Tracheostomy in the COVID-19 pandemic

Optimal timing and outcomes among COVID-19 patients undergoing tracheostomy

BACKGROUND

Patients who require mechanical ventilation secondary to severe COVID-19 infection have poor survival. It is unknown if the benefit of tracheostomy extends to COVID-19 patients. If so, what is the optimal timing?

METHODS

Retrospective cohort study within a large hospital system in the United States. The population included patients with COVID-19 from January 1, 2020 to September 30, 2020. In total, 93,918 cases were identified. They were excluded if no intubation or tracheostomy, underwent tracheostomy before intubation, <18 years old, hospice patients before admission, and bacterial pneumonia. In total, 5,911 patients met the criteria. Outcomes between patients who underwent endotracheal intubation only versus tracheostomy were compared. The primary outcome was inpatient mortality. All patients who underwent tracheostomy versus intubation only were compared. Three cohort analysis compared early (<10 days) versus late (>10 days) tracheostomy versus control. Eight cohort analysis compared days 0-2, days 3-6, days 7-10, days 11-14, days 15-18, days 19-22, and days 23+ to tracheostomy versus control.

RESULTS

There was an overall inpatient mortality rate of 37.5% in the tracheostomy cohort compared to 54.4% in the control group (P < .0001). There was an early tracheostomy group inpatient mortality rate of 44.7% (adjusted odds ratio 0.73, 95% confidence interval 0.52-1.01) compared to 33.1% (adjusted odds ratio 0.44, 95% confidence interval 0.34-0.58) in the late tracheostomy group.

CONCLUSION

COVID-19 patients with tracheostomy had a significantly lower mortality rate compared to intubated only. Optimal timing for tracheostomy placement for COVID-19 patients is 11 days or later. Future studies should focus on early tracheostomy patients.

Utility of Early Tracheostomy in Critically Ill Covid-19 Patients: A Systematic Review

COVID 19 has proven itself to be an agent of cataclysm and caused an uproar worldwide due to consistent strain on the finite resources available to tackle the situation. With the rapidly mutating viral nature, resultant disease is becoming more severe over time, causing significant numbers of critical cases needing invasive ventilatory support. Available literature dictates that tracheostomy might reduce the stress over healthcare infrastructure. Our systematic review is aimed towards understanding the influence of tracheostomy timing, over the course of the illness, by analyzing the relevant literature, thus aiding in decision making while managing critical COVID 19 patients. With predefined inclusion and exclusion criteria, PubMed data was explored using search terms like 'timing', 'tracheotomy'/'tracheostomy' and 'COVID'/'COVID-19'/'SARS CoV2' and 26 articles were finalised for formal review. 26 studies (3527 patients) were systematically reviewed. 60.3% and 39.5% patients underwent percutaneous dilational tracheostomy and open surgical tracheostomy respectively. We report 7.62%, 21.3%, 56% and 46.53% as approximate estimates, of complication rate, mortality rate, rate of mechanical ventilation weaning and rate of decannulation following tracheostomy in COVID 19 patients, respectively taking into account underestimation of the data. Provided that appropriate preventive measures and safety guidelines are strictly followed, moderately early tracheostomy (between 10 and 14 days of intubation) can prove quite efficacious in management of critical COVID 19 patients. Also, early tracheostomy was associated with early weaning and decannulation, thus reducing the enormous competition for intensive care unit beds.

Cricotracheostomy for patients with severe COVID-19: A case control study

Background

Tracheostomy is an important procedure for the treatment of severe coronavirus disease-2019 (COVID-19). Older age and obesity have been reported to be associated with the risk of severe COVID-19 and prolonged intubation, and anticoagulants are often administered in patients with severe COVID-19; these factors are also related to a higher risk of tracheostomy. Cricotracheostomy, a modified procedure for opening the airway through intentional partial cricoid cartilage resection, was recently reported to be useful in cases with low-lying larynx, obesity, stiff neck, and bleeding tendency. Here, we investigated the usefulness and safety of cricotracheostomy for severe COVID-19 patients.

Materials and methods

Fifteen patients with severe COVID-19 who underwent cricotracheostomy between January 2021 and April 2022 with a follow-up period of ≥ 14 days were included in this study. Forty patients with respiratory failure not related to COVID-19 who underwent traditional tracheostomy between January 2015 and April 2022 comprised the control group. Data were collected from medical records and comprised age, sex, body mass index, interval from intubation to tracheostomy, use of anticoagulants, complications of tracheostomy, and decannulation.

Results

Age, sex, and days from intubation to tracheostomy were not significantly different between the COVID-19/cricotracheostomy and control/traditional tracheostomy groups. Body mass index was significantly higher in the COVID-19 group than that in the control group (P = 0.02). The rate of use of anticoagulants was significantly higher in the COVID-19 group compared with the control group (P < 0.01). Peri-operative bleeding, subcutaneous emphysema, and stomal infection rates were not different between the groups, while stomal granulation was significantly less in the COVID-19 group (P = 0.04).

Conclusions

These results suggest that cricotracheostomy is a safe procedure in patients with severe COVID-19.

Elective Tracheostomy During Covid-19 Pandemic- A Tertiary Care Centre Experience

Aims and Objectives

: The aim of our study was to present an experience of elective tracheostomy in COVID-19 patients at our institute.

Materials and methods

The present prospective study was conducted, after approval by Institutional Ethics Committee, in the Department of ENT, SMGS Hospital, GMC Jammu from May 2020 to March 2021 over 60 patients having need for prolonged mechanical ventilation and having tested positive for COVID-19 with nasopharyngeal swab on rtPCR assay testing. Detailed information regarding following aspects was gathered :Age, Gender, Comorbidities (Diabetes, Cardiovascular disease, Pulmonary disease, Malignancy), time of endotracheal intubation to tracheostomy, time to wean sedation after tracheostomy, time to wean mechanical ventilation after tracheostomy, surgical complications, mortality, any health care worker in operating team getting infected by SARS-CoV-2. All 60 patients underwent Elective Open Tracheostomy Bed-side in the ICU section of our institute.

Results

The mean age of presentation was 55.9 ± 2.34 years, with male preponderance. The most common indication for tracheostomy was ARDS (Acute Respiratory Distress Syndrome) (56.6%). Out of 60 patients, co-morbidities were present in 44 patients (73.3%). The mean time between endotracheal intubation and tracheostomy was 12.2 ± 4.9 days. The mean time to wean mechanical ventilation after tracheostomy was 10.4 ± 2.31 days. The mean time to wean sedation was 2.2 ± 0.83 days. There were no deaths during the procedure. Out of 60 patients, 5 patients (8.3%) died due to complications of COVID-19.

