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Alamoudi NB, Hasen MA, Alamrie RM, Alabdulwahab NM, Alghamdi M, AlFaraj D, Alghamdi AA, Alsaied AS. Outcomes of delayed tracheostomy among intubated patients during the coronavirus disease pandemic. BMC Anesthesiol 2024; 24:268. [PMID: 39097688 PMCID: PMC11297775 DOI: 10.1186/s12871-024-02656-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 07/24/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Respiratory distress and failure is a complication of the coronavirus disease (COVID-19) and tracheostomy may be necessary in cases of prolonged intubation in order to reduce mechanical ventilation duration. However, according to the Canadian Society of Otolaryngology-Head and Neck Surgery guidelines, which our institution applies, patients should not undergo tracheostomy unless cleared of the virus to reduce its spread among healthcare workers because tracheostomy is an aerosolized procedure. This study aimed to identify the outcomes of prolonged intubation in patients with and without COVID-19 who underwent tracheostomy and to determine the morbidity and mortality rates in both groups. METHODS This retrospective cohort study included adult patients admitted to the intensive care unit of King Fahad Hospital of the University, Alkhobar, Saudi Arabia, between March 1 and October 31, 2020. This study compared and analyzed the outcomes of delayed tracheostomy in patients with and without COVID-19 in terms of complication, morbidity, and mortality rates. RESULTS Of the 228 study participants, 111 (48.68%) had COVID-19. The mean age of the study participants was 58.67 years (SD = 17.36, max.=93, min.=20), and the majority were males (n = 149, 65.35%). Regarding tracheostomy in patients with COVID-19, 11 (9.91%) patients underwent tracheostomy; however, four (36.36%) of them had prolonged intubation. The mean intensive care unit admission length of stay for tracheostomy patients was 37.17 days, while it was 12.09 days for patients without tracheostomy (t(226)=-9.32, p < 0.001). Regarding prolonged intubation among patients with COVID-19 (n = 7, 6.31%), the complications were as follows: six people (85.71%) had dysphonia, one (14.29%) had vocal cord granuloma, and two (28.57%) had subglottic tracheal stenosis. The mortality rate among our study participants was 51.32%, and the risk was significantly higher in older people (Odds ratio = 1.04, 95% Confidence Interval [CI] = 1.02-1.06) and in delayed tracheostomy cases (OR = 2.95, 95% CI = 1.31-6.63). However, COVID-19 status was not significantly related to the risk of mortality. CONCLUSIONS Delaying tracheostomy increases the risk of mortality. Therefore, we recommend weighing the risks and benefits for each patient to benefit both healthcare workers and patients with COVID-19.
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Affiliation(s)
- Naela B Alamoudi
- Department of Emergency Medicine, King Fahad Specialist Hospital, Eastern Health Cluster, Ministry of Health, Dammam, Saudi Arabia
| | - Majd A Hasen
- Department of Family and Community Medicine, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Rahmah M Alamrie
- Dermatology Department, Eastern Health cluster, Dammam, Saudi Arabia
| | - Noof M Alabdulwahab
- Department of Orthopedic Surgery, Dammam Medical Complex, Dammam, Saudi Arabia
| | - Mohammed Alghamdi
- Department of Emergency Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia.
| | - Dunya AlFaraj
- Department of Emergency Medicine, King Fahad University Hospital, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Amal A Alghamdi
- Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulmalik S Alsaied
- Department of ENT, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Tochigi K, Sakamoto H, Omura K, Kessoku H, Takeda T, Oguro R, Kojima H, Tanaka Y. Safety of cricotracheostomy with skin and tracheal membrane flaps for severe COVID-19 patients. Auris Nasus Larynx 2024; 51:583-587. [PMID: 38552421 DOI: 10.1016/j.anl.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 02/04/2024] [Accepted: 03/13/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE Airway surgery is performed for COVID-19 patients who require long-term tracheal intubation and mechanical ventilation. Tracheostomy sometimes causes postoperative complications represented by bleeding at a relatively high rate in COVID-19 patients. As an alternative surgical procedure to tracheostomy, cricotracheostomy may reduce these complications, but few studies have examined its safety. METHODS Data were retrospectively collected for sixteen COVID-19 patients (11 underwent tracheostomy, 5 underwent modified cricotracheostomy). In addition to patients' backgrounds and blood test data, the frequency of complications and additional care required for postoperative complications were collected. Statistical analysis was conducted by the univariate analysis of Fischer analysis and Mann-Whitney U test. RESULTS Five cases experienced postoperative bleeding, four cases experienced peristomal infection, and one case experienced subcutaneous emphysema in the tracheostomy patients. These complications were not observed in the cricotracheostomy patients. The number of additional cares for postoperative complications was significantly lower in cricotracheostomy than in tracheostomy patients (p < 0.05). CONCLUSIONS Modified cricotracheostomy could be a safe procedure in airway surgery for patients with COVID-19 from the point of fewer postoperative complications and additional care. It might be necessary to select the cricotracheostomy depending on patients' background to reduce postoperative complications.
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Affiliation(s)
- Kosuke Tochigi
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hikaru Sakamoto
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuhiro Omura
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan; Department of Otorhinolaryngology/Head and Neck Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Hisashi Kessoku
- Department of Otorhinolaryngology/Head and Neck Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Teppei Takeda
- Department of Otorhinolaryngology/Head and Neck Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryoji Oguro
- Department of Otorhinolaryngology/Head and Neck Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiromi Kojima
- Department of Otorhinolaryngology/Head and Neck Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasuhiro Tanaka
- Department of Otorhinolaryngology/Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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Szafran A, Dahms K, Ansems K, Skoetz N, Monsef I, Breuer T, Benstoem C. Early versus late tracheostomy in critically ill COVID-19 patients. Cochrane Database Syst Rev 2023; 11:CD015532. [PMID: 37982427 PMCID: PMC10658650 DOI: 10.1002/14651858.cd015532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
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 ongoing studies. RCT-based evidence We judged risk of bias for the RCT to be of low or some concerns regarding randomization and measurement of the outcome. Early tracheostomy may result in little to no difference in overall mortality (RR 0.82, 95% CI 0.52 to 1.29; RD 67 fewer per 1000, 95% CI 178 fewer to 108 more; 1 study, 150 participants; low-certainty evidence). As an indicator of improvement of clinical status, early tracheostomy may result in little to no difference in duration to liberation from invasive mechanical ventilation (MD 1.50 days fewer, 95%, CI 5.74 days fewer to 2.74 days more; 1 study, 150 participants; low-certainty evidence). As an indicator of worsening clinical status, early tracheostomy may result in little to no difference in the incidence of adverse events of any grade (RR 0.94, 95% CI 0.79 to 1.13; RD 47 fewer per 1000, 95% CI 164 fewer to 102 more; 1 study, 150 participants; low-certainty evidence); little to no difference in the incidence of ventilator-associated pneumonia (RR 1.08, 95% CI 0.23 to 5.20; RD 3 more per 1000, 95% CI 30 fewer to 162 more; 1 study, 150 participants; low-certainty evidence). None of the studies reported need for renal replacement therapy. Early tracheostomy may result in little benefit to no difference in ICU length of stay (MD 0.5 days fewer, 95% CI 5.34 days fewer to 4.34 days more; 1 study, 150 participants; low-certainty evidence). NRSI-based evidence We considered risk of bias for NRSIs to be critical because of possible confounding, study participant enrollment into the studies, intervention classification and potentially systematic errors in the measurement of outcomes. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases overall mortality (RR 1.47, 95% CI 0.43 to 5.00; RD 143 more per 1000, 95% CI 174 less to 1218 more; I2 = 79%; 2 studies, 719 participants) or duration to liberation from mechanical ventilation (MD 1.98 days fewer, 95% CI 0.16 days fewer to 4.12 more; 1 study, 50 participants), because we graded the certainty of evidence as very low. Three NRSIs reported ICU length of stay for 519 patients with early tracheostomy (≤ 10 days) as a median value, which we could not include in the meta-analyses. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases the ICU length of stay, because we graded the certainty of evidence as very low. AUTHORS' CONCLUSIONS We found low-certainty evidence that early tracheostomy may result in little to no difference in overall mortality in critically ill COVID-19 patients requiring prolonged mechanical ventilation compared with late tracheostomy. In terms of clinical improvement, early tracheostomy may result in little to no difference in duration to liberation from mechanical ventilation compared with late tracheostomy. We are not certain about the impact of early tracheostomy on clinical worsening in terms of the incidence of adverse events, need for renal replacement therapy, ventilator-associated pneumonia, or the length of stay in the ICU. Future RCTs should provide additional data on the benefits and harms of early tracheostomy for defined main outcomes of COVID-19 research, as well as of comparable diseases, especially for different population subgroups to reduce clinical heterogeneity, and report a longer observation period. Then it would be possible to draw conclusions regarding which patient groups might benefit from early intervention. Furthermore, validated scoring systems for more accurate predictions of the need for prolonged mechanical ventilation should be developed and used in new RCTs to ensure safer indication and patient safety. High-quality (prospectively registered) NRSIs should be conducted in the future to provide valuable answers to clinical questions. This could enable us to draw more reliable conclusions about the potential benefits and harms of early tracheostomy in critically ill COVID-19 patients.
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Affiliation(s)
- Agnieszka Szafran
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Karolina Dahms
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Kelly Ansems
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Breuer
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Carina Benstoem
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Bahk J, Dolan B, Sharma V, Sehmbhi M, Fung JY, Lee YI. Characteristics and Outcomes of Tracheostomized Patients With and Without COVID-19. Crit Care Explor 2023; 5:e0950. [PMID: 37546230 PMCID: PMC10403025 DOI: 10.1097/cce.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Outcomes of tracheostomized patients with COVID-19 are seldomly investigated with conflicting evidence from the existing literature. OBJECTIVES To create a study evaluating the impact of COVID-19 on tracheostomized patients by comparing clinical outcomes and weaning parameters in COVID-19 positive and negative cohorts. DESIGN SETTING AND PARTICIPANTS A retrospective observational cohort study of 604 tracheostomized patients hospitalized in 16 ICUs in New York City between March 9, 2020, and September 8, 2021. MAIN OUTCOMES AND MEASURES Patients were stratified into two cohorts: 398 COVID-19 negative (COVID-ve) and 206 COVID-19 positive (COVID+ve) patients. Clinical characteristics, outcomes, and weaning parameters (first pressure support [PS], tracheostomy collar [TC], speech valve placement, and decannulation) were analyzed. RESULTS COVID+ve had fewer comorbidities including coronary artery disease, congestive heart failure, malignancy, chronic kidney disease, liver disease, and HIV (p < 0.05). Higher Fio2 (53% vs 44%), positive end-expiratory pressure (PEEP) (7.15 vs 5.69), Pco2 (45.8 vs 38.2), and lower pH (7.41 vs 7.43) were observed at the time of tracheostomy in COVID+ve (p < 0.005). There was no statistical difference in post-tracheostomy complication rates. Longer time from intubation to tracheostomy (15.90 vs 13.60 d; p = 0.002), tracheostomy to first PS (2.87 vs 1.80 d; p = 0.005), and TC placement (11.07 vs 4.46 d; p < 0.001) were seen in COVID+ve. However, similar time to speech valve placement, decannulation, and significantly lower 1-year mortality (23.3% vs 36.7%; p = 0.001) with higher number of discharges to long-term acute care hospital (LTACH) (23.8% vs 13.6%; p = 0.015) were seen in COVID+ve. CONCLUSIONS AND RELEVANCE Patients with COVID-19 required higher Fio2 and PEEP ventilatory support at the time of tracheostomy, with no observed change in complication rates. Despite longer initial weaning period with PS or TC, similar time to speech valve placement or decannulation with significantly lower mortality and higher LTACH discharges suggest favorable outcome in COVID-19 positive patients. Higher ventilatory support requirements and prolonged weaning should not be a deterrent to pursuing a tracheostomy.
