Early versus late tracheostomy in critically ill COVID‐19 patients

Background The role of early tracheostomy as an intervention for critically ill COVID‐19 patients is unclear. Previous reports have described prolonged intensive care stays and difficulty weaning from mechanical ventilation in critically ill COVID‐19 patients, particularly in those developing acute respiratory distress syndrome. Pre‐pandemic evidence on the benefits of early tracheostomy is conflicting but suggests shorter hospital stays and lower mortality rates compared to late tracheostomy. Objectives To assess the benefits and harms of early tracheostomy compared to late tracheostomy in critically ill COVID‐19 patients. Search methods We searched the Cochrane COVID‐19 Study Register, which comprises CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv, as well as Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index) and WHO COVID‐19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions. We conducted the searches on 14 June 2022. Selection criteria We followed standard Cochrane methodology. We included randomized controlled trials (RCTs) and non‐randomized studies of interventions (NRSI) evaluating early tracheostomy compared to late tracheostomy during SARS‐CoV‐2 infection in critically ill adults irrespective of gender, ethnicity, or setting. Data collection and analysis We followed standard Cochrane methodology. To assess risk of bias in included studies, we used the Cochrane RoB 2 tool for RCTs and the ROBINS‐I tool for NRSIs. We used the GRADE approach to assess the certainty of evidence for outcomes of our prioritized categories: mortality, clinical status, and intensive care unit (ICU) length of stay. As the timing of tracheostomy was very heterogeneous among the included studies, we applied GRADE only to studies that defined early tracheostomy as 10 days or less, which was chosen according to clinical relevance. Main results We included one RCT with 150 participants diagnosed with SARS‐CoV‐2 infection and 24 NRSIs with 6372 participants diagnosed with SARS‐CoV‐2 infection. All participants were admitted to the ICU, orally intubated and mechanically ventilated. The RCT was a multicenter, parallel, single‐blinded study conducted in Sweden. Of the 24 NRSIs, which were mostly conducted in high‐ and middle‐income countries, eight had a prospective design and 16 a retrospective design. We did not find any o