Conclusion

Our study provides important clinical data (such as timing of tracheostomy, pre-operative evaluation of patients, recommendations during procedure, outcomes of tracheostomy and postoperative care) on this threatening issue of tracheostomy in COVID-19 patients and might be of immense help to various Otorhinolaryngologists who are dealing with the same situation.

[Risk factors at admission associated with intubation in patients with COVID-19]

Background

Intubation rates up to 33% have been found in patients diagnosed with COVID-19. Some cohorts have reported the presence of dyspnea in 84.1% of intubated patients, being this the only symptom associated with intubation. Oxygen saturation < 90% and increased respiratory rate have also been described as predictors of intubation.

Objective

To analyze the risk factors associated with intubation in patients hospitalized for COVID-19 at their admission.

Material and methods

An observational, retrospective, analytical, cross-sectional study was carried out. The universe of study consisted of patients over 18 years of age hospitalized due to a diagnosis of SARS-CoV-2 virus infection from April 1, 2020 to April 31, 2021 in the Hospital de Especialidades (Specialties Hospital) "Dr. Bernardo Sepúlveda Gutiérrez" at the National Medical Center.

Results

The mean age of intubated patients was 59.17 years (95% confidence interval [95% CI] -9.994 to -3.299, p < 0.001). Overall, 76.7% (230) of patients had a history of one or more preexisting comorbidities, including hypertension in 42.3% (127), obesity in 36.7% (110), and diabetes mellitus in 34.3% (103).

Conclusions

The main clinical characteristics of patients hospitalized for COVID-19 in our center who required intubation are very similar to those observed in different centers, including male sex, age over 50 years and obesity, which were the most common.

Tracheostomies of Patients With COVID-19: A Survey of Infection Reported by Health Care Professionals

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.

What Have We Learned About Transmission of COVID-19: Implications for PFT and Pulmonary Procedures

Because of the potential for high aerosol transmission during pulmonary function testing and pulmonary procedures, performing these tests and procedures must be considered carefully during the coronavirus disease-2019 (COVID-19) pandemic. Much has been learned about the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by aerosols and the potential for such transmission through pulmonary function tests and pulmonary procedures, and subsequently preventative practices have been enhanced and developed to reduce the risk of transmission of virus to patients and personnel. This article reviews what is known about the potential for transmission of SARS-CoV-2 during pulmonary function testing and pulmonary procedures and the recommended mitigation steps to prevent the spread of COVID-19.

Outcomes and survival of tracheostomised patients during the COVID-19 pandemic in a third level hospital

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.

Tracheostomy Outcomes in Patients With COVID-19 at a New York City Hospital

Objective

Tracheostomies have been performed in patients with prolonged intubation due to COVID-19. Understanding outcomes in different populations is crucial to tackle future epidemics.

Study Design

Prospective cohort study.

Setting

Tertiary academic medical center in New York City.

Methods

A prospectively collected database of patients with COVID-19 undergoing open tracheostomy between March 2020 and April 2020 was reviewed. Primary endpoints were weaning from the ventilator and from sedation and time to decannulation.

Results

Sixty-six patients underwent tracheostomy. There were 42 males (64%) with an average age of 62 years (range, 23-91). Patients were intubated for a median time of 26 days prior to tracheostomy (interquartile range [IQR], 23-30). The median time to weaning from ventilatory support after tracheostomy was 18 days (IQR, 10-29). Of those sedated at the time of tracheostomy, the median time to discontinuation of sedation was 5 days (IQR, 3-9). Of patients who survived, 39 (69%) were decannulated. Of those decannulated before discharge (n = 39), the median time to decannulation was 36 days (IQR, 27-49) following tracheostomy. The median time from ventilator liberation to decannulation was 14 days (IQR, 8-22). Thirteen patients (20.0%) had minor bleeding requiring packing. Two patients (3%) had bleeding requiring neck exploration. The all-cause mortality rate was 10.6%. No patients died of procedural causes, and no surgeons acquired COVID-19.

Conclusion

Open tracheostomies were successfully and safely performed at our institution in the peak of the COVID-19 pandemic. The majority of patients were successfully weaned from the ventilator and sedation. Approximately 60% of patients were decannulated prior to hospital discharge.

Characteristics, complications, and a comparison between early and late tracheostomy: A retrospective observational study on tracheostomy in patients with COVID‐19‐related acute respiratory distress syndrome

Background and Aims

As the coronavirus disease 2019 (COVID-19) pandemic spread worldwide in 2020, the number of patients requiring intensive care and invasive mechanical ventilation (IMV) has increased rapidly. During the pandemic, early recommendations suggested that tracheostomy should be postponed, as the potential benefits were not certain to exceed the risk of viral transmission to healthcare workers. The aim of this study was to assess the utility of tracheostomy in patients with COVID-19-related acute respiratory distress syndrome, in terms of patient and clinical characteristics, outcomes, and complications, by comparing between early and late tracheostomy.

Methods

A multicenter, retrospective observational study was conducted in Jönköping County, Sweden. Between 14 March 2020 and 13 March 2021, 117 patients were included. All patients ≥18 years of age with confirmed COVID-19, who underwent tracheostomy were divided into two groups based on the timing of the procedure (≤/>7 days). Outcomes including the time on IMV, intensive care unit (ICU) length of stay, and mortality 30 days after ICU admission, as well as complications due to tracheostomy were compared between the groups.

Results

Early tracheostomy (<7 days, n = 56) was associated with a shorter median duration of mechanical ventilation (7 [12], p = 0.001) as well as a shorter median ICU stay (8 [14], p = 0.001). The most frequent complication of tracheostomy was minor bleeding. With the exception of a higher rate of obesity in the group receiving late tracheostomy, the patient characteristics were similar between the groups.

Conclusion

This study showed that early tracheostomy was safe and associated with a shorter time on IMV as well as a shorter ICU length of stay, implicating possible clinical benefits in critically ill COVID-19 patients. However, it is necessary to verify these findings in a randomized controlled trial.