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Affiliation(s)
- Jeeyune Bahk
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bridget Dolan
- Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Venus Sharma
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mantej Sehmbhi
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jennifer Y Fung
- Division of Pulmonary and Critical Care, Department of Medicine, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Young Im Lee
- Division of Pulmonary and Critical Care, Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY
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Cavalli E, Belfiori G, Molinari G, Peghetti A, Zanoni A, Chinelli E. Does a decannulation protocol exist in COVID-19 patients? The importance of working in a multiprofessional team. DISCOVER HEALTH SYSTEMS 2023; 2:14. [PMID: 37520514 PMCID: PMC10099004 DOI: 10.1007/s44250-023-00031-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/27/2023] [Indexed: 08/01/2023]
Abstract
As a Covid Hub in Emilia Romagna, we have experienced an increasing number of tracheostomized patients, prompting us to develop a standardized decannulation protocol for COVID-19 ARDS patients. Currently, there are no guidelines or protocols for decannulation in this population, and few studies have investigated the early outcomes of tracheostomy in COVID-19 patients, with no detailed analysis of the decannulation process. We recognized the importance of mutual reliance among our team members and the significant achievements we made compared to previous decannulation methods. Through the optimization of the decannulation process, we identified a clear, safe, and repeatable method based on clinical best practice and literature evidence. We decided to implement an existing standardized decannulation protocol, which was originally designed for severe brain-damaged patients, due to the growing number of COVID-19 patients with tracheostomy. This protocol was designed for daily practice and aimed to provide a uniform approach to using devices like fenestrated cannulas, speaking valves, and capping. The results of our implementation include:expanding the applicability of the protocol beyond severe brain-damaged patients to different populations and settings (in this case, patients subjected to a long period of sedation and invasive ventilation)early activation of speech therapy to facilitate weaning from the cannula and recovery of physiological swallowing and phonationearly activation of otolaryngologist evaluation to identify organic problems related to prolonged intubation, tracheostomy, and ventilation and address proper speech therapy treatmentactivation of more fluid and effective management paths for decannulation with a multiprofessional team.
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Affiliation(s)
- E. Cavalli
- Physical Medicine and Rehabilitation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - G. Belfiori
- Physical Medicine and Rehabilitation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - G. Molinari
- Otolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - A. Peghetti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - A. Zanoni
- Anesthesia and Intensive Care in Local, Regional and National Emergencies and in Major Abdominal Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
| | - E. Chinelli
- Anesthesia and Intensive Care in Local, Regional and National Emergencies and in Major Abdominal Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni N°15, 40138 Bologna, Italy
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6
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McCauley P, Mohammed A, Casey M, Ramadan E, Galvin S, O'Neill JP, Curley G, Sulaiman I, O'Brien ME, O'Rourke J. Tracheostomy insertion in COVID-19: insertion practice and factors leading to unplanned tube exchange. J Thorac Dis 2023; 15:410-422. [PMID: 36910100 PMCID: PMC9992599 DOI: 10.21037/jtd-22-896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/12/2022] [Indexed: 02/10/2023]
Abstract
Background Tracheostomy insertion in patients with coronavirus disease 2019 (COVID-19) presents unique challenges. Patients frequently have high ventilatory requirements, and as an aerosol generating procedure, tracheostomy insertion creates the potential for staff transmission. Problems with tracheostomies contribute to morbidity and mortality, and tracheostomy changes may increase risks of staff transmission. We sought to quantify the incidence of clinically necessitated tracheostomy changes, establish the indications for change and investigate the incidence of staff transmission. Methods We conducted a single institution, retrospective, observational cohort study of all intensive care unit (ICU) patients with COVID-19 who had a tracheostomy between March 2020 and April 2021. The institution is a large tertiary referral centre in Ireland. Results Forty-three patients had a tracheostomy during the study period. All were a Shiley™ Flexible Adult Taperguard or Shiley™ XLT Tracheostomy. 14 patients (33%) required a tracheostomy change, with the majority (57%) involving a change from a standard size to an extended length tracheostomy. Persistent leak was the most common indication for change (71.6%). Other indications included patient-ventilator dyssynchrony, persistent cough and accidental decannulation. No staff transmission of COVID-19 occurred during this study. Conclusions The incidence of tracheostomy change was 33%, highlighting the importance of selecting the right tracheostomy for each patient. We discuss how key characteristics of tracheostomies such as type, size, length and inner diameter may impact flow, resistance and work of breathing, leading to unplanned tracheostomy change. No staff transmission occurred arising from tracheostomy insertion, adding to increasing evidence that tracheostomy insertion in COVID-19 appears safe with adherence to guidelines describing the correct use of personal protective equipment.
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Affiliation(s)
- Peter McCauley
- Department of Anaesthesia and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
| | - Amr Mohammed
- Department of Anaesthesia and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
| | - Michelle Casey
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | - Eslam Ramadan
- Department of Anaesthesia and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
| | - Sinéad Galvin
- Department of Anaesthesia and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
| | - James Paul O'Neill
- Department of Ear, Nose and Throat Surgery, Beaumont Hospital, Dublin, Ireland
| | - Gerard Curley
- Department of Anaesthesia and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
| | - Imran Sulaiman
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Ireland
| | | | - James O'Rourke
- Department of Anaesthesia and Critical Care Medicine, Beaumont Hospital, Dublin, Ireland
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7
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Shreckengost CSH, Wan L, Reitz AW, Lin A, Dhamsania RK, Spychalski J, Douglas JM, Lane A, Amin D, Roser S, Berkowitz D, Foianini JE, Moore R, Sreedharan JK, Niroula A, Smith R, Khullar OV. Tracheostomies of Patients With COVID-19: A Survey of Infection Reported by Health Care Professionals. Am J Crit Care 2023; 32:9-20. [PMID: 36065019 DOI: 10.4037/ajcc2022337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Health care professionals (HCPs) performing tracheostomies in patients with COVID-19 may be at increased risk of infection. OBJECTIVE To evaluate factors underlying HCPs' COVID-19 infection and determine whether tracheostomy providers report increased rates of infection. METHODS An anonymous international survey examining factors associated with COVID-19 infection was made available November 2020 through July 2021 to HCPs at a convenience sample of hospitals, universities, and professional organizations. Infections reported were compared between HCPs involved in tracheostomy on patients with COVID-19 and HCPs who were not involved. RESULTS Of the 361 respondents (from 33 countries), 50% (n = 179) had performed tracheostomies on patients with COVID-19. Performing tracheostomies on patients with COVID-19 was not associated with increased infection in either univariable (P = .06) or multivariable analysis (odds ratio, 1.48; 95% CI, 0.90-2.46; P = .13). Working in a low- or middle-income country (LMIC) was associated with increased infection in both univariable (P < .001) and multivariable analysis (odds ratio, 2.88; CI, 1.50-5.53; P = .001). CONCLUSIONS Performing tracheostomy was not associated with COVID-19 infection, suggesting that tracheostomies can be safely performed in infected patients with appropriate precautions. However, HCPs in LMICs may face increased infection risk.
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Affiliation(s)
| | - Limeng Wan
- Limeng Wan is a student, Rollins School of Public Health, Emory University
| | - Alexandra W Reitz
- Alexandra W. Reitz is a resident physician, Department of Surgery, Emory University
| | - Alice Lin
- Alice Lin is a student, Rollins School of Public Health, Emory University
| | - Rohan K Dhamsania
- Rohan K. Dhamsania is a student, Philadelphia College of Osteopathic Medicine, Suwanee, Georgia
| | - Julia Spychalski
- Julia Spychalski is a student, Rollins School of Public Health, Emory University
| | - J Miller Douglas
- J. Miller Douglas is a student, Department of Surgery and Rollins School of Public Health, Emory University
| | - Andrea Lane
- Andrea Lane is a student, Rollins School of Public Health, Emory University
| | - Dina Amin
- Dina Amin is an assistant professor, Department of Surgery, Emory University and a surgeon, Oral and Maxillofacial Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | - Steven Roser
- Steven Roser is a professor, Department of Surgery, Emory University and a surgeon, Oral and Maxillofacial Surgery, Grady Memorial Hospital, Atlanta, Georgia
| | - David Berkowitz
- David Berkowitz is a physician and professor, Department of Medicine, School of Medicine, Emory University
| | | | - Renée Moore
- Renée Moore is a professor, Rollins School of Public Health, Emory University
| | - Jithin K Sreedharan
- Jithin K. Sreedharan is general secretary, Indian Association of Respiratory Care, Kochi, India
| | - Abesh Niroula
- Abesh Niroula is a physician, Department of Medicine, School of Medicine, Emory University
| | - Randi Smith
- Randi Smith is a surgeon, Department of Surgery, Emory University, a professor, Rollins School of Public Health, Emory University, and a surgeon, Trauma and Surgical Critical Care, Grady Memorial Hospital
| | - Onkar V Khullar
- Onkar V. Khullar is a surgeon, Department of Surgery, Emory University
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8
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Arnold J, Gao CA, Malsin E, Todd K, Argento AC, Cuttica M, Coleman JM, Wunderink RG, Smith SB. Outcomes of Percutaneous Tracheostomy for Patients With SARS-CoV-2 Respiratory Failure. J Bronchology Interv Pulmonol 2023; 30:60-65. [PMID: 35696591 PMCID: PMC9532460 DOI: 10.1097/lbr.0000000000000854] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 02/17/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause severe respiratory failure leading to prolonged mechanical ventilation. Data are just emerging about the practice and outcomes of tracheostomy in these patients. We reviewed our experience with tracheostomies for SARS-CoV-2. METHODS We retrospectively reviewed the demographics, comorbidities, timing of mechanical ventilation, tracheostomy, and intensive care unit and hospital lengths of stay in SARS-CoV-2 patients who received tracheostomies performed by the interventional pulmonary team. A tertiary care, teaching hospital in Chicago, Illinois. From March 2020 to April 2021, our center had 473 patients intubated for SARS-CoV-2, and 72 (15%) had percutaneous bedside tracheostomy performed by the interventional pulmonary team. RESULTS Median time from intubation to tracheostomy was 20 (interquartile range: 16 to 25) days. Demographics and comorbidities were similar between early and late tracheostomy, but early tracheostomy was associated with shorter intensive care unit lengths of stay and a shorter total duration of ventilation. To date, 39 (54%) patients have been decannulated, 17 (24%) before hospital discharge; median time to decannulation was 22 (IQR: 18 to 36) days. Patients that were decannulated were younger (56 vs. 69 y). The rate of decannulation for survivors was 82%. No providers developed symptoms or tested positive for SARS-CoV-2. CONCLUSION Tracheostomy enhances care for patients with prolonged respiratory failure from SARS-CoV-2 since early tracheostomy is associated with shorter duration of critical care, and decannulation rates are high for survivors. It furthermore appears safe for both patients and operators.
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Affiliation(s)
| | - Catherine A. Gao
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth Malsin
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kristy Todd
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Angela Christine Argento
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael Cuttica
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John M. Coleman
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sean B. Smith
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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9
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Morales Castro D, Abdelnour-Berchtold E, Urner M, Dragoi L, Cypel M, Fan E, Douflé G. Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 Patients. J Cardiothorac Vasc Anesth 2022; 36:4296-4304. [PMID: 36038441 PMCID: PMC9338225 DOI: 10.1053/j.jvca.2022.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVES A paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19. DESIGN Single-center retrospective cohort study. SETTING The study took place in the intensive care unit of an academic tertiary center. PARTICIPANTS The authors included 107 patients with confirmed SARS-CoV-2 infection who underwent bedside venovenous ECMO (VV ECMO) cannulation under TEE guidance between May 2020 and June 2021. INTERVENTIONS TEE-guided bedside VV ECMO cannulation. MEASUREMENTS Patient characteristics, physiologic and ventilatory parameters, and echocardiographic findings were analyzed. The primary outcome was the number of successful TEE-guided bedside cannulations without complications. The secondary outcomes were cannulation complications, frequency of cannula repositioning, and TEE-related complications. MAIN RESULTS TEE-guided cannulation was successful in 99% of the patients. Initial cannula position was adequate in all but 1 patient. Fourteen patients (13%) required cannula repositioning during ECMO support. Forty-five patients (42%) had right ventricular systolic dysfunction, and 9 (8%) had left ventricular systolic dysfunction. Twelve patients (11%) had intracardiac thrombi. One superficial arterial injury and 1 pneumothorax occurred. No pericardial tamponade, hemothorax or intraabdominal bleeding occurred in the authors' cohort. No TEE-related complications or COVID-19 infection of healthcare providers were reported during this study. CONCLUSIONS Bedside TEE guidance for VV ECMO cannulation is safe in patients with severe respiratory failure due to COVID-19. No tamponade or hemothorax, nor TEE-related complications were observed in the authors' cohort.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | | | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Marcelo Cypel
- Department of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada,Department of Medicine, University of Toronto, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada.
