Re: Early versus late tracheostomy: a systematic review and meta-analysis.

Liu et al report the conclusion that the cumulative result of all 11 studies is that early tracheostomy is associated with a decrease in intensive care unit (ICU) length of stay. The largest, best-designed studies do not concur. The largest effect size, suggesting ICU stay is shortened in association with early tracheostomy, is produced by much smaller studies, which are less robustly designed and considerably underpowered. By including all of these studies, the accurate answer is at risk of being drowned out by background “noise.” In this situation, Slavin’s principle of “best evidence” must be remembered when considering conclusions drawn from meta-analyses. Here, surely the best evidence included in the meta-analysis clearly shows no decrease in ICU length of stay? Neeraj Sethi, MRCS, DOHNS Leeds Institute of Cancer and Pathology, St James’ University Hospital, Leeds, UK