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

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

doi:10.1016/j.bjane.2026.844727

Artigo de Revisão

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

Traqueostomia precoce em lesão cerebral traumática grave: revisão sistemática em guarda-chuva

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

http://dx.doi.org/10.1016/j.bjane.2026.844727 Braz J Anesthesiol, vol.76, n3, 844727, 2026

PDF

Downloads: 0

Abstract

Background

Tracheostomy is an option to ensure airway safety in patients with severe traumatic brain injury. However, the optimal timing for tracheostomy remains unclear based on current evidence.

Methods

Umbrella systematic review to determine the effectiveness of early tracheostomy in TBI. Databases: PubMed, Embase, Scopus, Web of Science, Lilacs, Cochrane, Open Grey, and clinical trials. Inclusion criteria: Meta-analysis of early tracheostomy in severe TBI patients. Exclusion criteria: if there was no data regarding the time of death or the follow-up period. Data extraction: Selection, risk of bias evaluation, and data extraction were performed by two independent authors.

Results

Four meta-analyses were included from 5673 initial records, and a new meta-analysis was performed from data obtained in primary studies. The evidence included in this umbrella review showed that early tracheostomy reduced ICU (MD = -5.69 days; 95% CI [-7.78, -3.59]) and Hospital (MD = -3.53 days; 95% CI [-4.44, -2.62]) length of stay, time in mechanical ventilation (MD = -5.08; 95% CI [-7.12, -3.05]) and risk of ventilator associated pneumonia (RR = 0.78; 95% CI [0.70, 0.86],). These studies cannot determine the effectiveness of early tracheostomy on mortality (RR = 1.32; 95% CI [0.89, 1.96],) or neurological prognosis.

Conclusions

This umbrella review suggests that early tracheostomy is effective in reducing ICU and Hospital length of stay, time in mechanical ventilation, and ventilator-associated pneumonia.

Inplasy protocol

202280096.

Keywords

Epidemiology; Length of Stay; Mortality; Tracheostomy; Traumatic brain injury

Resumo

Introdução

A traqueostomia é uma opção para garantir a segurança das vias aéreas em pacientes com lesão cerebral traumática grave. No entanto, o momento ideal para sua realização ainda permanece incerto com base nas evidências atuais.

Métodos

Revisão sistemática em guarda-chuva com o objetivo de determinar a eficácia da traqueostomia precoce em pacientes com TCE grave. Bases de dados: PubMed, Embase, Scopus, Web of Science, Lilacs, Cochrane, Open Grey e registros de ensaios clínicos. Critérios de inclusão: metanálises sobre traqueostomia precoce em pacientes com TCE grave. Critérios de exclusão: ausência de dados sobre tempo de óbito ou período de seguimento. A extração de dados, seleção e avaliação de risco de viés foram realizadas por dois autores independentes.

Resultados

Quatro metanálises foram incluídas a partir de 5.673 registros iniciais, e uma nova metanálise foi realizada a partir de dados de estudos primários. As evidências incluídas nesta revisão em guarda-chuva mostraram que a traqueostomia precoce reduziu o tempo de permanência na UTI (MD = -5,69 dias; IC 95% [-7,78, -3,59]), tempo de internação hospitalar (MD = -3,53 dias; IC 95% [-4,44, -2,62]), tempo de ventilação mecânica (MD = -5,08; IC 95% [-7,12, -3,05]) e risco de pneumonia associada ao ventilador (RR = 0,78; IC 95% [0,70, 0,86]). Esses estudos não conseguiram determinar efeito sobre mortalidade (RR = 1,32; IC 95% [0,89, 1,96]) ou prognóstico neurológico.

Conclusão

Esta revisão em guarda-chuva sugere que a traqueostomia precoce é eficaz na redução do tempo de permanência em UTI e hospital, do tempo de ventilação mecânica e da incidência de pneumonia associada ao ventilador.

Protocolo de Inplasia

202280096.

Palavras-chave

Epidemiologia; Tempo de internação; Mortalidade; Traqueostomia; Lesão cerebral traumática

Referências

1. Dewan MC, Rattani A, Gupta S, et al. Estimating the global inci- dence of traumatic brain injury. J Neurosurg. 2018;130: 1080−97.

2. Santos JC. Traumatismo cranioencefálico no Brasil: análise epidemiológica. Rev Cient Esc Estadual Saúde Pública Goiás "Can- dido Santiago". 2020;6:e6000014.

3. Teasdale G, Jennett B. Assessment of coma and impaired con- sciousness. Lancet. 1974;304:81−4.

4. ATLS. Advanced Trauma Life Support. 2018. 10a Ed.

5. Belda FJ, et al. Manejo ventilatorio del paciente con traumatismo craneoencefálico grave. Rev Esp Anestesiol Reanim. 2004;51:143−50.

6. Asehnoune K, Roquilly A, Cinotti R. Respiratory Management in Patients with Severe Brain Injury. Crit Care (London, England). 2018;22:76.

7. Almeida KJ, Rodrigues ^AB, Lemos LEAS, et al. Hemotransfu- sion and mechanical ventilation time are associated with intra-hospital mortality in patients with traumatic brain injury admitted to intensive care unit. Arq Neuropsiquiatr. 2016;74:644−9.

8. Alves IK, Santos AA, Sousa TR, et al. Relação do traumatismo cranioencefálico grave com o tempo de permanência na ventilação mecânica invasiva. Rev Eletrônica Acervo Saúde. 2021;13:6691.

9. Loss SH, Oliveira RP de, Maccari JG, et al. The reality of patients requiring prolonged mechanical ventilation: a multi- center study. Rev Bras Ter Intensiva. 2015;27:26−35.