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10
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Singh Y, Soni KD, Singh A, Choudhary N, Perveen F, Aggarwal R, Patel N, Kumar S, Trikha A. Clinical characteristics of COVID-19 patients who underwent tracheostomy and its effect on outcome: A retrospective observational study. World J Virol 2022; 11:477-484. [PMID: 36483098 PMCID: PMC9724205 DOI: 10.5501/wjv.v11.i6.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/12/2022] [Accepted: 09/22/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The exponential rise in Coronavirus disease 2019 (COVID-19) cases has resulted in an increased number of patients requiring prolonged ventilatory support and subsequent tracheostomy. With the limited availability of literature regarding the outcomes of COVID-19 patients with tracheostomy, we attempted to study the clinical characteristics and multiple parameters affecting the outcomes in these patients.
AIM To determine all-cause mortality following tracheostomy and its association with various risk factors in COVID-19 patients.
METHODS This retrospective study included 73 adult COVID-19 patients admitted to the ICU between 1 April, 2020 and 30 September, 2021 who underwent tracheostomy as a result of acute respiratory failure due to COVID-19. The data collected included demographics (age, sex), comorbidities, type of oxygen support at admission, severity of COVID-19, complications, and other parameters such as admission to tracheostomy, intubation to tracheostomy, ICU stay, hospital stay, and outcome.
RESULTS This study included 73 adult patients with an average age of 52 ± 16.67 years, of which 52% were men. The average time for admission to tracheostomy was 18.12 ± 12.98 days while intubation to tracheostomy was 11.97 ± 9 days. The mortality rate was 71.2% and 28.8% of patients were discharged alive. The mean duration of ICU and hospital stay was 25 ± 11 days and 28.21 ± 11.60 days, respectively. Greater age, severe COVID-19, mechanical ventilation, shock and acute kidney injury were associated with poor prognosis; however, early tracheostomy in intubated patients resulted in better outcomes.
CONCLUSION Patients with severe COVID-19 requiring mechanical ventilation have a poor prognosis but patients with early tracheostomy may benefit with no added risk. We recommend that the timing of tracheostomy be decided on a case-by-case basis and a well-designed randomised controlled trial should be performed to elucidate the potential benefit of early tracheostomy in such patients.
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Affiliation(s)
- Yudhyavir Singh
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Kapil Dev Soni
- Department of Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Abhishek Singh
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Nikita Choudhary
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Fahina Perveen
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Richa Aggarwal
- Department of Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Nishant Patel
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shailendra Kumar
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anjan Trikha
- Department of Anesthesia, All India Institute of Medical Sciences, New Delhi 110029, India
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11
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Standiford TC, Farlow JL, Brenner MJ, Blank R, Rajajee V, Baldwin NR, Chinn SB, Cusac JA, De Cardenas J, Malloy KM, McDonough KL, Napolitano LM, Sjoding MW, Stoneman EK, Washer LL, Park PK. COVID-19 Transmission to Health Care Personnel During Tracheostomy Under a Multidisciplinary Safety Protocol. Am J Crit Care 2022; 31:452-460. [PMID: 35953441 DOI: 10.4037/ajcc2022538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Tracheostomies are highly aerosolizing procedures yet are often indicated in patients with COVID-19 who require prolonged intubation. Robust investigations of the safety of tracheostomy protocols and provider adherence and evaluations are limited. OBJECTIVES To determine the rate of COVID-19 infection of health care personnel involved in COVID-19 tracheostomies under a multidisciplinary safety protocol and to investigate health care personnel's attitudes and suggested areas for improvement concerning the protocol. METHODS All health care personnel involved in tracheostomies in COVID-19-positive patients from April 9 through July 11, 2020, were sent a 22-item electronic survey. RESULTS Among 107 health care personnel (80.5%) who responded to the survey, 5 reported a positive COVID-19 test result (n = 2) or symptoms of COVID-19 (n = 3) within 21 days of the tracheostomy. Respondents reported 100% adherence to use of adequate personal protective equipment. Most (91%) were familiar with the tracheostomy protocol and felt safe (92%) while performing tracheostomy. Suggested improvements included creating dedicated tracheostomy teams and increasing provider choices surrounding personal protective equipment. CONCLUSIONS Multidisciplinary engagement in the development and implementation of a COVID-19 tracheostomy protocol is associated with acceptable safety for all members of the care team.
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Affiliation(s)
- Taylor C Standiford
- Taylor C. Standiford is a second-year resident, Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco
| | - Janice L Farlow
- Janice L. Farlow is a head and neck surgical oncology fellow, Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus
| | - Michael J Brenner
- Michael J. Brenner is an associate professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Ross Blank
- Ross Blank is an assistant professor, Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Venkatakrishna Rajajee
- Venkata-krishna Rajajee is a professor, Department of Neurosurgery, University of Michigan, Ann Arbor
| | - Noel R Baldwin
- Noel R. Baldwin is a registered nurse, Critical Care Medicine Unit, University of Michigan, Ann Arbor
| | - Steven B Chinn
- Steven B. Chinn is an assistant professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Jessica A Cusac
- Jessica A. Cusac is a respiratory therapist, clinical specialist, University Hospital/Cardiovascular Center, University of Michigan, Ann Arbor
| | - Jose De Cardenas
- Jose De Cardenas is an associate professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Kelly M Malloy
- Kelly M. Malloy is an associate professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Kelli L McDonough
- Kelli L. McDonough is a clinical research project manager, Department of Surgery, University of Michigan, Ann Arbor
| | - Lena M Napolitano
- Lena M. Napolitano is a professor, Department of Surgery, University of Michigan, Ann Arbor
| | - Michael W Sjoding
- Michael W. Sjoding is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Emily K Stoneman
- Emily K. Stoneman is an associate professor, Division of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor
| | - Laraine L Washer
- Laraine L. Washer is a professor, Division of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor
| | - Pauline K Park
- Pauline K. Park is a professor, Department of Surgery, University of Michigan, Ann Arbor
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12
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Kang K, Wang J, Du X, Li N, Jin S, Ji Y, Liu X, Chen P, Yue C, Wu J, Wang X, Tang Y, Lai Q, Lu B, Gao Y, Yu K. A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study. Front Surg 2022; 9:1018637. [PMID: 36386537 PMCID: PMC9649830 DOI: 10.3389/fsurg.2022.1018637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE The number of infections and deaths caused by the global epidemic of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) invasion is steadily increasing daily. In the early stages of outbreak, approximately 15%-20% of patients with coronavirus disease 2019 (COVID-19) inevitably developed severe and critically ill forms of the disease, especially elderly patients and those with several or serious comorbidities. These more severe forms of disease mainly manifest as dyspnea, reduced blood oxygen saturation, severe pneumonia, acute respiratory distress syndrome (ARDS), thus requiring prolonged advanced respiratory support, including high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), and invasive mechanical ventilation (IMV). OBJECTIVE This study aimed to propose a safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19. DESIGN This is a single center quality improvement study. PARTICIPANTS Tracheotomy is a necessary and important step in airway management for COVID-19 patients with prolonged endotracheal intubation, IMV, failed extubation, and ventilator dependence. Standardized third-level protection measures and bulky personal protective equipment (PPE) may hugely impede the implementation of tracheotomy, especially when determining the optimal pre-surgical positioning for COVID-19 patients with ambiguous surface position, obesity, short neck or limited neck extension, due to vision impairment, reduced tactile sensation and motility associated with PPE. Consequently, the aim of this study was to propose a safer and more practical tracheotomy, namely percutaneous dilated tracheotomy (PDT) with delayed endotracheal intubation withdrawal under the guidance of bedside ultrasonography without the conventional use of flexible fiberoptic bronchoscopy (FFB), which can accurately determine the optimal pre-surgical positioning, as well as avoid intraoperative damage of the posterior tracheal wall and prevent the occurrence of tracheoesophageal fistula (TEF).
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Affiliation(s)
- Kai Kang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Junfeng Wang
- Department of Ultrasound, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xue Du
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Nana Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Songgen Jin
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuanyuan Ji
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinjia Liu
- Department of Ultrasound, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pengfei Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chuangshi Yue
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jihan Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xintong Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yujia Tang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qiqi Lai
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Baitao Lu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yang Gao
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Harbin Medical University, Harbin, China,Institute of Critical Care Medicine, The Sino Russian Medical Research Center of Harbin Medical University, Harbin, China,Correspondence: Yang Gao Kaijiang Yu
| | - Kaijiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China,Institute of Critical Care Medicine, The Sino Russian Medical Research Center of Harbin Medical University, Harbin, China,Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, China,Key Laboratory of Cell Transplantation, National Health Commission, Harbin, China,Correspondence: Yang Gao Kaijiang Yu
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13
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Association of mortality and early tracheostomy in patients with COVID-19: a retrospective analysis. Sci Rep 2022; 12:15406. [PMID: 36104383 PMCID: PMC9474557 DOI: 10.1038/s41598-022-19567-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/31/2022] [Indexed: 12/15/2022] Open
Abstract
COVID-19 adds to the complexity of optimal timing for tracheostomy. Over the course of this pandemic, and expanded knowledge of the disease, many centers have changed their operating procedures and performed an early tracheostomy. We studied the data on early and delayed tracheostomy regarding patient outcome such as mortality. We performed a retrospective analysis of all tracheostomies at our institution in patients diagnosed with COVID-19 from March 2020 to June 2021. Time from intubation to tracheostomy and mortality of early (≤ 10 days) vs. late (> 10 days) tracheostomy were the primary objectives of this study. We used mixed cox-regression models to calculate the effect of distinct variables on events. We studied 117 tracheostomies. Intubation to tracheostomy shortened significantly (Spearman’s correlation coefficient; rho = − 0.44, p ≤ 0.001) during the course of this pandemic. Early tracheostomy was associated with a significant increase in mortality in uni- and multivariate analysis (Hazard ratio 1.83, 95% CI 1.07–3.17, p = 0.029). The timing of tracheostomy in COVID-19 patients has a potentially critical impact on mortality. The timing of tracheostomy has changed during this pandemic tending to be performed earlier. Future prospective research is necessary to substantiate these results.
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14
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Mitton T, Atwood C, Kenee P, Wynings E, Tibbetts KM. Predictors of Mortality in Patients With COVID-19 Undergoing Tracheotomy. Ann Otol Rhinol Laryngol 2022:34894221115752. [PMID: 35923104 DOI: 10.1177/00034894221115752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify factors predictive of 30-day mortality following tracheotomy in patients with COVID-19. METHODS A retrospective chart review of patients with COVID-19 who underwent tracheotomy at a tertiary medical center between March 2020 and October 2021 was conducted. Univariate and multivariable analyses of factors correlated with 30-day post-tracheotomy mortality were performed. The outcomes of tracheotomies performed in the operating room and at bedside were compared with t-tests and multivariable analysis. RESULTS One hundred-twenty patients met inclusion criteria, with 48 female patients (40%). Mean age was 59.8 [12.6] years, and the 30-day mortality rate was 18.3%. On univariate analysis, age (odds ratio (OR) = 1.06; P = .015), FiO2 at the time of tracheotomy (OR = 1.06; P < .001), and bedside tracheotomy (OR = 3.21; P = .019) were associated with increased risk of 30-day mortality. After including control variables, increased FiO2 continued to predict increased odds of 30-day mortality (OR = 1.08; P = .02); specifically, patients with FiO2 > 65% were significantly more likely to pass within 30 days than those with FiO2 ≤ 40% (OR = 28.24; P < .001). There was a significant difference in the 30-day mortality rate of bedside tracheotomies (31%) and OR tracheotomies (12%; P = .02), but this association was eliminated on multivariable analysis (OR = 0.95; P = .96). CONCLUSION Intubated patients with COVID-19 undergoing tracheotomy with FiO2 > 65% have 25 times greater odds of 30-day mortality than those with FiO2 ≤ 40%. There were no differences in outcomes between bedside and OR tracheotomies.
