JOURNAL READING Disusun oleh :

Mohamad Reza Hendratmoko / 30101206681

Dessy Surya Hadi Setiya Ningrum / 30101306909
Pembimbing :
Dr. Bambang Agus Susanto, Sp. THT-KL
 IDENTITAS JURNAL
 JUDUL : Early versus Late Tracheostomy: A Systematic
Review and Meta-Analysis
 PENULIS : C. Carrie Liu, MD, et al.
 PENERBIT : American Academy of Otolaryngology-Head
and Neck Surgery Foundation
 TAHUN TERBIT : 6 November 2014
INTRODUCTION
 1 Hospital mortality

2 Length of ICU stay

3 Length of mechanical ventilation

OUTCOME 4 Incidence of pneumonia

5 Laryngotracheal injury

6 Sedation use
METHOD
 INCLUSION CRITERIA
1 Randomized control trial

2 Critically ill patients requiring prolonged mechanical ventilation

3 Early VS late tracheostomy

Outcomes include at least one of : hospital mortality, length of ICU

4 stay, length of mechanical ventilation, incidence of pneumonia,
laryngotracheal injury, sedation use
 STATISTICAL ANALYSIS
1 Statistical analysis measured with RevMan 5 software

2 Differences measured by RR (Relative Risk) with 95% Confidence Interval

3 Significant p value is less than 0,05

4 I2 statistic used to quantify heterogeneity

RESULT : PNEUMONIA INCIDENCE
RESULT : LENGTH OF MECHANICAL
VENTILATION
RESULT : ICU LENGTH OF STAY
RESULT : HOSPITAL MORTALITY
RESULT : SEDATION USE AND LARYNGOTRACHEAL INJURY
Sedation use and laryngotracheal injury could only be qualitatively summarized as they were
heterogeneous and could not be combined in a quantitative analysis.

Bosel et al found a Rumbak et al also found a

significant decrease in
the use of sedatives in
the early tracheostomy
group (42%) compared
with the late
tracheostomy group
(62%)  (median
difference, 17.5 days;
95% CI, 3.3-29.2;
P = .02).
Young et al23
significant decrease in
found a significant
sedation use, with a
decrease in the median
mean (SD) of 3.2 (0.4)
number of days
days of sedation in the
of sedation use in the
early tracheostomy group
early tracheostomy group
compared with a mean
compared with the late
(SD) of 14.1 (2.9) days of
tracheostomy group (5 vs
sedation in the late
8 days, P < .001)
tracheostomy group
(P < .001).
RESULT : SEDATION USE AND LARYNGOTRACHEAL INJURY
SUBGROUP ANALYSIS
 DISCUSSION
Meta-analysis

Early Tracheostomy vs Late Tracheostomy

No Incidence of Length of Sedation Laryngotracheal

Decreased
difference pneumonia mechanical Use Injury
length of
was seen ventilation
ICU stay Did not lend
in hospital themselves to a no significant
Significant meta analysis differences in
mortality
heterogencity the
all 3 studies
occurrence of
examining
≠ pooled analysis  reported by early or late
this outcome
injury based
the reviewed studies varied in found a
on the timing
significant
direction (benefit & detriment) of
decrease in
tracheostomy
the early
tracheostomy
group
 DISCUSSION
Previous Meta-Analysis Result
Griffith et al Did not find a significant difference in mortality or pneumonia, but
they did find a significant decrease in the duration of mechanical
ventilation and ICU length of stay.
Wang et al Did not find a significant difference in any of the outcomes, including
mortality, pneumonia, length of mechanical ventilation, and length of
ICU stay.

Our meta-analysis also included 4 additional trials that have been reported since the Wang et al study.
Finally, we employed a more conservative and rigorous approach in the statistical analysis and interpretation
of our data. Specifically, we chose to forego pooled analyses for 2 of our outcomes due to significant
heterogeneity. In both the Griffith et al and Wang et al studies, data were combined for every outcome even
when significant heterogeneity was found (with the I2 statistic ranging from 58% to 87% in the Griffith et al
study and 0% to 98% in the Wang et al study). The following paragraph discusses the issue of combining data
in the presence of high statistical heterogeneity.
 DISCUSSION

1 Heterogeneity of the data

A common limitation Not have included all randomized

encountered in meta-analyses : 2
and quasi-randomized trials

Examining the optimal timing of

3
tracheostomies is the accuracy
with which the length of
mechanical ventilation can be
predicted
 Conclusion
When performed within 7 days, an early tracheostomy was significantly associated with a
decreased length of ICU stay. There was no difference in hospital mortality. There is not
1
enough evidence at present to support an early tracheostomy with regard to the incidence
of pneumonia or length of mechanical ventilation.