10. Heffner JE. The role of tracheotomy in weaning. Chest, Park Ridge. 2001;120:477−81.

11. Publicações GS. Diretrizes Brasileiras de Ventilação Mecânica 2013 [Internet] wwwjornaldepneumologiacombr; 2013 [Internet].

12. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1.

13. Andrade RR, Pereira EVS, Aguiar IHA, et al. Effectiveness of Early Tracheostomy compared with Late Tracheostomy Or Prolonged Orotracheal Intubation in Traumatic Brain Injury: Protocol of Umbrella Review. Inplasy Protocol. 2022:202280096.

14. McCredie VA, Alali AS, Scales DC, et al. Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care. 2017;26:14−25.

15. Lu Q, Xie Y, Qi X, et al. Is early tracheostomy better for severe traumatic brain injury? A meta-analysis. World Neurosurg. 2018;112:e324−30.

16. Franca SA, Tavares WM, Salinet ASM, et al. Early Tracheostomy in Severe Traumatic Brain Injury Patients: A Meta-Analysis and Com- parison With Late Tracheostomy. Crit Care Med. 2020;48:325−31.

17. Marra A, Vargas M, Buonanno P, Iacovazzo C, Coviello A, Servillo G. Early vs. Late tracheostomy in patients with traumatic brain injury: Systematic review and meta-analysis. J Clin Med. 2021;10:3319.

18. Sugerman HJ, Wolfe L, Pasquale MD, et al. Multicenter, random- ized, prospective trial of early tracheostomy. J Trauma. 1997;43:741−7.

19. Bouderka MA, Fakhir B, Bouaggad A, et al. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma. 2004;57:251−4.

20. Dunham CM, Cutrona AF, Gruber BS, Calderon JE, Ransom KJ, Flowers LL. Early tracheostomy in severe traumatic brain injury: evidence for decreased mechanical ventilation and increased hospital mortality. Int J Burns Trauma. 2014;4:14−24.

21. Shibahashi K, Sugiyama K, Houda H, et al. The effect of trache- ostomy performed within 72 h after traumatic brain injury. Br J Neurosurg. 2017;31:564−8.

22. Siddiqui U, Shamim M, Tahir M, et al. Clinical outcome and cost effectiveness of early tracheostomy in isolated severe head injury patients. Surg Neurol Int. 2015;6:65.

23. Robba C, Galimberti S, Graziano F, et al. Tracheostomy practice and timing in traumatic brain-injured patients: A CENTER-TBI study. Intensiv Care Med. 2020;46:983−94.

24. Khalili H, Paydar S, Safari R, et al. Experience with Traumatic Brain Injury: Is Early Tracheostomy Associated with Better Prog- nosis? World Neurosurg. 2017;103:88−93.

25. Rizk EB, Patel AS, Stetter CM, et al. Impact of tracheostomy timing on outcome after severe head injury. Neurocrit Care. 2011;15:481−9.

26. Alali AS, Scales DC, Fowler RA, et al. Tracheostomy timing in traumatic brain injury: a propensity-matched cohort study. J Trauma Acute Care Surg. 2014;76:70−6.

27. Ahmed N, Kuo YH. Early versus late tracheostomy in patients with severe traumatic head injury. Surg Infect (Larchmt). 2007;8:343−7.

28. Wang HK, Lu K, Liliang PC, et al. The impact of tracheostomy timing in patients with severe head injury: an observational cohort study. Injury. 2012;43:1432−6.

29. Qiu Y, Yin Z, Wang Z, et al. Early versus late tracheostomy in stroke-related patients: A systematic review and meta-analysis. J Clin Neurosci. 2023;114:48−54.

30. Tavares WM, Araujo de Fran¸ca S, Paiva WS, Teixeira MJ. Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis. Aust Crit Care. 2023;36:1110−6.

31. Mubashir T, Arif AA, Ernest P, et al. Early Versus Late Tra- cheostomy in Patients with Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis. Anesth Analg. 2020;132:384−94.

32. Barquist ES, Amortegui J, Hallal A, et al. Tracheostomy in venti- lator dependent trauma patients: a prospective, randomized intention-to-treat study. J Trauma. 2006;60:91−7.

33. Andriolo BN, Andriolo RB, Saconato H, Atallah ÁN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2023;11:CD015532.

34. Meng L, Wang C, Li J, Zhang J. Early vs late tracheostomy in critically ill patients: a systematic review and meta-analysis. Clin Respir J. 2015;10:684−92.

35. Quinn L, Veenith T, Bion J, Hemming K, Whitehouse T, Lilford R. Bayesian analysis of a systematic review of early versus late tra- cheostomy in ICU patients. Br J Anaesth. 2022;129:693−702.

36. Chorath K, Hoang A, Rajasekaran K, Moreira A. Association of Early vs Late Tracheostomy Placement with Pneumonia and Ven- tilator Days in Critically Ill Patients. JAMA Otolaryngol Head Neck Surg. 2021;147:450−9.

37. Villemure-Poliquin N, Lessard Bonaventure P, Costerousse O, et al. Impact of Early Tracheostomy Versus Late or No Tracheos- tomy in Nonneurologically Injured Adult Patients: A Systematic Review and Meta-Analysis*. Crit Care Med. 2022;51:310−8.

38. Bertini P, Marabotti A, Paternoster G, et al. Early versus late tracheostomy for traumatic brain injury: a systematic review and meta-analysis. Minerva Anestesiol. 2023;89:455−67.

39. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135.

Submetido em:
27/07/2025

Aceito em:
22/12/2025