/53	18/99	≤ 6 days
VAP	RCT
	Bouderka et al. (2004)¹⁹	12/31	7/31	5‒6 days	213 (3 RCTs)	⨁⨁◯◯ Lowa	RR = 0.94 [0.70, 1.27]; I² = 0%
	Dunhan et al. (2014)²⁰	0/15	0/9	3‒5 days
	Surgerman et al. (1997)¹⁸	5/35	1/32	3‒5 days
	Cohorts
	Ahmed & Kuo et al. (2007)²⁷	11/27	14/28	≤ 7 days	2039 (7 Cohorts)	⨁⨁◯◯ Lowb	RR = 0.78 [0.70, 0.86]; I² = 0%
	Alali et al. (2014)²⁶	238/571	301/571	≤ 8 days
	Shibahashi et al. (2017)²¹	13/40	21/51	≤ 72 hours
	Wang et al. (2012)²⁸	7/16	38/50	≤ 7 days
	Siddiqui et al. (2015)²²	22/49	32/51	≤ 7 days
	Khalili et al. (2017)²⁴	28/53	59/99	≤ 6 days
	Robba et al. (2020)²³	49/180	100/253	≤ 7 days
Time in MV	RCT
	Bouderka et al. (2004)¹⁹	14.5 ± 7.3d / 31p	17.5 ± 10.6d / 31p	5‒6 days	86 (2 RCTs)	⨁⨁◯◯ Lowa
	Dunhan et al. (2014)²⁰	14.1 ± 5.7d / 15p	19 ± 11.3d / 32 p	3‒5 days	86 (2 RCTs)	⨁⨁◯◯ Lowa	MD = -2.95 [-6.16, 0.26]; I² = 0%
	Retrospective cohorts
	Ahmed & Kuo et al. (2007)²⁷	15.7 ± 6d / 27p	25.8 ± 11.8d / 28p	≤ 7 days	1288 (3 cohorts)	⨁⨁⨁◯ Moderatec
	Alali et al. (2014)²⁶	21.4 ± 10.45d/571p*	24.9 ± 5.95d/ 571p*	≤ 8 days			MD = -3.26 [-3.94, -2.57]; I² = 0%
	Shibahashi et al. (2017)²¹	5 ± 1.54d / 40p*	8 ± 3.05d/ 51p*	≤ 72 hours			MD = -3.26 [-3.94, -2.57]; I² = 0%
	Prospective cohorts
	Wang et al. (2012)²⁸	13.7 ± 7.3d / 16p	23.4 ± 11d / 50p	≤ 7 days	499 (2 cohorts)	⨁⨁⨁⨁ Highd	MD = -7.53 [-9.05, -6.01]; I² = 0%
	Robba et al. (2020)²³	12.35 ± 6.73d/180p*	19.63 ± 10.29d/253p*	≤ 7 days	499 (2 cohorts)	⨁⨁⨁⨁ Highd	MD = -7.53 [-9.05, -6.01]; I² = 0%
ICU lenght of stay	RCT
	Surgerman et al. (1997)¹⁸	16 ± 5.9d / 35p	19 ± 11.3d / 32p	3‒5 days
	Retrospective cohorts
	Ahmed & Kuo et al. (2007)²⁷	19 ± 7.7d / 27p	25.8 ± 11.8d / 28p	≤ 7 days
	Alali et al. (2014)²⁶	13.7 ± 5.95d / 571p*	19.7 ± 7.43 / 571p*	≤ 8 days	1288 (3 Cohorts)	⨁⨁⨁◯ Moderatee	MD = -4.67 [-7.85, -1.5]; I² = 0%
	Shibahashi et al. (2017)²¹	10 ± 4.61d / 40p*	12.06 ± 3.81d / 51p*	≤ 72 hours	1288 (3 Cohorts)	⨁⨁⨁◯ Moderatee	MD = -4.67 [-7.85, -1.5]; I² = 0%
	Prospective cohorts
	Wang et al. (2012)²⁸	14.9 ± 8.9d / 16p	22.1 ± 7.6d / 50p	≤ 7 days	651 (3 Cohorts)	⨁⨁⨁◯ Moderatef	MD = -7.34 [-9.76, -4.92]; I² = 0%
	Khalili et al. (2017)²⁴	26.79 ± 13.16d/ 53p	34.92 ± 20.07d/ 99p	≤ 6 days
	Robba et al. (2020)²³	19.6 ± 19.9d / 180p	26.7 ± 12.5d / 253p	≤ 7 days
Hospital lenght of stay	Cohorts
	Ahmed & Kuo et al. (2007)²⁷	24.36 ± 5.48d / 27p*	28 ± 6,25d / 28p*	≤ 7 days	1939 (6 Cohorts)	⨁⨁⨁◯ Moderatef	MD = -3.53 [-4.44, -2.62]; I² = 0%
	Alali et al. (2014)²⁶	21.4 ± 10.41d/571p*	24.9 ± 5.95/571p*	≤ 8 days
	Shibahashi et al. (2017)²¹	52.64 ± 19.22d/40p*	56.29 ± 16.78d/51p	≤ 72 hours
	Wang et al. (2012)²⁸	38.0 ± 21.4d/ 16p	46.8 ± 22d / 50p	≤ 7 days
	Robba et al. (2020)²³	35.1 ± 34.4d /180p	34.7 ± 33.6d / 253 p	≤ 7 days
	Khalili et al. (2017)²⁴	38.58 ± 20.18d/ 53p	46.40 ± 24.56d/ 99p	≤ 6 days

[TFN1] ^a
Small number of events, Large IC.

[TFN2] ^b
LFK index: -2,10 (Major asymmetry), I² = 0%.

[TFN3] ^c
High magnitude of effect, I² = 0%, LFK index: -2,71 (Major asymmetry).

[TFN4] ^d
No asymmetry, I² = 0%, high magnitude of effect.

[TFN5] ^e
High magnitude of effect, High heterogeneity.

[TFN6] ^f
High magnitude of effect, I² = 0% (Major asymmetry).

ET, Early Tracheostomy; LT, Late Tracheostomy; PI, Prolonged Intubation; p, Participants.

Data in Mean ± Standard Deviation / participants.

[TFN7] ^⁎
Data converted of Median and Interquartile interval from primary studies by Wan et al. (2014).³⁹