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Affiliation(s)
- Tanner Mitton
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlyn Atwood
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parker Kenee
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erin Wynings
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kathleen M Tibbetts
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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15
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Chong WH, Tan CK. Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1121-1132. [PMID: 35506907 DOI: 10.1177/08850666221098930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated. OBJECTIVES To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients. METHODS Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021. RESULTS Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups. CONCLUSIONS Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.
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Affiliation(s)
- Woon Hean Chong
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
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16
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Ji Y, Fang Y, Cheng B, Li L, Fang X. Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis. Crit Care 2022; 26:40. [PMID: 35135597 PMCID: PMC8822732 DOI: 10.1186/s13054-022-03904-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/26/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients' outcomes. METHODS We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14 days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model. RESULTS Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV (2098 patients; MD - 9.08 days, 95% CI - 10.91 to - 7.26 days, p < 0.01) and duration of ICU stay (1224 patients; MD - 9.41 days, 95% CI - 12.36 to - 6.46 days, p < 0.01). Mortality was reported for 2343 patients and was comparable between groups (OR 1.09, 95% CI 0.79-1.51, p = 0.59). CONCLUSIONS The results of this meta-analysis suggest that, compared with late tracheostomy, early tracheostomy in COVID-19 patients was associated with shorter duration of IMV and ICU stay without modifying the mortality rate. These findings may have important implications to improve ICU availability during the COVID-19 pandemic. Trial registration The protocol was registered at INPLASY (INPLASY202180088).
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Affiliation(s)
- Yun Ji
- Department of Surgical Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Yumin Fang
- Department of Intensive Care Unit, Suichang People's Hospital, Lishui, Zhejiang, China
| | - Baoli Cheng
- Department of Anesthesiology and Intensive Care, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Libin Li
- Department of Surgical Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Xiangming Fang
- Department of Anesthesiology and Intensive Care, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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17
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Favier V, Lescroart M, Pequignot B, Grimmer L, Florentin A, Gallet P. Measurement of airborne particle emission during surgical and percutaneous dilatational tracheostomy COVID-19 adapted procedures in a swine model: Experimental report and review of literature. PLoS One 2022; 17:e0278089. [PMID: 36417482 PMCID: PMC9683587 DOI: 10.1371/journal.pone.0278089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Surgical tracheostomy (ST) and Percutaneous dilatational tracheostomy (PDT) are classified as high-risk aerosol-generating procedures and might lead to healthcare workers (HCW) infection. Albeit the COVID-19 strain slightly released since the vaccination era, preventing HCW from infection remains a major economical and medical concern. To date, there is no study monitoring particle emissions during ST and PDT in a clinical setting. The aim of this study was to monitor particle emissions during ST and PDT in a swine model. METHODS A randomized animal study on swine model with induced acute respiratory distress syndrome (ARDS) was conducted. A dedicated room with controlled airflow was used to standardize the measurements obtained using an airborne optical particle counter. 6 ST and 6 PDT were performed in 12 pigs. Airborne particles (diameter of 0.5 to 3 μm) were continuously measured; video and audio data were recorded. The emission of particles was considered as significant if the number of particles increased beyond the normal variations of baseline particle contamination determinations in the room. These significant emissions were interpreted in the light of video and audio recordings. Duration of procedures, number of expiratory pauses, technical errors and adverse events were also analyzed. RESULTS 10 procedures (5 ST and 5 PDT) were fully analyzable. There was no systematic aerosolization during procedures. However, in 1/5 ST and 4/5 PDT, minor leaks and some adverse events (cuff perforation in 1 ST and 1 PDT) occurred. Human factors were responsible for 1 aerosolization during 1 PDT procedure. ST duration was significantly shorter than PDT (8.6 ± 1.3 vs 15.6 ± 1.9 minutes) and required less expiratory pauses (1 vs 6.8 ± 1.2). CONCLUSIONS COVID-19 adaptations allow preventing for major aerosol leaks for both ST and PDT, contributing to preserving healthcare workers during COVID-19 outbreak, but failed to achieve a perfectly airtight procedure. However, with COVID-19 adaptations, PDT required more expiratory pauses and more time than ST. Human factors and adverse events may lead to aerosolization and might be more frequent in PDT.
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Affiliation(s)
- Valentin Favier
- Department of Otolaryngology-Head and Neck Surgery, Gui de Chauliac Hospital, University Hospital of Montpellier, Montpellier, France
- Montpellier Laboratory of Informatics, Robotics and Microelectonics (LIRMM), ICAR Team, French National Centre for Scientific Research (CNRS), Montpellier University, Montpellier, France
- * E-mail:
| | - Mickael Lescroart
- Intensive Care Unit Brabois, University Regional Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Benjamin Pequignot
- Intensive Care Unit Brabois, University Regional Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Léonie Grimmer
- Department of Hygiene, Environmental Risks and Healthcare Associated Risks, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Arnaud Florentin
- Department of Hygiene, Environmental Risks and Healthcare Associated Risks, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Infection Prevention and Control Team, Regional University Hospital of Nancy, Vandœuvre-lès-Nancy, France
| | - Patrice Gallet
- ENT Department, Regional University Hospital of Nancy, University of Lorraine, Vandœuvre-lès-Nancy, France
- Virtual Hospital of Lorraine, University of Lorraine, Vandoeuvre-lès-Nancy, France
- NGERE, INSERM U1256 Lab, University of Lorraine, Vandoeuvre-lès-Nancy, France
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18
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Almutairi D, Alqahtani R, Alghamdi A, Binammar D, Alzaidi S, Ghafori A, Alsharif H. Tracheotomy Outcomes in 71 COVID-19 Patients: A Multi-Centric Study in Saudi Arabia. Clin Pract 2021; 11:947-953. [PMID: 34940008 PMCID: PMC8700003 DOI: 10.3390/clinpract11040109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/03/2022] Open
Abstract
Since its outbreak in late 2019, the COVID-19 pandemic has seen a sharp rise in the demand for oxygen and ventilation facilities due to the associated extensive damage that it causes to the lungs. This study is considered the first and largest study in Saudi Arabia to evaluate the outcomes of tracheostomy in intubated COVID-19 patients. This is a retrospective, observational cohort study that was conducted at King Abdulaziz Medical City (KAMC) in Jeddah, Western Region, Saudi Arabia and King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. The findings of the study revealed that seventy-one patients with COVID-19 underwent tracheotomy between 1 March 2020 and 31 October 2020. The average period between intubation and tracheostomy was 9.97 days. Hypertension, diabetes, lung disease and obesity (BMI > 30) were significant risk factors of mortality. The overall 30-day mortality rate was 38.4%.
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Affiliation(s)
- Dakheelallah Almutairi
- Department of Otorhinolaryngology-Head and Neck Surgery, King Abdulaziz Medical City, Jeddah 21423, Saudi Arabia;
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
| | - Raneem Alqahtani
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
- Correspondence: ; Tel.: +966-55-352-1010
| | - Arwa Alghamdi
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
| | - Dina Binammar
- College of Medicine, King Saud Bin-Abdul-Aziz University for Health Sciences, Ministry of National Guard, Jeddah 14611, Saudi Arabia; (A.A.); (D.B.)
| | - Suzan Alzaidi
- Department of Otorhinolaryngology-Head and Neck Surgery, King Fahad Armed Forces Hospital, Jeddah 23311, Saudi Arabia; (S.A.); (A.G.)
| | - Abdullah Ghafori
- Department of Otorhinolaryngology-Head and Neck Surgery, King Fahad Armed Forces Hospital, Jeddah 23311, Saudi Arabia; (S.A.); (A.G.)
| | - Hassan Alsharif
- Intensive Care Department (ICD), King Fahad Armed Forces Hospital, Jeddah 23311, Saudi Arabia;
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19
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Guarnieri M, Andreoni P, Gay H, Giudici R, Bottiroli M, Mondino M, Casella G, Chiara O, Morelli O, Conforti S, Langer T, Fumagalli R. Tracheostomy in Mechanically Ventilated Patients With SARS-CoV-2-ARDS: Focus on Tracheomalacia. Respir Care 2021; 66:1797-1804. [PMID: 34548406 PMCID: PMC9993780 DOI: 10.4187/respcare.09063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. The aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence. METHODS This retrospective, single-center study was performed in an Italian teaching hospital. All adult subjects admitted to the ICU between February 24, 2020, and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, whereas information regarding airway management was collected daily. RESULTS A total of 151 subjects were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 40%. A tracheostomy was performed in 73 (48%), open surgical technique in 54 (74%), and percutaneous Ciaglia technique in 19 (26%). Subjects who had a tracheostomy performed had, compared to the other subjects, a longer duration of mechanical ventilation and longer ICU and hospital stay. Tracheomalacia was diagnosed in 8 (5%). The factors associated with tracheomalacia were female sex, obesity, and tracheostomy. CONCLUSIONS In our population, approximately 50% of subjects with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized subjects had a longer ICU and hospital stay. In our population, 5% were diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature, and the underlying mechanisms are not fully understood.