Recommendations from the Italian Society of Otolaryngology for clinical management during the SARS-CoV-2 pandemic

The coronavirus disease (COVID-19) pandemic has deeply impacted health, and affects many different medical specialties. Head and neck surgeons, in particular, have been recognised as one of the professionals at the highest risk of infection through aerosol-generating procedures as part of their usual job. The aim of this document is to review the current literature on the topic, to provide useful recommendations to avoid both healthcare staff exposure to contagion and the delay in the diagnosis and treatment of Head and Neck diseases, in this new phase of COVID-19 pandemic.

Percutaneous Tracheostomy in Respiratory Failure Due to COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) can lead to hypoxemic respiratory failure resulting in prolonged mechanical ventilation. Typically, tracheostomy is considered in patients who remain ventilator dependent beyond 2 weeks. However, in the setting of this novel respiratory virus, the safety and benefits of tracheostomy are not well-defined. Our aim is to describe our experience with percutaneous tracheostomy in patients with COVID-19.

MATERIALS AND METHODS

This is a single center retrospective descriptive study. We reviewed comorbidities and outcomes in patients with respiratory failure due to COVID-19 who underwent percutaneous tracheostomy at our institution from April 2020 to September 2020. In addition, we provide details of our attempt to minimize aerosolization by using a modified protocol with brief periods of planned apnea.

RESULTS

A total of 24 patients underwent percutaneous tracheostomy during the study. The average body mass index was 33.0±10.0. At 30 days posttracheostomy 17 (71%) patients still had the tracheostomy tube and 14 (58%) remained ventilator dependent. There were 3 (13%) who died within 30 days. At the time of data analysis in November 2020, 9 (38%) patients had died and 7 (29%) had been decannulated. None of the providers who participated in the procedure experienced signs or symptoms of COVID-19 infection.

CONCLUSION

Percutaneous tracheostomy in prolonged respiratory failure due to COVID-19 appears to be safe to perform at the bedside for both the patient and health care providers in the appropriate clinical context. Morbid obesity did not limit the ability to perform percutaneous tracheostomy in COVID-19 patients.

Extensive Tracheal Injuries: A Reasoned Multistep Approach to Guarantee Mechanical Ventilatory Support Developed During the COVID-19 Pandemic

The COVID-19 pandemic has notably increased the need for prolonged mechanical ventilation (MV) in patients with respiratory failure. This has increased the risk of extensive tracheal injury (ETI) associated with life-threatening complications in complex cases. Furthermore, tracheal injury treatment in patients with COVID-19 has not been described yet. Three patients with COVID-19 and ETI who required MV between April and November 2020 were included. A multistep approach was performed to restore tracheal integrity with a custom-remodeled stent and tracheostomy tube placement to allow ventilatory support. Efficient MV with no residual air leaks was obtained in all cases. One patient died 6 weeks after the procedure due to COVID-19 lung damage. Two patients have completely been weaned from MV. This multistep procedure could be used to maintain ventilatory support in the case of ETI, working as a bridge to subsequent surgery when clinical conditions improve.

Dysphagia Characteristics of Patients Post SARS-CoV-2 During Inpatient Rehabilitation

OBJECTIVE

To investigate dysphagia in patients recovering from SARS-CoV-2 admitted to acute inpatient rehabilitation by summarizing clinical swallow evaluation and videofluoroscopic swallow study findings.

DESIGN

Retrospective cohort study.

SETTING

Urban inpatient rehabilitation hospital.

PARTICIPANTS

The first inpatients admitted with SARS-CoV-2 (N=40) who participated in a videofluoroscopic swallow study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patient characteristics upon admission (duration of intubation, tracheostomy status, comorbidities, videofluoroscopic swallow study (VFSS) completion at previous level of care); admission International Dysphagia Diet level (IDDSI); Mann Assessment of Swallowing Ability (MASA), Functional Oral Intake Scale (FOIS), dysphagia severity rating; penetration aspiration scale (PAS) rated during VFSS; and IDDSI level recommended after completion of VFSS.

RESULTS

Twenty percent of patients had been evaluated by videofluoroscopy in acute care. Nineteen of 37 (51%) individuals were upgraded to IDDSI level 7 regular diet with level 0 thin liquids and achieved a FOIS of 7 after the completion of the VFSS. Five individuals (13%) received a diet downgrade or remained on the same diet recommendations from their admission. Total numerical score (TNS) of less than 170 on the MASA predicted presence of aspiration in 27% of patients (6 of 22). Seventy-two percent of the sample (16 of 22) had a TNS less than 170 but did not demonstrate any instances of aspiration. The odds of patients having a PAS of 3 or greater increased by approximately 15% (odds ratio, 1.15; 95% confidence interval, 1.03-1.27; P=.013). Thus, with each additional day of intubation during acute care stay, there was a 15% greater likelihood of having airway invasion.

CONCLUSIONS

Instrumental swallow evaluations are imperative to diagnose and treat dysphagia in the post-coronavirus disease population. Because of the heterogeneity of this population, high incidence of prolonged intubation, and limitations of the clinical swallowing evaluation, instrumental assessments need to be performed on a more consistent basis as infection prevention protocols evolve.

Early Tracheostomy for Managing ICU Capacity During the COVID-19 Outbreak: A Propensity-Matched Cohort Study

BACKGROUND

During the first wave of the COVID-19 pandemic, shortages of ventilators and ICU beds overwhelmed health care systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ICU stay is controversial.

RESEARCH QUESTION

Can failure-free day outcomes focused on ICU resources help to decide the optimal timing of tracheostomy in overburdened health care systems during viral epidemics?

STUDY DESIGN AND METHODS

This retrospective cohort study included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, when ICU occupancy modified clinician criteria to perform tracheostomy in Patients with COVID-19. We compared ventilator-free days at 28 and 60 days and ICU- and hospital bed-free days at 28 and 60 days in propensity score-matched cohorts who underwent tracheostomy at different timings (≤ 7 days, 8-10 days, and 11-14 days after intubation).

RESULTS

Of 1,939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (≤ 7 days vs > 7 days [116 patients included in the analysis]: median, 9 days [interquartile range (IQR), 0-15 days] vs 3 days [IQR, 0-7 days]; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs > 10 days [222 patients analyzed]: 6 days [IQR, 0-10 days] vs 0 days [IQR, 0-6 days]; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs > 14 days [318 patients analyzed]: 4 days [IQR, 0-9 days] vs 0 days [IQR, 0-2 days]; difference, 3 days; 95% CI, 2.1-3.9 days). Except hospital bed-free days at 28 days, all other end points were better with early tracheostomy.