Subgroup analysis did not suggest a difference in outcomes based on the etiology of
2 critical illness or whether the early tracheostomy was performed at 2 to 3 days, 4 to 5
days, or 7 to 8 days of endotracheal intubation.
 CRITICAL
APPRAISAL
 Analisa PICO…
• Patient with critical illness that need prolonged
P mechanical ventilation and using tracheostomy

I • Early Tracheostomy

• Late Tracheostomy
C

• Hospital mortality, intensive care unit length of

stay, length of mechanical ventilation, incidence of
O pneumonia, laryngotracheal injury, and sedation use
 V I A analysis
VALIDITY
Apakah alokasi pasien pada penelitian ini dilakukan Ya
secara acak?
Apakah pengamatan pasien dilakukan secara cukup Ya
panjang dan lengkap?

Apakah semua populasi dalam kelompok yang Ya

diacak, dianalisis?

Apakah pasien dan dokter tetap blind dalam Ya

melakukan terapi, selain dari terapi yang diuji?
V I A analysis
IMPORTANT
 V I A analysis
APPLICABLE
Apakah pada pasien kita terdapat perbedaan bila Tidak ada
dibandingkan dengan yang terdapat pada penelitian pembanding
sblmnya sehingga hasil tersebut tidak dapat diterapkan
pada pasien kita?
Apakah pemberian terapi tersebut mungkin dapat Ya
diterapkan pada pasien kita?
Apakah pasien memiliki potensi yang menguntungkan Ya
bila terapi diatas diberikan?
the therapy study is VALID

the therapy study is

IMPORTANT

the therapy study is

APPLICABLE
 CRITICAL
APPRAISAL
 JUDUL & PENGARANG
No. Kriteria Ya( +) / Tidak (-)
1 Jumlah kata dalam judul ,< 12 kata YA (9 kata)

2. Deskripsi Judul +

3. Daftar penulis sesuai aturan jurnal +

4. Korespondensi penulis +

5. Tempat & waktu penelitian dalam Tidak ada

judul
 ABSTRAK
No. Kriteria Ya (+) / Tidak (-)

1. Abstrak 1 paragraf +

2. Mencakup IMRC +

3. Secara keseluruhan Informatif +

4. Tanpa singkatan selain yang baku +

5. Kurang dari 250 kata TIDAK (256 kata)

 PENDAHULUAN
No. Kriteria Ya (+) / Tidak
(-)
1. Terdiri dari 2 bagian atau 2 paragraf TIDAK (3)

2. Paragraf pertama mengemukakan alasan YA

dilakukan penelitian
3. Paragraf kedua menyatakan hipotesis atau YA
tujuan penelitian
4. Didukung oleh pustaka yang relevan +

5. Kurang dari 1 halaman +

 BAHAN & METODE PENELITIAN
No. Kriteria Ya (+), tidak (-)
1 Jenis dan rancangan penelitian Meta analysis
2 Waktu dan tempat penelitian Waktu +, tempat -
3 Populasi sumber +
4 Teknik sampling +
5 Kriteria inklusi +
6 Kriteria eksklusi -
7 Perkiraan dan perhitungan besar sampel -
8 Perincian cara penelitian +
9 Blind Tidak diketahui
10 Uji statistik +
11 Program komputer +
12 Persetujuan subjektif -
 HASIL
No. Kriteria Ya (+),tidak (-)

1 Jumlah subjek +

2 Tabel karakteristik subjek +

3 Tabel hasil penelitian +

4 Komentar dan pendapat penulis ttg hasil +

5 Tabel analisis data dengan uji +

 PEMBAHASAN, KESIMPULAN, DAFTAR
PUSTAKA
No. Kriteria Ya (+) / Tidak (-)

1 Pembahasan dan kesimpulan terpisah +

2 Pembahasan & kesimpulan dipaparkan dengan jelas +
3 Pembahasan mengacu dari penelitian sebelumnya +
4 Pembahasan sesuai landasan teori +
5 Keterbatasan penelitian +
6 Simpulan utama +
7 Simpulan berdasarkan penelitian +
8 Saran penelitian +

9 Penulisan daftar pustaka sesuai aturan +