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Affiliation(s)
- Marcello Guarnieri
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Patrizia Andreoni
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Hedwige Gay
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Riccardo Giudici
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Maurizio Bottiroli
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Michele Mondino
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Gianpaolo Casella
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Osvaldo Chiara
- Department of Emergency and Trauma Surgery, Niguarda Hospital, University of Milan, Milan, Italy
| | - Oscar Morelli
- Department of Otolaryngology, Niguarda Hospital, Milan, Italy
| | - Serena Conforti
- Department of Thoracic Surgery, Niguarda Hospital, Milan, Italy
| | - Thomas Langer
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, Niguarda Hospital, Milan, Italy
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20
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Tang L, Kim C, Paik C, West J, Hasday S, Su P, Martinez E, Zhou S, Clark B, O'Dell K, Chambers TN. Tracheostomy Outcomes in COVID-19 Patients in a Low Resource Setting. Ann Otol Rhinol Laryngol 2021; 131:1217-1223. [PMID: 34852660 DOI: 10.1177/00034894211062542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES COVID-19 predominately affects safety net hospitals. Tracheostomies improve outcomes and decrease length of stay for COVID-19 patients. Our objectives are to determine if (1) COVID-19 tracheostomies have similar complication and mortality rates as non-COVID-19 tracheostomies and (2) to determine the effectiveness of our tracheostomy protocol at a safety net hospital. METHODS Patients who underwent tracheostomy at Los Angeles County Hospital between August 2009 and August 2020 were included. Demographics, SARS-CoV-2 status, body mass index (BMI), Charlson Co-morbidity Index (CCI), length of intubation, complication rates, decannulation rates, and 30-day all-cause mortality versus tracheostomy related mortality rates were all collected. RESULTS Thirty-eight patients with COVID-19 and 130 non-COVID-19 patients underwent tracheostomies. Both groups were predominately male with similar BMI and CCI, though the COVID-19 patients were more likely to be Hispanic and intubated for a longer time (P = .034 and P < .0001, respectively). Both groups also had similar, low intraoperative complications at 2% to 3% and comparable long-term post-operative complications. However, COVID-19 patients had more perioperative complications within 7 days of surgery (P < .01). Specifically, they were more likely to have perioperative bleeding at their tracheostomy sites (P = .03) and long-term post-operative mucus plugging (P < .01). However, both groups had similar 30-day mortality rates. There were no incidences of COVID-19 transmission to healthcare workers. CONCLUSIONS COVID-19 tracheostomies are safe for patients and healthcare workers. Careful attention should be paid to suctioning to prevent mucus plugging. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Liyang Tang
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Celeste Kim
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Connie Paik
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Jonathan West
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Steven Hasday
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Peiyi Su
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Eduardo Martinez
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Sheng Zhou
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Bhavishya Clark
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Karla O'Dell
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tamara N Chambers
- Caruso Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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21
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Barbera-Mirza J, Chan K, Newsome K, McKenny M, Elkbuli A. Indications and Recommendations for Tracheostomy in Trauma Population With COVID-19 Infection: A Review of the Literature. Am Surg 2021:31348211054711. [PMID: 34743584 DOI: 10.1177/00031348211054711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This review explores the current body of evidence pertaining to tracheostomy placement in COVID-19 seropositive patients and summarizes the research by tracheostomy indications, timing, and procedure. Literature review was performed in accordance with the 2020 PRISMA guidelines and includes 12 papers discussing protocols for adult patients seropositive for COVID-19. The studies demonstrated high mortality rates after tracheostomy, especially in geriatric patients, and suggested a multifactorial determination of whether to perform a tracheostomy. There was inconclusive data regarding wait time between testing seropositive, tracheostomy, and weaning off of ventilation. COVID-19 generally reaches highest infectivity between days 9 and 10; furthermore, high early mortality rates seen in COVID-19 may confound mortality implicated by tracheostomy placement. Due to the aerosol-generating nature of tracheostomy placement, management and maintenance, techniques, equipment, and personnel should be carefully considered and altered for COVID-19 patients. With surgical tracheostomy, literature suggested decreased usage of electrocautery; with percutaneous tracheostomy, single-use bronchoscope should be used. The nonemergent exchange of tracheostomy should be done only after the patient tested negative for COVID-19. Placement of tracheostomy should only be considered in COVID-19 patients who are no longer transmissible, with rigorous attention to safety precautions. Understanding procedures for airway maintenance in a respiratory disease like COVID-19 is imperative, especially due to current shortages in ventilators and PPE. However, because of a lack of available data and its likelihood of change as more data emerges, we lack complete guidelines for tracheostomy placement in COVID-19 seropositive patients, and those existing will likely evolve with the disease.
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Affiliation(s)
- Jacqueline Barbera-Mirza
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Kelvin Chan
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Kevin Newsome
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenny
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
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22
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Ferro A, Kotecha S, Auzinger G, Yeung E, Fan K. Systematic review and meta-analysis of tracheostomy outcomes in COVID-19 patients. Br J Oral Maxillofac Surg 2021; 59:1013-1023. [PMID: 34294476 PMCID: PMC8130586 DOI: 10.1016/j.bjoms.2021.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/07/2021] [Indexed: 01/04/2023]
Abstract
A systematic review and meta-analysis of the entire COVID-19 Tracheostomy cohort was conducted to determine the cumulative incidence of complications, mortality, time to decannulation and ventilatory weaning. Outcomes of surgical versus percutaneous and outcomes relative to tracheostomy timing were also analysed. Studies reporting outcome data on patients with COVID-19 undergoing tracheostomy were identified and screened by 2 independent reviewers. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Outcome data were analysed using a random-effects model. From 1016 unique studies, 39 articles reporting outcomes for a total of 3929 patients were included for meta-analysis. Weighted mean follow-up time was 42.03±26 days post-tracheostomy. Meta-analysis showed that 61.2% of patients were weaned from mechanical ventilation [95%CI 52.6%-69.5%], 44.2% of patients were decannulated [95%CI 33.96%-54.67%], and cumulative mortality was found to be 19.23% [95%CI 15.2%-23.6%] across the entire tracheostomy cohort. The cumulative incidence of complications was 14.24% [95%CI 9.6%-19.6%], with bleeding accounting for 52% of all complications. No difference was found in incidence of mortality (RR1.96; p=0.34), decannulation (RR1.35, p=0.27), complications (RR0.75, p=0.09) and time to decannulation (SMD 0.46, p=0.68) between percutaneous and surgical tracheostomy. Moreover, no difference was found in mortality (RR1.57, p=0.43) between early and late tracheostomy, and timing of tracheostomy did not predict time to decannulation. Ten confirmed nosocomial staff infections were reported from 1398 tracheostomies. This study provides an overview of outcomes of tracheostomy in COVID-19 patients, and contributes to our understanding of tracheostomy decisions in this patient cohort.
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Affiliation(s)
- A. Ferro
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, SE1 9RT London, United Kingdom
| | - S. Kotecha
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, SE1 9RT London, United Kingdom
| | - G. Auzinger
- Liver Intensive Care Unit, Department of Critical Care, King's College Hospital NHS Foundation Trust, Denmark Hill, SE1 9RT London, United Kingdom
| | - E. Yeung
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, SE1 9RT London, United Kingdom
| | - K. Fan
- Oral and Maxillofacial Surgery Department, King's College Hospital NHS Foundation Trust, Denmark Hill, SE1 9RT London, United Kingdom,Corresponding author at: King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, United Kingdom. Tel.: +4420 3299 5754
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23
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Mesalles-Ruiz M, Hamdan M, Huguet-Llull G, Penella A, Portillo A, Bagudà E, Capelleras M, Caballero JM, Golet M, Fulla M, Bartel R, Cisa E, Cruellas F, Tornero J, Lares HR, Farré A, Skufca J, Nogués J, Mañós M, Gonzàlez-Compta X. Outcomes and survival of tracheostomised patients during the COVID-19 pandemic in a third level hospital. Eur Arch Otorhinolaryngol 2021; 279:3095-3103. [PMID: 34637016 PMCID: PMC8506095 DOI: 10.1007/s00405-021-07120-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/16/2021] [Indexed: 12/17/2022]
Abstract
Purpose Analyse the evolution and outcomes of COVID-19 tracheostomised patients. Clarify if this cohort presents an increased risk of haemorrhagic complications and verify the correlation between some risk factors with increased mortality. Methods A retrospective single-centre observational study of a prospective cohort of all COVID-19 patients admitted to our centre between March and April 2020. A control group was obtained from a historical cohort of patients who required tracheostomy due to prolonged invasive mechanical ventilation (IMV) before 2020. Results A total of 1768 patients were included: 67 tracheostomised non-COVID-19 patients (historic cohort), 1371 COVID-19 patients that did not require ICU admission, 266 non-tracheostomised COVID-19 patients and 64 tracheostomised COVID-19 patients. Comparing the obesity prevalence, 54.69% of the tracheostomised COVID-19 patients were obese and 10.53% of the non-tracheostomised COVID-19 patients (p < 0.001). The median of ICU admission days was lower (p < 0.001) in the non-tracheostomised cohort (12.5 days) compared with the COVID-19 tracheostomised cohort (34 days). The incidence of haemorrhagic complications was significantly higher in tracheostomised COVID-19 patients (20.31%) compared with tracheostomised non-COVID-19 patients (5.97%) and presented a higher percentage of obesity, hypertension, diabetes and smoking, significantly different from the historic cohort (p < 0.001). A Cox model showed that tracheostomy had no statistically significant effect on mortality in COVID-19 patients. Conclusion Obesity and smoking may be risk factors for tracheostomy in COVID-19 patients, tracheostomised COVID-19 patients present a higher risk of bleeding complications than those admitted for other reasons and an elevated LDH and INR on ICU admission may be associated with increased mortality.
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Affiliation(s)
- Marta Mesalles-Ruiz
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain. .,Departament de Ciències Clíniques, Universitat de Barcelona, Carrer de Casanova 143, 08036, Barcelona, Spain.
| | - Miriam Hamdan
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Gabriel Huguet-Llull
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Departament de Ciències Clíniques, Universitat de Barcelona, Carrer de Casanova 143, 08036, Barcelona, Spain
| | - Anna Penella
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Alejandro Portillo
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Eva Bagudà
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Marta Capelleras
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - José Maria Caballero
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Mireia Golet
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Marta Fulla
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Departament de Ciències Clíniques, Universitat de Barcelona, Carrer de Casanova 143, 08036, Barcelona, Spain
| | - Ricardo Bartel
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Departament de Ciències Clíniques, Universitat de Barcelona, Carrer de Casanova 143, 08036, Barcelona, Spain
| | - Enric Cisa
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Francesc Cruellas
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Jordi Tornero
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Henry Rafael Lares
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Anna Farré
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Javier Skufca
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Julio Nogués
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Manuel Mañós
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Departament de Ciències Clíniques, Universitat de Barcelona, Carrer de Casanova 143, 08036, Barcelona, Spain
| | - Xavier Gonzàlez-Compta
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Carrer de la Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Departament de Ciències Clíniques, Universitat de Barcelona, Carrer de Casanova 143, 08036, Barcelona, Spain
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24
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Robba C, Battaglini D, Ball L, Pelosi P, Rocco PR. Ten things you need to know about intensive care unit management of mechanically ventilated patients with COVID-19. Expert Rev Respir Med 2021; 15:1293-1302. [PMID: 33734900 PMCID: PMC8040493 DOI: 10.1080/17476348.2021.1906226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/17/2021] [Indexed: 02/08/2023]
Abstract
Introduction: The ongoing pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has posed important challenges for clinicians and health-care systems worldwide.Areas covered: The aim of this manuscript is to provide brief guidance for intensive care unit management of mechanically ventilated patients with COVID-19 based on the literature and our direct experience with this population. PubMed, EBSCO, and the Cochrane Library were searched up until 15th of January 2021 for relevant literature.Expert opinion: Initially, the respiratory management of COVID-19 relied on the general therapeutic principles for acute respiratory distress syndrome; however, recent findings have suggested that the pathophysiology of hypoxemia in patients with COVID-19 presents specific features and changes over time. Several therapies, including antiviral and anti-inflammatory agents, have been proposed recently. The optimal intensive care unit management of patients with COVID-19 remains unclear; therefore, ongoing and future clinical trials are warranted to clarify the optimal strategies to adopt in this cohort of patients.
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Affiliation(s)
- Chiara Robba
- Policlinico San Martino, IRCCS per l’Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Denise Battaglini
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l’Oncologia e le Neuroscienze, Genoa, Italy
| | - Lorenzo Ball
- Policlinico San Martino, IRCCS per l’Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Paolo Pelosi
- Policlinico San Martino, IRCCS per l’Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Patricia R.M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- COVID-19 Virus Network from Ministry of Science, Technology, and Innovation, Brazilian Council for Scientific and Technological Development, and Foundation Carlos Chagas Filho Research Support of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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25
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Lai HH, Tseng PY, Wang CY, Wang JY. Long-Term Survival and Medical Costs of Patients with Prolonged Mechanical Ventilation and Tracheostomy: A Nationwide Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910272. [PMID: 34639575 PMCID: PMC8507749 DOI: 10.3390/ijerph181910272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/25/2021] [Accepted: 09/26/2021] [Indexed: 12/15/2022]
Abstract
Few large-scale studies have focused on tracheostomy in patients with prolonged mechanical ventilation. This retrospective population-based study extracted data from the longitudinal National Health Insurance Research Database in Taiwan to compare long-term mortality between patients on prolonged mechanical ventilation with and without tracheostomy and their related medical expenditures. Data on newly developed respiratory failure in patients on ventilator support were extracted from 1 January 2002 to 31 December 2008. Of 10,705 patients included, 1372 underwent tracheostomy (n = 563) or translaryngeal intubation (n = 779). Overall survival of the patients with tracheostomy was followed for 5 years. Average survival was 4.98 years for the patients with tracheostomy and 5.48 years for the patients with translaryngeal intubation (not significant). Sex, age, premium-based monthly salary difference, occupation, urbanization level, chronic obstructive pulmonary disease, chronic heart failure, chronic renal disease, and cerebrovascular diseases were significantly associated with mortality for endotracheal intubation. Male sex, chronic heart failure, chronic renal disease, age ≥45 years, and low income were associated with significantly higher mortality. Although total medical expenditures were higher for the patients with tracheostomy, annual medical expenditures were not significantly different. There were no differences in long-term mortality between the two groups.