INTERPRETATION

Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on a ventilator in particular may improve ICU availability.

The value of tracheostomy of critically ill COVID-19 patients - A multicentral study

Purpose

Tracheostomy is an aerosol-generating procedure, thus performing it during the COVID-19 pandemic arises considerations such as the most appropriate timing and the patients to whom it is suitable. Medical teams lack sufficient data to assist determining whether or not to conduct tracheostomy, its short- and long-term implications are not fully understood. This study aims to shed light on the critically ill COVID-19 patients that require tracheostomy, and to investigate its value.

Methods

A retrospective multicentral case-control study of 157 hospitalized critically ill COVID-19 patients, among whom 30 patients went through tracheostomy and consisted of our study group.

Results

The mean age was similar between study and control groups (68.9 ± 12.7 years vs 70.5 ± 15.8 years, p = 0.57), as well as comorbidity prevalence (56.7% vs 67.7%, p = 0.25). Patients in the study group were hospitalized for longer duration until defined critically ill (5 ± 4.3 vs 3 ± 3.9 days; p = 0.01), until admitted to the intensive care unit (6 ± 6.6 vs 2.5 ± 3.7 days respectively; p = 0.005), and until discharged (24 ± 9.7 vs 10.7 ± 9.1 days, p < 0.001). Mortality rate was lower in the study group (30% vs 59.8%, p = 0.003). Kaplan Meier survival analysis revealed a statistically significant difference in survival time between groups (Log rank chi-sq = 20.91, p < 0.001) with mean survival time of 41 ± 3.1 days vs 21 ± 2.2 days. Survival was significantly longer in the study group (OR = 0.37, p = 0.004).

Conclusion

Tracheostomy allows for more prolonged survival for gradually deteriorating critically ill COVID-19 patients. This should be integrated into the medical teams' considerations when debating whether or not to conduct tracheostomy.

Tracheostomy Outcomes in COVID-19 Patients in a Low Resource Setting

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.

Systematic review and meta-analysis of tracheostomy outcomes in COVID-19 patients

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.

Early vs. late tracheostomy in ventilated COVID-19 patients - A retrospective study

Background

Tracheostomy is one of the most common surgical procedures performed on ventilated COVID-19 patients, yet the appropriate timing for operating is controversial.

Objectives

Assessing the effect of early tracheostomy on mortality and decannulation; elucidating changes in ventilation parameters, vasopressors and sedatives dosages immediately following the procedure.

Methods

A retrospective cohort of 38 ventilated COVID-19 patients, 19 of them (50%) underwent tracheostomy within 7 days of intubation (early tracheostomy group) and the rest underwent tracheostomy after 8 days or more (late tracheostomy group).

Results

Decannulation rates were significantly higher while mortality rates were non-significantly lower in the early tracheostomy group compared with the late tracheostomy group (58% vs 21% p < 0.05; 42% vs 74% p = 0.1, respectively). Tidal volume increased (446 ml vs 483 ml; p = 0.02) while PEEP (13 cmH₂0 vs 11.6 cmH₂O, p = 0.04) decreased at the immediate time following the procedure. No staff member participating in the procedures was infected with SARS-CoV-2 virus.

Conclusion

Early tracheostomy might offer improved outcomes with higher decannulation rates and lower mortality rates in ventilated COVID-19 patients, yet larger scale studies are needed. Most likely, early exposure to COVID-19 patients with appropriate personal protective equipment during open tracheostomy does not put the surgical team at risk.

Post-Acute COVID-19 Syndrome for Anesthesiologists: A Narrative Review and a Pragmatic Approach to Clinical Care

Post-acute coronavirus disease 2019 (COVID-19) syndrome is a novel, poorly understood clinical entity with life-impacting ramifications. Patients with this syndrome, also known as "COVID-19 long-haulers," often present with nonspecific ailments involving more than one body system. The most common complaints include dyspnea, fatigue, brain fog, and chest pain. There currently is no single agreed-upon definition for post-acute COVID-19 syndrome, but most agree that criterion for this syndrome is the persistence of mental and physical health consequences after initial infection. Given the millions of acute infections in the United States over the course of the pandemic, perioperative providers will encounter these patients in clinical practice in growing numbers. Symptoms of the COVID-19 long-haulers should not be minimized, as these patients are at higher risk for postoperative respiratory complications and perioperative mortality for up to seven weeks after initial illness. Instead, a cautious multidisciplinary preoperative evaluation should be performed. Perioperative care should be viewed through the prism of best practices already in use, such as avoidance of benzodiazepines in patients with cognitive impairment and use of lung-protective ventilation. Recommendations especially relevant to the COVID-19 long-haulers include assessment of critical care myopathies and neuropathies to determine suitable neuromuscular blocking agents and reversal, preoperative workup of insidious cardiac or pulmonary pathologies in previously healthy patients, and, thorough medication review, particularly of anticoagulation regimens and chronic steroid use. In this article, the authors define the syndrome, synthesize the available scientific evidence, and make pragmatic suggestions regarding the perioperative clinical care of COVID-19 long-haulers.

Tracheotomy in COVID-19 Patients: A Systematic Review and Meta-analysis of Weaning, Decannulation, and Survival

OBJECTIVES

A systematic review and meta-analysis was conducted to determine the cumulative incidences of decannulation and mechanical ventilation weaning in patients with coronavirus disease 2019 (COVID-19) who have undergone a tracheotomy. Weighted average mean times to tracheotomy, to decannulation, and to death were calculated from reported or approximated means.

DATA SOURCES

PubMed, SCOPUS, CINAHL, and the Cochrane library.

REVIEW METHODS

Studies were screened by 3 investigators independently. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Studies including patients with COVID-19 who underwent a tracheotomy were identified. Studies without reported mechanical ventilation weaning or decannulation were excluded. Data were pooled using a random-effects model.

RESULTS

After identifying 232 unique studies, 18 articles encompassing outcomes for 3234 patients were ultimately included for meta-analysis, with a weighted mean follow-up time of 28.6 ± 6.2 days after tracheotomy. Meta-analysis revealed that 55.0% of tracheotomized patients were weaned successfully from mechanical ventilation (95% CI, 47.4%-62.2%). Approximately 34.9% of patients were decannulated successfully, with a mean decannulation time of 18.6 ± 5.7 days after tracheotomy. The pooled mortality in tracheotomized patients with COVID-19 was 13.1%, with a mean time of death of 13.0 ± 4.0 days following tracheotomy.

CONCLUSION

At the current state of the coronavirus pandemic, over half of patients who have required tracheotomies are being weaned off of mechanical ventilation. While 13.1% patients have died prior to decannulation, over a third of all tracheotomized patients with COVID-19 reported in the literature have undergone successful decannulation.

Outcomes of Ttracheostomy in COVID-19 Patients: A Single Centre Experience

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.

What we learned in the past year in managing our COVID-19 patients in intensive care units?

Coronavirus disease 2019 is a pandemic, was first recognized at Wuhan province, China in December 2019. The disease spread quickly across the globe, spreading stealthily from human to human through both symptomatic and asymptomatic individuals. A multisystem disease which appears to primarily spread via bio aerosols, it has exhibited a wide clinical spectrum involving multiple organ systems with the respiratory system pathology being the prime cause of morbidity and mortality. Initially unleashing a huge destructive trail at Wuhan China, Lombardy Italy and New York City, it has now spread to all parts of the globe and has actively thrived and mutated into new forms. Health care systems and Governments responded initially with panic, with containment measures giving way to mitigation strategies. The global medical and scientific community has come together and responded to this huge challenge. Professional medical societies quickly laid out "expert" guidelines which were conservative in their approach. Many drugs were re formulated and tested quickly with the help of national and international collaborative groups, helping carve out effective treatment strategies and help build a good scientific foundation for evidence-based medicine. Out of the darkness of chaos, we now have an orderly approach to manage this disease both from a public health preventive and therapeutic standpoint. With preventive measures such as masking and social distancing to the development of highly effective and potent vaccines, the public health success of such measures has been tempered by behavioral responses and resource mobilization. From a therapy standpoint, we now have drugs that were promising but now proven ineffective, and those that are effective when given early during viral pathogenesis or later when immune dysregulation has established, and the goal is to help reign in the destructive cascade. It has been a fascinating journey for mankind and our work here recapitulates the evolution of various aspects of critical care and other inpatient practices which continue to evolve.

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

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.

Tracheostomy Timing and Outcome in Severe COVID-19: The WeanTrach Multicenter Study

BACKGROUND

Tracheostomy can be performed safely in patients with coronavirus disease 2019 (COVID-19). However, little is known about the optimal timing, effects on outcome, and complications.

METHODS

A multicenter, retrospective, observational study. This study included 153 tracheostomized COVID-19 patients from 11 intensive care units (ICUs). The primary endpoint was the median time to tracheostomy in critically ill COVID-19 patients. Secondary endpoints were survival rate, length of ICU stay, and post-tracheostomy complications, stratified by tracheostomy timing (early versus late) and technique (surgical versus percutaneous).

RESULTS

The median time to tracheostomy was 15 (1-64) days. There was no significant difference in survival between critically ill COVID-19 patients who received tracheostomy before versus after day 15, nor between surgical and percutaneous techniques. ICU length of stay was shorter with early compared to late tracheostomy (p < 0.001) and percutaneous compared to surgical tracheostomy (p = 0.050). The rate of lower respiratory tract infections was higher with surgical versus percutaneous technique (p = 0.007).

CONCLUSIONS

Among critically ill patients with COVID-19, neither early nor percutaneous tracheostomy improved outcomes, but did shorten ICU stay. Infectious complications were less frequent with percutaneous than surgical tracheostomy.

Increasing the Safety of Percutaneous Dilatational Tracheostomy in COVID-19 Patients

How to cite this article: Bhosale SJ, Khatib KI. Increasing the Safety of Percutaneous Dilatational Tracheostomy in COVID-19 Patients. Indian J Crit Care Med 2021;25(6):610-612.

Is 2020 the golden year of Otolaryngology research? The impact of COVID-19 on the Italian academic production

BACKGROUND AND AIM

The aim of this research was to review the articles published by the Otolaryngology (ORL) departments of the Italian University Hospitals in 2019 and in 2020 in order to analyze the impact of the COVID-19 pandemic on the academic production.

METHODS

PubMed and Scopus were searched for the articles published by the ORL departments of the Italian Universities in 2019 and in 2020. The main eligibility criteria were English-language articles, while there were no exclusion criteria related to topic. The articles were classified into seven domains corresponding to the main ORL subspecialties.

RESULTS

There was an overall increase in the number of articles by the 42.2% in 2020. Publications pertaining Rhinology and Laryngology increased more significantly in 2020, respectively by the 50.5% and 72.2%. Additionally, there was an increase in the number of articles concerning topics of general interest, by the 95.2% in 2020. Also, the citation trends of the articles published by the Italian University Hospitals increased remarkably in 2020.

CONCLUSIONS

These results evidenced an overall increase in the number of ORL articles. Although 2020 is going to be remembered as a year to forget, it should be acknowledged for being the "golden year of research".

Outcome of 1890 tracheostomies for critical COVID-19 patients: a national cohort study in Spain

BACKGROUND

The question of an optimal strategy and outcomes in COVID-19 tracheostomy has not been answered yet. The critical focus in our case study is to evaluate the outcomes of tracheostomy on intubated COVID-19 patients.

METHODS

A multicentric prospective observational study of 1890 COVID-19 patients undergoing tracheostomy across 120 hospitals was conducted over 7 weeks in Spain (March 28 to May 15, 2020). Data were collected with an innovative approach: instant messaging via WhatsApp.

OUTCOME MEASUREMENTS

complications, achieved weaning and decannulation and survival.

RESULTS

We performed 1,461 surgical (81.3%) and 429 percutaneous tracheostomies. Median timing of tracheostomy was 12 days (4-42 days) since orotracheal intubation. A close follow-up of 1616/1890 (85.5%) patients at the cut-off time of 1-month follow-up showed that in 842 (52.1%) patients, weaning was achieved, while 391 (24.2%) were still under mechanical ventilation and 383 (23.7%) patients had died from COVID-19. Decannulation among those in whom weaning was successful (n = 842) was achieved in 683 (81%) patients.

CONCLUSION

To the best of our knowledge, this is the largest cohort of COVID-19 patients undergoing tracheostomy. The critical focus is the unprecedented amount of tracheostomies: 1890 in 7 weeks. Weaning could be achieved in over half of the patients with follow-up. Almost one out of four tracheotomized patients died from COVID-19.