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Affiliation(s)
- Hui-Hsuan Lai
- Department of Nursing, China Medical University Hospital, Taichung 404332, Taiwan;
| | - Pei-Ying Tseng
- Department of Public Health, China Medical University, Taichung 406040, Taiwan;
- Department of Medical, Lee’s General Hospital, Yuanli Town, Miaoli 358011, Taiwan
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407752, Taiwan;
- Department of Nursing, Hungkuang University, Taichung 433304, Taiwan
| | - Jong-Yi Wang
- Department of Health Services Administration, China Medical University, Taichung 406040, Taiwan
- Correspondence: ; Tel.: +886-4-2296-7979 (ext. 6313)
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Fuchs A, Lanzi D, Beilstein CM, Riva T, Urman RD, Luedi MM, Braun M. Clinical recommendations for in-hospital airway management during aerosol-transmitting procedures in the setting of a viral pandemic. Best Pract Res Clin Anaesthesiol 2021; 35:333-349. [PMID: 34511223 PMCID: PMC7723398 DOI: 10.1016/j.bpa.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 12/03/2020] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to severe pneumonia and multiorgan failure. While most of the infected patients develop no or only mild symptoms, some need respiratory support or even invasive ventilation. The exact route of transmission is currently under investigation. While droplet exposure and direct contact seem to be the most significant ways of transmitting the disease, aerosol transmission appears to be possible under circumstances favored by high viral load. Despite the use of personal protective equipment (PPE), this situation potentially puts healthcare workers at risk of infection, especially if they are involved in airway management. Various recommendations and international guidelines aim to protect healthcare workers, although evidence-based research confirming the benefits of these approaches is still scarce. In this article, we summarize the current literature and recommendations for airway management of COVID-19 patients.
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Daniele Lanzi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
| | - Matthias Braun
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Thomas Williams
- Academic Foundation Trainee, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Brendan A McGrath
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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28
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Farlow JL, Park PK, Sjoding MW, Kay SG, Blank R, Malloy KM, Washer L, Napolitano LM, Rajajee V, Brenner MJ, Chinn SB, De Cardenas J. Tracheostomy for COVID-19 respiratory failure: timing, ventilatory characteristics, and outcomes. J Thorac Dis 2021; 13:4137-4145. [PMID: 34422343 PMCID: PMC8339767 DOI: 10.21037/jtd-21-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/29/2021] [Indexed: 01/08/2023]
Abstract
Background Whereas data from the pre-pandemic era have demonstrated that tracheostomy can accelerate liberation from the ventilator, reduce need for sedation, and facilitate rehabilitation, concerns for healthcare worker safety have led to disagreement on tracheostomy placement in COVID-19 patients. Data on COVID-19 patients undergoing tracheostomy may inform best practices. Thus, we report a retrospective institutional cohort experience with tracheostomy in ventilated patients with COVID-19, examining associations between time to tracheostomy and duration of mechanical ventilation in relation to patient characteristics, clinical course, and survival. Methods Clinical data were extracted for all COVID-19 tracheostomies performed at a quaternary referral center from April-July 2020. Outcomes studied included mortality, adverse events, duration of mechanical ventilation, and time to decannulation. Results Among 64 COVID-19 tracheostomies (13% of COVID-19 hospitalizations), patients were 64% male and 42% African American, with a median age of 54 (range, 20–89). Median time to tracheostomy was 22 (range, 7–60) days and median duration of mechanical ventilation was 39.4 (range, 20–113) days. Earlier tracheostomy was associated with shortened mechanical ventilation (R2=0.4, P<0.01). Median decannulation time was 35.3 (range, 7–79) days. There was 19% mortality and adverse events in 45%, mostly from bleeding in therapeutically anticoagulated patients. Conclusions Tracheostomy was associated with swifter liberation from the ventilator and acceptable safety for physicians in this series of critically ill COVID-19 patients. Patient mortality was not increased relative to historical data on acute respiratory distress syndrome (ARDS). Future studies are required to establish conclusions of causality regarding tracheostomy timing with mechanical ventilation, complications, or mortality in COVID-19 patients.
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Affiliation(s)
- Janice L Farlow
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Pauline K Park
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Stephen G Kay
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Ross Blank
- Department of Anesthesia, Michigan Medicine, Ann Arbor, MI, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Laraine Washer
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | | | | | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA.,Global Tracheostomy Collaborative, Raleigh, NC, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Jose De Cardenas
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA.,Division of Pulmonary and Critical Care, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
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29
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Mehta Y, Kochar G. Tracheostomy in COVID Times. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1732837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Yatin Mehta
- Department of Anesthesiology and Critical Care, Medanta – The Medicity, Gurugram, India
| | - Gaurav Kochar
- Department of Anesthesiology and Critical Care, Medanta – The Medicity, Gurugram, India
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30
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McGrath BA, Naunheim MR, Brenner MJ. Measuring Tracheotomy Risk in Patients With COVID-19: Time to Look Beyond Surgery and Surgeons. JAMA Otolaryngol Head Neck Surg 2021; 147:678-679. [PMID: 33885722 DOI: 10.1001/jamaoto.2021.0554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Brendan A McGrath
- Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom.,Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Matthew R Naunheim
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan.,Global Tracheostomy Collaborative, Raleigh, North Carolina
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Chandran A, Kumar R, Kanodia A, Shaphaba K, Sagar P, Thakar A. Outcomes of Ttracheostomy in COVID-19 Patients: A Single Centre Experience. Indian J Otolaryngol Head Neck Surg 2021; 74:3043-3049. [PMID: 34277386 PMCID: PMC8276681 DOI: 10.1007/s12070-021-02758-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/04/2021] [Indexed: 02/08/2023] Open
Abstract
The rapid emergence of COVID-19 has led to increase in the number of patients requiring prolonged ventilation and tracheostomy. Though global guidelines are evolving, there is a paucity of literature about optimal timing and outcome after tracheostomy in COVID-19 patients. We set out to assess the clinical characteristics and outcome of COVID-19 patients who underwent tracheostomy.This single-center, prospective observational cohort study analyzed all the consecutive tracheostomy performed on COVID-19 patients from April 1 2020 to January 31, 2021. The primary outcome measure was the 30-day mortality rate following tracheostomy and association with various prognostic risk factors. The secondary outcome measures included various tracheostomy-related events, perioperative complications, and decannulation rate.The study included 51 patients with a median age of 52 years and the majority were male (62.74%). 62.74% (32 of 51) tracheostomies were done early (within 10 days of intubation) and the mean duration from endotracheal intubation to tracheostomy was 10.27 days. The 30-day mortality rate was 66.66% (34 of 51) with no tracheostomy-related mortality and the mean duration between tracheostomy and death was 8.29 days. The presence of sepsis was associated with a higher rate of mortality (p = 0.002) while the timing of tracheostomy was not related to increased mortality (p = 0.365). The most common perioperative complication was tracheostoma bleeding (16.64%). At a median follow-up of 7.5 months, only four patients were decannulated.Though associated with a higher rate of 30-day mortality rate, tracheostomy among COVID-19 patients is a safe and an effective weaning tool.
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Affiliation(s)
- Aswin Chandran
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Rajeev Kumar
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Anupam Kanodia
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Konthoujam Shaphaba
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Prem Sagar
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Alok Thakar
- Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
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32
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Staibano P, Levin M, McHugh T, Gupta M, Sommer DD. Association of Tracheostomy With Outcomes in Patients With COVID-19 and SARS-CoV-2 Transmission Among Health Care Professionals: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:646-655. [PMID: 34042963 PMCID: PMC8160928 DOI: 10.1001/jamaoto.2021.0930] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022]
Abstract
Importance Approximately 5% to 15% of patients with COVID-19 require invasive mechanical ventilation (IMV) and, at times, tracheostomy. Details regarding the safety and use of tracheostomy in treating COVID-19 continue to evolve. Objective To evaluate the association of tracheostomy with COVID-19 patient outcomes and the risk of SARS-CoV-2 transmission among health care professionals (HCPs). Data Sources EMBASE (Ovid), Medline (Ovid), and Web of Science from January 1, 2020, to March 4, 2021. Study Selection English-language studies investigating patients with COVID-19 who were receiving IMV and undergoing tracheostomy. Observational and randomized clinical trials were eligible (no randomized clinical trials were found in the search). All screening was performed by 2 reviewers (P.S. and M.L.). Overall, 156 studies underwent full-text review. Data Extraction and Synthesis We performed data extraction in accordance with Meta-analysis of Observational Studies in Epidemiology guidelines. We used a random-effects model, and ROBINS-I was used for the risk-of-bias analysis. Main Outcomes and Measures SARS-CoV-2 transmission between HCPs and levels of personal protective equipment, in addition to complications, time to decannulation, ventilation weaning, and intensive care unit (ICU) discharge in patients with COVID-19 who underwent tracheostomy. Results Of the 156 studies that underwent full-text review, only 69 were included in the qualitative synthesis, and 14 of these 69 studies (20.3%) were included in the meta-analysis. A total of 4669 patients were included in the 69 studies, and the mean (range) patient age across studies was 60.7 (49.1-68.8) years (43 studies [62.3%] with 1856 patients). We found that in all studies, 1854 patients (73.8%) were men and 658 (26.2%) were women. We found that 28 studies (40.6%) investigated either surgical tracheostomy or percutaneous dilatational tracheostomy. Overall, 3 of 58 studies (5.17%) identified a small subset of HCPs who developed COVID-19 that was associated with tracheostomy. Studies did not consistently report the number of HCPs involved in tracheostomy. Among the patients, early tracheostomy was associated with faster ICU discharge (mean difference, 6.17 days; 95% CI, -11.30 to -1.30), but no change in IMV weaning (mean difference, -2.99 days; 95% CI, -8.32 to 2.33) or decannulation (mean difference, -3.12 days; 95% CI, -7.35 to 1.12). There was no association between mortality or perioperative complications and type of tracheostomy. A risk-of-bias evaluation that used ROBINS-I demonstrated notable bias in the confounder and patient selection domains because of a lack of randomization and cohort matching. There was notable heterogeneity in study reporting. Conclusions and Relevance The findings of this systematic review and meta-analysis indicate that enhanced personal protective equipment is associated with low rates of SARS-CoV-2 transmission during tracheostomy. Early tracheostomy in patients with COVID-19 may reduce ICU stay, but this finding is limited by the observational nature of the included studies.
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Affiliation(s)
- Phillip Staibano
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Marc Levin
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tobial McHugh
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Michael Gupta
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Doron D. Sommer
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
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Usefulness of Respiratory Mechanics and Laboratory Parameter Trends as Markers of Early Treatment Success in Mechanically Ventilated Severe Coronavirus Disease: A Single-Center Pilot Study. J Clin Med 2021; 10:jcm10112513. [PMID: 34204119 PMCID: PMC8201161 DOI: 10.3390/jcm10112513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022] Open
Abstract
Whether a patient with severe coronavirus disease (COVID-19) will be successfully liberated from mechanical ventilation (MV) early is important in the COVID-19 pandemic. This study aimed to characterize the time course of parameters and outcomes of severe COVID-19 in relation to the timing of liberation from MV. This retrospective, single-center, observational study was performed using data from mechanically ventilated COVID-19 patients admitted to the ICU between 1 March 2020 and 15 December 2020. Early liberation from ventilation (EL group) was defined as successful extubation within 10 days of MV. The trends of respiratory mechanics and laboratory data were visualized and compared between the EL and prolonged MV (PMV) groups using smoothing spline and linear mixed effect models. Of 52 admitted patients, 31 mechanically ventilated COVID-19 patients were included (EL group, 20 (69%); PMV group, 11 (31%)). The patients’ median age was 71 years. While in-hospital mortality was low (6%), activities of daily living (ADL) at the time of hospital discharge were significantly impaired in the PMV group compared to the EL group (mean Barthel index (range): 30 (7.5–95) versus 2.5 (0–22.5), p = 0.048). The trends in respiratory compliance were different between patients in the EL and PMV groups. An increasing trend in the ventilatory ratio during MV until approximately 2 weeks was observed in both groups. The interaction between daily change and earlier liberation was significant in the trajectory of the thrombin–antithrombin complex, antithrombin 3, fibrinogen, C-reactive protein, lymphocyte, and positive end-expiratory pressure (PEEP) values. The indicator of physiological dead space increases during MV. The trajectory of markers of the hypercoagulation status, inflammation, and PEEP were significantly different depending on the timing of liberation from MV. These findings may provide insight into the pathophysiology of COVID-19 during treatment in the critical care setting.
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Pauli N, Eeg‐Olofsson M, Bergquist H. Tracheotomy in COVID-19 patients: A retrospective study on complications and timing. Laryngoscope Investig Otolaryngol 2021; 6:446-452. [PMID: 34195366 PMCID: PMC8223451 DOI: 10.1002/lio2.560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/05/2021] [Accepted: 03/29/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The aim of this study was to analyze the timing of tracheotomy and the duration of mechanical ventilation and stay in the intensive care unit (ICU) in patients with COVID-19 infection. Furthermore, we aimed to investigate tracheotomy complications and mortality. METHODS Consecutive patients with COVID-19 infection admitted to the Department of Infectious Diseases in Gothenburg, Sweden were identified. Medical records were retrieved and retrospectively assessed. RESULTS One hundred eighty-eight patients with COVID-19 infection requiring hospital care were identified. Of these, 116 patients were critically ill and intubated, and 55 patients underwent tracheotomy. The mean time from endotracheal intubation to tracheotomy was 12 days (range 5-28 days). There was a correlation between the timing of tracheotomy and the duration of mechanical ventilation, where a shorter time between intubation and tracheotomy was correlated with a shorter duration of mechanical ventilation (r .58, P < .001), and a correlation was identified between the timing of tracheotomy and the duration of ICU stay (r .52, P < .001). Perioperative hypoxemia was registered in 9% of tracheotomies performed, whereas postoperative bleeding was observed in 27% of cases, the majority of which were minor. CONCLUSIONS This retrospective cohort study indicates that early tracheotomy is related to a reduced need for mechanical ventilation and a shorter duration of stay in the ICU in severe cases of COVID-19 disease. Complications during and after tracheotomy in this specific cohort included risk perioperative hypoxia and postoperative bleeding. Prospective randomized controlled trials would be of value to confirm these findings. LEVEL OF EVIDENCE 4, Case series.
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Affiliation(s)
- Nina Pauli
- Department of OtorhinolaryngologyInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
| | - Måns Eeg‐Olofsson
- Department of OtorhinolaryngologyInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
| | - Henrik Bergquist
- Department of OtorhinolaryngologyInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
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35
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Smith JD, Correll JA, Stein JL, Kupfer RA, Hogikyan ND, Morrison RJ, Stein AP. Discordant SARS-CoV-2 Detection in the Nasopharynx Versus Trachea for Patients With Tracheostomies. Laryngoscope 2021; 131:E2634-E2638. [PMID: 33959969 PMCID: PMC8242790 DOI: 10.1002/lary.29617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/02/2021] [Accepted: 04/19/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES/HYPOTHESIS Patients with tracheostomies have an anatomically altered connection between their upper and lower airways that could impact SARS-CoV-2 testing. Our goal was to evaluate for discordance in SARS-CoV-2 detection in hospitalized patients with COVID-19 and tracheostomies based on the site analyzed. STUDY DESIGN Retrospective chart review METHODS: This single-institution study evaluated hospitalized patients with COVID-19 who had tracheostomies placed during their treatment. We analyzed SARS-CoV-2 RNA nucleic acid amplification test (NAAT) results after tracheostomy. All included patients had nasopharyngeal (NP) and tracheal (TR) samples taken within a 48-hour period, allowing us to characterize rate of test concordance. RESULTS Forty-five patients met our inclusion criteria. Thirty-two (71.1%) patients had entirely concordant results after tracheostomy. However, 13 (28.9%) patients had at least one set of discordant results, the majority of which were NP negative and TR positive. There were no statistically significant differences in demographic or clinical variables, including time to tracheostomy and time to testing, among patients with concordant versus discordant SARS-CoV-2 results. CONCLUSION This represents the first study to examine SARS-CoV-2 RNA NAAT concordance between NP and TR sites in hospitalized patients with COVID-19 and tracheostomies. One-third of patients demonstrated discordant testing when NP and TR specimens were collected within a 48-hour time period. Thus, patients with tracheostomies may have a higher false-negative rate if only one site is assessed for SARS-CoV-2. We recommend analyzing samples from both the nasopharynx and trachea for these patients until more prospective data exist. LEVEL OF EVIDENCE IV Laryngoscope, 2021.
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Affiliation(s)
- Joshua D Smith
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Jason A Correll
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Jennifer L Stein
- Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, U.S.A
| | - Robbi A Kupfer
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Norman D Hogikyan
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Robert J Morrison
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Andrew P Stein
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, U.S.A
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36
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Nasa P, Azoulay E, Khanna AK, Jain R, Gupta S, Javeri Y, Juneja D, Rangappa P, Sundararajan K, Alhazzani W, Antonelli M, Arabi YM, Bakker J, Brochard LJ, Deane AM, Du B, Einav S, Esteban A, Gajic O, Galvagno SM, Guérin C, Jaber S, Khilnani GC, Koh Y, Lascarrou JB, Machado FR, Malbrain MLNG, Mancebo J, McCurdy MT, McGrath BA, Mehta S, Mekontso-Dessap A, Mer M, Nurok M, Park PK, Pelosi P, Peter JV, Phua J, Pilcher DV, Piquilloud L, Schellongowski P, Schultz MJ, Shankar-Hari M, Singh S, Sorbello M, Tiruvoipati R, Udy AA, Welte T, Myatra SN. Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method. Crit Care 2021; 25:106. [PMID: 33726819 PMCID: PMC7962430 DOI: 10.1186/s13054-021-03491-y] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION The study was registered with Clinical trials.gov Identifier: NCT04534569.
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Affiliation(s)
- Prashant Nasa
- Critical Care Medicine, NMC Speciality Hospital, Dubai, United Arab Emirates
| | - Elie Azoulay
- Saint-Louis teaching hospital - APHP - and University of Paris, Paris, France
| | - Ashish K Khanna
- Wake Forest University School of Medicine, Winston-Salem, NC and Outcomes Research Consortium , Cleveland, USA
| | - Ravi Jain
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Sachin Gupta
- Narayana Super Speciality Hospital, Gurugram, India
| | - Yash Javeri
- Regency Super Speciality Hospital, Lucknow, India
| | | | | | | | | | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Jan Bakker
- New York University School of Medicine and Columbia University College of Physicians & Surgeons, New York, USA
- Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, and University of Toronto, Toronto, Canada
| | - Adam M Deane
- Royal Melbourne Hospital and The University of Melbourne, Melbourne, Australia
| | - Bin Du
- Peking Union Medical College Hospital, Peking, China
| | - Sharon Einav
- The Shaare Zedek Medical Center, Jerusalem, Israel
| | - Andrés Esteban
- Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | | | | | - Claude Guérin
- University de Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, Medecine Intensive Réanimation Hôpital Edouard Herriot Lyon, and Medecine Intensive Réanimation Hôpital Edouard Herriot Lyon, Créteil, France
| | - Samir Jaber
- Montpellier University Hospital, Montpellier, France
- Hôpital Saint-Éloi, CHU de Montpellier, Phy Med Exp, Université de Montpellier, Montpellier, France
| | | | - Younsuck Koh
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Manu L N G Malbrain
- International Fluid Academy, Lovenjoel, Belgium
- Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | | | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Academic Health Sciences Centre, Manchester, UK
| | - Sangeeta Mehta
- Sinai Health and the University of Toronto, Toronto, Canada
| | - Armand Mekontso-Dessap
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri-Mondor, Service de Medicine Intensive Réanimation, and Univ Paris Est Créteil, CARMAS, Créteil, France
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael Nurok
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, USA
| | | | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences , Genoa, Italy
- Department of Surgical Sciences and Integrated Sciences, University of Genoa , Genoa, Italy
| | | | - Jason Phua
- Alexandra Hospital and National University Hospital, Singapore, Singapore
| | | | - Lise Piquilloud
- Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | | | - Marcus J Schultz
- Amsterdam University Medical Center, Amsterdam, The Netherlands
- Mahidol University, Bangkok, Thailand
- University of Oxford, Oxford, UK
| | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Suveer Singh
- Royal Brompton Hospital and Chelsea and Westminster Hospital, Imperial College, London, UK
| | | | | | | | - Tobias Welte
- Department of Respiratory Medicine, German Centre of Lung Research, Hannover, Germany
| | - Sheila N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. Ernest Borges Road, Parel, Mumbai, India.
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Nasa P, Azoulay E, Khanna AK, Jain R, Gupta S, Javeri Y, Juneja D, Rangappa P, Sundararajan K, Alhazzani W, Antonelli M, Arabi YM, Bakker J, Brochard LJ, Deane AM, Du B, Einav S, Esteban A, Gajic O, Galvagno SM, Guérin C, Jaber S, Khilnani GC, Koh Y, Lascarrou JB, Machado FR, Malbrain MLNG, Mancebo J, McCurdy MT, McGrath BA, Mehta S, Mekontso-Dessap A, Mer M, Nurok M, Park PK, Pelosi P, Peter JV, Phua J, Pilcher DV, Piquilloud L, Schellongowski P, Schultz MJ, Shankar-Hari M, Singh S, Sorbello M, Tiruvoipati R, Udy AA, Welte T, Myatra SN. Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method. CRITICAL CARE (LONDON, ENGLAND) 2021. [PMID: 33726819 DOI: 10.1186/s13054-021-03491-y.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION The study was registered with Clinical trials.gov Identifier: NCT04534569.
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Affiliation(s)
- Prashant Nasa
- Critical Care Medicine, NMC Speciality Hospital, Dubai, United Arab Emirates
| | - Elie Azoulay
- Saint-Louis teaching hospital - APHP - and University of Paris, Paris, France
| | - Ashish K Khanna
- Wake Forest University School of Medicine, Winston-Salem, NC and Outcomes Research Consortium , Cleveland, USA
| | - Ravi Jain
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Sachin Gupta
- Narayana Super Speciality Hospital, Gurugram, India
| | - Yash Javeri
- Regency Super Speciality Hospital, Lucknow, India
| | | | | | | | | | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Jan Bakker
- New York University School of Medicine and Columbia University College of Physicians & Surgeons, New York, USA.,Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, and University of Toronto, Toronto, Canada
| | - Adam M Deane
- Royal Melbourne Hospital and The University of Melbourne, Melbourne, Australia
| | - Bin Du
- Peking Union Medical College Hospital, Peking, China
| | - Sharon Einav
- The Shaare Zedek Medical Center, Jerusalem, Israel
| | - Andrés Esteban
- Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | | | | | - Claude Guérin
- University de Lyon, Lyon, France.,Institut Mondor de Recherches Biomédicales, Medecine Intensive Réanimation Hôpital Edouard Herriot Lyon, and Medecine Intensive Réanimation Hôpital Edouard Herriot Lyon, Créteil, France
| | - Samir Jaber
- Montpellier University Hospital, Montpellier, France.,Hôpital Saint-Éloi, CHU de Montpellier, Phy Med Exp, Université de Montpellier, Montpellier, France
| | | | - Younsuck Koh
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Manu L N G Malbrain
- International Fluid Academy, Lovenjoel, Belgium.,Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | | | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Academic Health Sciences Centre, Manchester, UK
| | - Sangeeta Mehta
- Sinai Health and the University of Toronto, Toronto, Canada
| | - Armand Mekontso-Dessap
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri-Mondor, Service de Medicine Intensive Réanimation, and Univ Paris Est Créteil, CARMAS, Créteil, France
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael Nurok
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, USA
| | | | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences , Genoa, Italy.,Department of Surgical Sciences and Integrated Sciences, University of Genoa , Genoa, Italy
| | | | - Jason Phua
- Alexandra Hospital and National University Hospital, Singapore, Singapore
| | | | - Lise Piquilloud
- Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | | | - Marcus J Schultz
- Amsterdam University Medical Center, Amsterdam, The Netherlands.,Mahidol University, Bangkok, Thailand.,University of Oxford, Oxford, UK
| | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - Suveer Singh
- Royal Brompton Hospital and Chelsea and Westminster Hospital, Imperial College, London, UK
| | | | | | | | - Tobias Welte
- Department of Respiratory Medicine, German Centre of Lung Research, Hannover, Germany
| | - Sheila N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. Ernest Borges Road, Parel, Mumbai, India.