Interventional pulmonology during COVID-19 pandemic: current evidence and future perspectives

COVID-19, caused by SARS-CoV-2 infection, has become increasingly prevalent worldwide, reaching a pandemic stage in March 2020. The organization of health care services had to change because of this new disease, with the need to reallocate staff and materials, besides changing management protocols. A very important challenge is not to expose patients and health care workers to the risk of infection and not to waste personal protective equipment (PPE). In the field of interventional pulmonology, various aspects related to COVID-19 must be taken into great consideration. Although bronchoscopy is not a first-line test for patients with suspected SARS-CoV-2 infection, it has a role in selected cases and it can be useful for differential diagnosis. However, bronchoscopy is an aerosol-generating procedure, that’s why its unjustified use could contribute to propagate the virus. For this reason, the utility of each procedure must be carefully evaluated, the patient has to be properly investigated before the procedure, which has to be performed with specific precautions, including adequate PPE. In this review, we summarize the knowledge and the principal statements about endoscopic activity in COVID-19 period, in both diagnosis of COVID-19 and management of patients. How to safely perform both bronchoscopic and pleural-related procedures (thoracoscopy, pleural biopsy and drainage of pleural effusions) is described with the aim to help the staff to decide when and how performing a procedure. We also highlight how interventional pulmonology could help in matter of complications related to COVID-19.

Percutaneous Tracheostomy With a Demistifier Canopy in the COVID-19 Era: A Safe Technique in the Intensive Care Unit

BACKGROUND

Endoscopic percutaneous tracheostomy (PT) is a safe technique that is performed frequently by otolaryngologists and intensivists. New challenges have been identified in order to maintain the safety of this procedure during the COVID-19 pandemic. A novel approach, using a modified demistifier canopy, was developed during the first wave of the pandemic and implemented for 17 consecutive percutaneous tracheostomies in order to enhance procedural safety.

METHODS

A protocol was developed after performing a literature review of tracheostomy in COVID-19 patients. A multidisciplinary tracheostomy team was established, including the departments of otolaryngology, critical care, and respiratory therapy. Simulation was performed prior to each PT, and postoperative debriefings were done.

RESULTS

A protocol and technical description of PT using a modified demistifier canopy covering was written and video documented. Data were collected on 17 patients who underwent this procedure safely in our tertiary care hospital. There were no procedure-related complications, and no evidence of COVID-19 transmission to any member of the health care team during the study period.

CONCLUSION

As patients continue to recover from COVID-19, their need for tracheostomy will increase. The technique described provides a safe, multidisciplinary method of performing PT in COVID-19 patients.

Elective tracheostomy during COVID-19 outbreak: to whom, when, how? Early experience from Venice, Italy

PURPOSE

The need for prolonged invasive mechanical ventilation in COVID-19 patients is placing the otorhinolaryngologist in front of an increasing request for tracheostomy. Nowadays, there is uncertainty regarding the timing of tracheostomy, the prognosis of these patients and the safety of healthcare workers. The aim of this study is to evaluate the efficacy and safety of tracheostomy placement in patients with COVID-19.

METHODS

A retrospective cohort study on 23 COVID 19 patients, to analyse the timing of tracheostomy, the risk factors associated with in-hospital death and the infection of the involved health care workers. Early tracheostomy was defined as ≤ 10 days and late ones > 10 days.

RESULTS

The mortality rate of COVID-19 patients admitted to ICU that underwent tracheostomy was 18%. The overall mortality of patients admitted to ICU was 53%. The univariate analysis revealed that early tracheostomy, SOFA score > 6, and D-dimer level > 4 were significantly associated with a greater risk of death. At the multivariate analysis SOFA score > 6 and D-dimer level > 4 resulted as significant factors for a higher risk of death. No health care workers associated with tracheostomy are confirmed to be infected by SARS-CoV2.

CONCLUSION

We suggest to wait at least 14 days to perform tracheostomy. In patients with SOFA score > 6 and D dimer > 4, tracheostomy should not be performed or should be postponed. Optimized procedures and enhanced personal protective equipment can make the tracheostomy safe and beneficial in COVID-19 patients.

Tracheostomy in patients with SARS-CoV-2 reduces time on mechanical ventilation but not intensive care unit stay

Cross-sectional study to know if tracheostomy influences the time on mechanical ventilation and reduces the ICU stay in patients with SARS-CoV2. From February 14 to May 31, 2020, 29 patients: 23 men and 6 women, with an average age (SD) of 66.4 years (±6,2) required tracheostomy. The average intensive care unit (ICU) stay was 36 days [31–56.5]. The average days on mechanical ventilation was 28,5 days (±9.7). Mean time to tracheostomy was 15.2 days (±9.5) with an average disconnection time after procedure of 11.3 days (±7.4). The average hospital stay was 55 days [39–79]. A directly proportional relation between the number of days of MV and the number of days from ICU admission until tracheostomy showed a significant value of p = 0.008. For each day of delay in tracheostomy, the days of mechanical ventilation were increased by 0.6 days. There was no relation between days to tracheostomy and days to disconnection (p = 0.092). PaO2 / FiO2 (PAFI) before tracheostomy and Simplified Acute Physiology Score III (SAPS III) at admission presented a statistical relation with mortality, with an OR of 1.683 (95%CI; 0.926–2.351; p = 0.078) and an OR of 1.312 (CI95%: 1.011–1.703; p = 0.034) respectively. The length of stay in the ICU until the tracheostomy was not related to the risk of death (p = 0.682). PEEP and PaO2/FiO2 (PAFI) at admission and before tracheostomy and APACHE II, SAPS III and SOFA at admission did not show influence over time on MV. We conclude that the delay in tracheostomy increase the days on mechanical ventilation but does not influence stay or mortality.

Surgical tracheotomy in COVID-19 patients: an Italian single centre experience

Purpose

Coronavirus infection disease 2019 (COVID-19) causes in 10% of patients a severe respiratory distress syndrome managed with invasive mechanical ventilation (IMV), sometimes difficult to wean. The role of tracheotomy is debated for the possible risks for patients and staff. We are going to describe here our experience with surgical tracheotomy in COVID-19 positive patients.

Methods

We enrolled all intensive care unit (ICU) patients requiring longer than 10 days of IMV. Demographic, clinical, respiratory, complications, and outcomes data were collected, in a particular length of weaning from sedation and IMV, in-ICU and in-hospital mortality rate. All healthcare operators involved were tested for SARS-CoV2 by pharyngeal swab and blood test (antibody test).