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38
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Attaway AH, Scheraga RG, Bhimraj A, Biehl M, Hatipoğlu U. Severe covid-19 pneumonia: pathogenesis and clinical management. BMJ 2021; 372:n436. [PMID: 33692022 DOI: 10.1136/bmj.n436] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission. During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.
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Affiliation(s)
- Amy H Attaway
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rachel G Scheraga
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adarsh Bhimraj
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michelle Biehl
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umur Hatipoğlu
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Pandian V, Murgu S, Lamb CR. COUNTERPOINT: Tracheostomy in Patients With COVID-19: Should We Do It Before 14 Days? No. Chest 2021; 159:1727-1729. [PMID: 33651999 PMCID: PMC7910655 DOI: 10.1016/j.chest.2020.12.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/27/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
| | | | - Carla R Lamb
- Lahey Hospital and Medical Center, Tufts University, Burlington, MA.
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40
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Arnold J, Gao CA, Malsin E, Todd K, Argento AC, Cuttica M, Coleman JM, Wunderink RG, Smith SB. Outcomes of Percutaneous Tracheostomy for Patients with SARS-CoV-2 Respiratory Failure. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021:2021.02.23.21252231. [PMID: 33655275 PMCID: PMC7924300 DOI: 10.1101/2021.02.23.21252231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND SARS-CoV-2 can cause severe respiratory failure leading to prolonged mechanical ventilation. Data are just emerging about the practice and outcomes of tracheostomy in these patients. We reviewed our experience with tracheostomies for SARS-CoV-2 at our tertiary-care, urban teaching hospital. METHODS We reviewed the demographics, comorbidities, timing of mechanical ventilation, tracheostomy, and ICU and hospital lengths-of-stay (LOS) in SARS-CoV-2 patients who received tracheostomies. Early tracheostomy was considered <14 days of ventilation. Medians with interquartile ranges (IQR) were calculated and compared with Wilcoxon rank sum, Spearman correlation, Kruskal-Wallis, and regression modeling. RESULTS From March 2020 to January 2021, our center had 370 patients intubated for SARS-CoV-2, and 59 (16%) had percutaneous bedside tracheostomy. Median time from intubation to tracheostomy was 19 (IQR 17 - 24) days. Demographics and comorbidities were similar between early and late tracheostomy, but early tracheostomy was associated with shorter ICU LOS and a trend towards shorter ventilation. To date, 34 (58%) of patients have been decannulated, 17 (29%) before hospital discharge; median time to decannulation was 24 (IQR 19-38) days. Decannulated patients were younger (56 vs 69 years), and in regression analysis, pneumothorax was associated was associated with lower decannulation rates (OR 0.05, 95CI 0.01 - 0.37). No providers developed symptoms or tested positive for SARS-CoV-2. CONCLUSIONS Tracheostomy is a safe and reasonable procedure for patients with prolonged SARS-CoV-2 respiratory failure. We feel that tracheostomy enhances care for SARS-CoV-2 since early tracheostomy appears associated with shorter duration of critical care, and decannulation rates appear high for survivors.
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41
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Martin-Villares C, Bernal-Sprekelsen M, Molina-Ramirez CP, Bartolome-Benito M. Risk of contagion of SARS-CoV-2 among otorhinolaryngologists in Spain during the "Two waves". Eur Arch Otorhinolaryngol 2021; 278:3571-3577. [PMID: 33464400 PMCID: PMC7814253 DOI: 10.1007/s00405-020-06582-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/20/2020] [Indexed: 03/25/2023]
Abstract
Introduction The aim of our study was to obtain data about the contagion rate among Otolaryngologists in Spanish ENT Departments and about the clinical outcomes in positive otolaryngologists. As a secondary objective, we aim to assess the rate of contagion in the first and the second Covid-19 wave in Spain among Otorhinolaryngologists and the regional distribution by ENT-Departments. Methods Study design and population: This is a prospective observational study in a cohort of 975 Otolaryngologists from 87 ENT Departments conducted from March 25 to November 17 in our collaborative group, COVID ORL ESP. COVID‐19 polymerase chain reaction (PCR) was the diagnostic standard. Hospitalization and/or intensive care admission and mortality was recorded as non-identified data. Results Data collected from 975 otolaryngologist from 87 Departments resulted in 157 (16.5%) otolaryngologists testing positive for SARS-CoV-19 by RT-PCR. Important geographic differences in contagion are reported. A total of 136 (86.6%) otolaryngologists were tested positive during the first wave and 21 (13.3%) during the second wave. At the last cut-off point of the study only 30/87 ENT Departments (34.5%) remained COVID19-free and 5 Departments reported more than 50% staff members testing positive. The majority of positive tested otolaryngologists (126/157; 80.2%) had only mild or no symptoms, 17 developed moderate symptoms (10.8%) and 3 had pneumonia not requiring hospitalization (2%). Five colleagues were admitted at hospital, 4 required ICU (2.5%) and 2 colleges died from COVID-19. Conclusions During the first wave of the SARS-CoV-19 pandemic otolaryngologists in Spain have been overall the group suffering the highest rate of contagion, particularly during the first month. Subsequently, the Spanish Ministry of Health should include otorhinolaryngologists as a high-risk group in airborne pandemics.
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Affiliation(s)
- Cristina Martin-Villares
- Department of Otorhinolaryngology, Anatomy of Department of Medicine, Surgery and Anatomy, Hospital Universitario El Bierzo, University of León, Médicos sin Fronteras s/n. 24401-Ponferrda, León, Spain.
| | | | - Carmen Perez Molina-Ramirez
- Department of Otorhinolaryngology, Complejo Universitario Hospitalario de Segovia, University of Valladolid, Valladolid, Spain
| | - Margarita Bartolome-Benito
- Department of Otorhinolaryngology, Hospital Infantil Universitario Niño Jesús, Autonomous University of Madrid, Madrid, Spain
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42
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Tang Y, Wu Y, Zhu F, Yang X, Huang C, Hou G, Xu W, Hu M, Zhang L, Cheng A, Xu Z, Liu B, Hu S, Zhu G, Fan X, Zhang X, Yang Y, Feng H, Yu L, Wang B, Li Z, Peng Y, Shen Z, Fu S, Ouyang Y, Xu J, Zou X, Fang M, Yu Z, Hu B, Shang Y. Tracheostomy in 80 COVID-19 Patients: A Multicenter, Retrospective, Observational Study. Front Med (Lausanne) 2020; 7:615845. [PMID: 33425960 PMCID: PMC7793766 DOI: 10.3389/fmed.2020.615845] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/27/2020] [Indexed: 01/08/2023] Open
Abstract
Background: The outbreak of coronavirus disease 2019 (COVID-19) has led to a large and increasing number of patients requiring prolonged mechanical ventilation and tracheostomy. The indication and optimal timing of tracheostomy in COVID-19 patients are still unclear, and the outcomes about tracheostomy have not been extensively reported. We aimed to describe the clinical characteristics and outcomes of patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia who underwent elective tracheostomies. Methods: The multi-center, retrospective, observational study investigated all the COVID-19 patients who underwent elective tracheostomies in intensive care units (ICUs) of 23 hospitals in Hubei province, China, from January 8, 2020 to March 25, 2020. Demographic information, clinical characteristics, treatment, details of the tracheostomy procedure, successful weaning after tracheostomy, and living status were collected and analyzed. Data were compared between early tracheostomy patients (tracheostomy performed within 14 days of intubation) and late tracheostomy patients (tracheostomy performed after 14 days). Results: A total of 80 patients were included. The median duration from endotracheal intubation to tracheostomy was 17.5 [IQR 11.3-27.0] days. Most tracheotomies were performed by ICU physician [62 (77.5%)], and using percutaneous techniques [63 (78.8%)] at the ICU bedside [76 (95.0%)]. The most common complication was tracheostoma bleeding [14 (17.5%)], and major bleeding occurred in 4 (5.0%) patients. At 60 days after intubation, 31 (38.8%) patients experienced successful weaning from ventilator, 17 (21.2%) patients discharged from ICU, and 43 (53.8%) patients had died. Higher 60 day mortality [22 (73.3%) vs. 21 (42.0%)] were identified in patients who underwent early tracheostomy. Conclusions: In patients with SARS-CoV-2 pneumonia, tracheostomies were feasible to conduct by ICU physician at bedside with few major complications. Compared with tracheostomies conducted after 14 days of intubation, tracheostomies within 14 days were associated with an increased mortality rate.
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Affiliation(s)
- Yun Tang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yongran Wu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fangfang Zhu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chaolin Huang
- Research Center for Translational Medicine, Wuhan Jinyin-Tan Hospital, Wuhan, China
| | - Guo Hou
- Department of Critical Care Medicine, Renmin Hospital, Wuhan University, Wuhan, China
| | - Wenhao Xu
- Department of Critical Care Medicine, Xiaogan Central Hospital, Xiaogan, China
| | - Ming Hu
- Department of Critical Care Medicine, Wuhan Pulmonary Hospital, Wuhan, China
| | - Lu Zhang
- Department of Critical Care Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Aiguo Cheng
- Department of Critical Care, The Third People's Hospital of Yichang, Yichang, China
| | - Zhengqin Xu
- Department of Critical Care Medicine, Xiangyang No.1 People's Hospital, Affiliated Hospital of Hubei University of Medicine, Xiangyang, China
| | - Boyi Liu
- Department of Critical Care Medicine, Taihe Hospital Affiliated to Hubei University Medicine, Shiyan, China
| | - Song Hu
- Department of Critical Care Medicine, Fifth Hospital of Wuhan, Wuhan, China
| | - Guochao Zhu
- Department of Critical Care Medicine, The Affiliated Hospital of Jianghan University, Wuhan, China
| | - Xuepeng Fan
- Department of Critical Care, Wuhan No.1 Hospital, Wuhan, China
| | - Xijing Zhang
- Intensive Care Unit (ICU) Center of Xijing Hospital, Airforce Medical University, Xi'an, China
| | - Yadong Yang
- Department of Critical Care Medicine, Huanggang Central Hospital, Huanggang, China
| | - Huibin Feng
- Department of Intensive Care Unit (ICU), Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Edong Healthcare Group, Huangshi, China
| | - Lixia Yu
- Department of Critical Care Medicine, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, China
| | - Bing Wang
- Department of Critical Care Medicine, No.2 Hospital of Huangshi, Huangshi, China
| | - Zhiqiang Li
- Department of Critical Care Medicine, The First People's Hospital of Jingmen, Jingmen, China
| | - Yong Peng
- Intensive Care Unit, Xiehe Wuhan Red Cross Hospital, Wuhan, China
| | - Zubo Shen
- Department of Critical Care Medicine, Ezhou Central Hospital, Ezhou, China
| | - Shouzhi Fu
- Department of Intensive Care Unit (ICU)/Emergency, Wuhan Third Hospital, Wuhan, China
| | - Yaqi Ouyang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Minghao Fang
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhui Yu
- Research Center for Translational Medicine, Wuhan Jinyin-Tan Hospital, Wuhan, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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