Results

13 out of 68 ICU patients (19.1%) underwent surgical tracheotomy after a median intubation period of 14 days. The mean age was 60 (56–65) years. 85% were male patients. Postoperative mild bleeding was seen in 30.7%, pneumothorax in 7.7%. Mean weaning from sedation required 3 days, 19 days from IMV. In-ICU and in-hospital COVID-infection-related mortality was 23.1% and 30.7%, respectively. None of the healthcare operators was found SARS-CoV2 positive during the period of the study.

Conclusions

In COVID-19 pandemic surgical tracheotomy enables to wean from sedation and subsequently from IMV in a safe way for both patients and personnel.

Coronavirus Disease 2019: A Wake-Up Call for Neurosurgeons to Learn Percutaneous Tracheostomy

Tracheostomy is a commonly performed operation in neurosurgical patients. It is an aerosol generating procedure and is considered a high-risk operation in times of the coronavirus disease 2019 pandemic. Though percutaneous tracheostomy has been around for some time, many neurosurgeons still perform open surgical tracheostomy as they have been trained in doing so and are well versed with the procedure. However, this pandemic is a wake-up call for them to learn a new skill that is simple, quick, and has several advantages over the traditional method.

Early Percutaneous Tracheostomy in Coronavirus Disease 2019: Association With Hospital Mortality and Factors Associated With Removal of Tracheostomy Tube at ICU Discharge. A Cohort Study on 121 Patients

OBJECTIVES

Early tracheotomy, defined as a procedure performed within 10 days from intubation, is associated with more ventilator free days, shorter ICU stay, and lower mortality than late tracheotomy. During the coronavirus disease 2019 pandemic, it was especially important to save operating room resources and to have a shorter ICU stay for patients, when ICUs had insufficient beds. In this context of limited resources, early percutaneous tracheostomy could be an effective way to manage mechanically ventilated patients. Nevertheless, current recommendations suggest delaying or avoiding the tracheotomy in coronavirus disease 2019 patients. Aim of the study was to analyze the hospital mortality of coronavirus disease 2019 patients who had received early percutaneous tracheostomy and factors associated with removal of tracheostomy cannula at ICU discharge.

DESIGN

Cohort study.

SETTING

Coronavirus disease 2019 ICU.

PATIENTS

Adult patients with coronavirus disease 2019 3 days after ICU admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Three days after ICU admission, 164 patients were present in ICU and included in the analysis. One-hundred and twenty-one patients (74%) were tracheostomized, whereas the other 43 (26%) were managed with translaryngeal intubation only. In multivariable analysis, early percutaneous tracheostomy was associated with lower hospital mortality. Sixty-six of tracheostomized patients (55%) were discharged alive from the hospital. Age and male sex were the only characteristics that were independently associated with mortality in the tracheostomized patients (45.5% and 62.8% in tracheostomized and nontracheostomized patients, respectively; p = 0.009). Tracheostomy tube was removed in 47 of the tracheostomized patients (71%). The only variable independently associated with weaning from tracheostomy at ICU discharge was a faster start of spontaneous breathing after tracheotomy was performed.

CONCLUSIONS

Early percutaneous tracheostomy was safe and effective in coronavirus disease 2019 patients, giving a good chance of survival and of weaning from tracheostomy cannula at ICU discharge.

Bedside tracheostomy for a COVID-19 cohort

The use of tracheostomy in ventilator dependent COVID-19 patients is novel because of the recent and rapid spread of this pandemic with risk of transmission of infection to healthcare workers. This case-series of mechanically ventilated COVID-19 patients indicates that percutaneous tracheostomy performed at bedside with careful precautions and limited modification of standard technique was effective in promoting weaning from mechanical ventilation with few complications and no transmission of COVID-19 infection to the procedural healthcare workers.

The COVID TIDE Approach: A Protocol for Safe Tracheostomy Practice in COVID Patients

We all are aware of COVID 19 pandemic. As the numbers are increasing, the critical care demand is also increasing. Tracheostomy is one of the commonest procedures which has been performed on COVID positive ventilated patients. It is important to understand and follow the utmost safe practices for the patient and the health care workers for such aerosol generating procedures. The aim of this study is to identify the lacunae in tracheostomy practices during this COVID times and suggest a systematic approach for the safe practices. An online questionnaire survey-based study was performed in September 2020. The target population was practicing otolaryngologists of India with various years of experience. The aim of the study was to evaluate the lacunae in tracheostomy safe practices and to create a systematic approach for the safety of health care workers. Data compilation and analysis was done by using Microsoft Excel. A systematic COVID TIDE tracheostomy safe practices approach was designed after reviewing various tracheostomy guidelines and recommendations. Total 114 otolaryngologists responded with a complete survey report. 72.2% responders were not up to date with their knowledge of tracheostomy safe practices. 79.8% were not performing this procedure in a negative pressure room. 15.8% were not aware of the personal protective equipment level they are using. Only 56.1% survey responders were holding the ventilation before tracheal incision. Overall, 94.7% responders were keen to know about the safe approach of tracheostomy in COVID positive patients. Tracheostomy is an aerosol generating procedure, lacunae in the knowledge can cause major risk to health care professionals. Finally, in such crises, consideration should be taken for simulation exercises, dedicated airway teams and a systematic COVID TIDE approach to improve the safety of the staff and patients.

Surgical Tracheostomy Outcomes in COVID-19-Positive Patients

Objective

The aim of this case series was to demonstrate that surgical tracheostomy can be undertaken safely in critically ill mechanically ventilated patients with coronavirus disease 2019 (COVID-19) and that it is an effective weaning tool.

Study Design

Retrospective case series.

Setting

Single academic teaching hospital in London.

Methods

All adult patients admitted to the adult intensive care unit (AICU), diagnosed with severe COVID-19 infection and requiring surgical tracheostomy between the March 10, 2020, and May 1, 2020, were included. Data collection focused upon patient demographics, AICU admission data, tracheostomy-specific data, and clinical outcomes.

Results

Twenty patients with COVID-19 underwent surgical tracheostomy. The main indication for tracheostomy was to assist in respiratory weaning. Patients had undergone mechanical ventilation for a median of 16.5 days prior to surgical tracheostomy. Tracheostomy remained in situ for a median of 12.5 days. Sixty percent of patients were decannulated at the end of the data collection period. There were no serious immediate or short-term complications. Surgical tracheostomy facilitated significant reduction in intravenous sedation at 48 hours after tracheostomy formation. There was no confirmed COVID-19 infection or reported sickness in the operating surgical or anesthetic teams.

Conclusion

Surgical tracheostomy has been demonstrated to be an effective weaning tool in patients with severe COVID-19 infection.

Tracheostomy in 80 COVID-19 Patients: A Multicenter, Retrospective, Observational Study

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.

Open Tracheostomy for Critically Ill Patients with COVID-19

Background

COVID-19 is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy can shorten ICU length of stay and help weaning. Aims/Objectives. To describe the long-term evolution of the critically patient with COVID-19 and the need for invasive mechanical ventilation and orotracheal intubation (OTI), with or without tracheostomy. Material and Methods. A prospective study was performed including all patients admitted to the ICU due to COVID-19 from 10^th March to 30^th April 2020. Epidemiological data, performing a tracheostomy or not, mean time of invasive mechanical ventilation until tracheotomy, mean time from tracheotomy to weaning, and final outcome after one month of minimum follow-up were recorded. The Otolaryngology team was tested for COVID-19 before and after the procedures.

Results

Out of a total of 1612 hospital admissions for COVID-19, only 5.8% (93 patients) required ICU admission and IOT. Twenty-seven patients (29%) underwent a tracheostomy. After three months, within the group of tracheotomized patients, 29.6% died and 48.15% were extubated in a mean time of 28.53 days. In the nontracheostomized patients, the mortality was 42.4%.

Conclusions

Tracheostomy is a safe procedure for COVID-19 and helps weaning of prolonged OTI. Mortality after tracheostomy was less common than in nontracheostomized patients.

Is Timing of Tracheotomy a Factor Influencing the Clinical Course in COVID-19 Patients?

The timing of tracheotomy is a complex decision that requires understanding of the relative risks and benefits as compared with prolonging intubation. The role of tracheotomy during the COVID-19 pandemic remains to be determined. There is no evidence that early tracheostomy improves patient's clinical course and it is not impact on the natural history of these patients. In our opinion, the tracheotomy should be proposed in stable COVID-19 patients after 18th days after orotracheal intubation when the viral load is finished. Only in the case of patients with difficult of intubation do we perform earlier tracheotomies.

Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation

OBJECTIVES

Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT-anaesthetics department led tracheostomy team.

METHOD

A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020.

RESULTS

Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13-20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23-40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7-16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related.

CONCLUSION

Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.

Challenges of tracheostomy in COVID-19 patients in a tertiary centre in inner city London

The rapid global spread of SARS-CoV-2, the causative agent of COVID-19, has dominated healthcare services, with exponential numbers requiring mechanical ventilation in the intensive care unit (ICU). Tracheostomy facilitates respiratory and sedative weaning but risks potential viral transmission. This study reviewed the tracheostomy provision, techniques, and outcomes for a single-centre prospective cohort during the resource-pressured COVID-19 period. Seventy-two of 176 patients underwent tracheostomy at a median 17 days: 44 surgical (open), 28 percutaneous. Their median age was 58 years, the male to female ratio was 2.4:1, 75.1% were of BAME backgrounds, 76% had a BMI≥25kg/m2, and 65% had ≥2 major co-morbidities. Seventy-nine percent of patients were weaned from sedation at a median 2 days, 61% were weaned from mechanical ventilation at a median 10 days, 39% were discharged from the ICU at a median 11.5 days, and 19.4% were discharged home at a median 24 days. All patients survived the procedure. The mortality rate was 9.7% at a median 12 days. No clinician reported COVID-19 symptoms within 14 days of the procedure. The role of tracheostomy in COVID-19 is currently unclear. Delivery of tracheostomy by maxillofacial surgeons relieved the workload pressure from ICU clinicians. The choice of technique was influenced by the patient and resource factors, resulting in a mixed cohort of open and percutaneous tracheostomy in COVID-19 patients. Preliminary data suggest that open tracheostomy is as favourable as percutaneous tracheostomy for COVID-19 patients, and is safe for clinicians.

Timing of Tracheostomy for Prolonged Respiratory Wean in Critically Ill Coronavirus Disease 2019 Patients: A Machine Learning Approach

OBJECTIVES

To propose the optimal timing to consider tracheostomy insertion for weaning of mechanically ventilated patients recovering from coronavirus disease 2019 pneumonia. We investigated the relationship between duration of mechanical ventilation prior to tracheostomy insertion and in-hospital mortality. In addition, we present a machine learning approach to facilitate decision-making.

DESIGN

Prospective cohort study.

SETTING

Guy's & St Thomas' Hospital, London, United Kingdom.

PATIENTS

Consecutive patients admitted with acute respiratory failure secondary to coronavirus disease 2019 requiring mechanical ventilation between March 3, 2020, and May 5, 2020.

INTERVENTIONS

Baseline characteristics and temporal trends in markers of disease severity were prospectively recorded. Tracheostomy was performed for anticipated prolonged ventilatory wean when levels of respiratory support were favorable. Decision tree was constructed using C4.5 algorithm, and its classification performance has been evaluated by a leave-one-out cross-validation technique.

MEASUREMENTS AND MAIN RESULTS

One-hundred seventy-six patients required mechanical ventilation for acute respiratory failure, of which 87 patients (49.4%) underwent tracheostomy. We identified that optimal timing for tracheostomy insertion is between day 13 and day 17. Presence of fibrosis on CT scan (odds ratio, 13.26; 95% CI [3.61-48.91]; p ≤ 0.0001) and Pao2:Fio2 ratio (odds ratio, 0.98; 95% CI [0.95-0.99]; p = 0.008) were independently associated with tracheostomy insertion. Cox multiple regression analysis showed that chronic obstructive pulmonary disease (hazard ratio, 6.56; 95% CI [1.04-41.59]; p = 0.046), ischemic heart disease (hazard ratio, 4.62; 95% CI [1.19-17.87]; p = 0.027), positive end-expiratory pressure (hazard ratio, 1.26; 95% CI [1.02-1.57]; p = 0.034), Pao2:Fio2 ratio (hazard ratio, 0.98; 95% CI [0.97-0.99]; p = 0.003), and C-reactive protein (hazard ratio, 1.01; 95% CI [1-1.01]; p = 0.005) were independent late predictors of in-hospital mortality.

CONCLUSIONS

We propose that the optimal window for consideration of tracheostomy for ventilatory weaning is between day 13 and 17. Late predictors of mortality may serve as adverse factors when considering tracheostomy, and our decision tree provides a degree of decision support for clinicians.