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Lee JH, Kim SB, Lee KW, Kim SH. Prognostic factors for tracheostomy early decannulation in acquired brain injury patients. Int J Rehabil Res 2024; 47:97-102. [PMID: 38451479 DOI: 10.1097/mrr.0000000000000618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
After severe brain injuries, a tracheostomy tube is usually inserted for respiratory support. This study aimed to clarify the prognostic factors for tracheostomy early decannulation in patients with acquired brain injuries. We retrospectively reviewed the medical records of inpatients with acquired brain injuries who underwent successful tracheostomy decannulation between March 2021 and June 2022. Fifty-six patients were included; median age was 68 (59-72) years; 28 (50%) were men; 28 (50%) underwent tracheostomy due to stroke. The median time to decannulation was 47 days. The patients were divided into the early and the late decannulation groups based on the median time, and compared. In univariate analysis, the early decannulation group had a higher BMI, peak cough flow, and acquired brain injuries due to trauma, and a lower penetration-aspiration scale score, duration of antibiotic use, and duration of oxygen use. Multivariate Cox regression analysis revealed that a higher initial peak cough flow [hazard ratio (HR) 1.142; 95% confidence interval (CI) 0.912-0.954; P < 0.001] and lower duration of oxygen use (HR 0.930; 95% CI 0.502-0.864; P = 0.016) were independent factors for early tracheostomy decannulation, with each unit increase in peak cough flow corresponding to a 14.2% increase and each additional day of duration of oxygen use corresponding to a 7.0% decrease in the likelihood of early decannulation. In conclusion, key prognostic factors for early tracheostomy decannulation were identified as the initial cough strength and duration of oxygen use. These results could play important role in decannulation plans for patients with tracheostomy tube.
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Affiliation(s)
- Jong Hwa Lee
- Department of Physical Medicine and Rehabilitation, Dong-A University College of Medicine, Seo-gu, Busan, Korea
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2
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Erler KS, Robinson EM, Bandini JI, Regel EV, Zwirner M, Cremens C, McCoy TH, Romain F, Courtwright A. Clinical Ethics Consultation During the First COVID-19 Pandemic Surge at an Academic Medical Center: A Mixed Methods Analysis. HEC Forum 2023; 35:371-388. [PMID: 35290566 PMCID: PMC8922390 DOI: 10.1007/s10730-022-09474-y] [Citation(s) in RCA: 1] [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] [Accepted: 02/01/2022] [Indexed: 11/25/2022]
Abstract
While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim to fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters.
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Affiliation(s)
- Kimberly S Erler
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
- School of Health and Rehabilitation Science, MGH Institute of Health Professions, Boston, MA, USA.
| | - Ellen M Robinson
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Patient Care Services Office of Quality, Safety and Practice, Boston, MA, USA
| | - Julia I Bandini
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- RAND Corporation, Boston, MA, USA
| | - Eva V Regel
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Mary Zwirner
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Cornelia Cremens
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Fred Romain
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Respiratory Care, Mass General Hospital, Boston, MA, USA
| | - Andrew Courtwright
- Optimum Care Committee, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
- Pulmonary and Critical Care Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
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3
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Lin CW, Wang YH, Li YE, Chiang TY, Chiu LW, Lin HC, Chang CT. COVID-related dysphonia and persistent long-COVID voice sequelae: A systematic review and meta-analysis. Am J Otolaryngol 2023; 44:103950. [PMID: 37354724 PMCID: PMC10250057 DOI: 10.1016/j.amjoto.2023.103950] [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: 05/11/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Dysphonia is a common symptom due to the coronavirus disease of the 2019 (COVID-19) infection. Nonetheless, it is often underestimated for its impact on human's health. We conducted this first study to investigate the global prevalence of COVID-related dysphonia as well as related clinical factors during acute COVID-19 infection, and after a mid- to long-term follow-up following the recovery. METHODS Five electronic databases including PubMed, Embase, ScienceDirect, the Cochrane Library, and Web of Science were systematically searched for relevant articles until Dec, 2022, and the reference of the enrolled studies were also reviewed. Dysphonia prevalence during and after COVID-19 infection, and voice-related clinical factors were analyzed; the random-effects model was adopted for meta-analysis. The one-study-removal method was used for sensitivity analysis. Publication bias was determined with funnel plots and Egger's tests. RESULTS Twenty-one articles comprising 13,948 patients were identified. The weighted prevalence of COVID-related dysphonia during infection was 25.1 % (95 % CI: 14.9 to 39.0 %), and male was significantly associated with lower dysphonia prevalence (coefficients: -0.116, 95 % CI: -0.196 to -0.036; P = .004) during this period. Besides, after recovery, the weighted prevalence of COVID-related dysphonia declined to 17.1 % (95 % CI: 11.0 to 25.8 %). 20.1 % (95 % CI: 8.6 to 40.2 %) of the total patients experienced long-COVID dysphonia. CONCLUSIONS A quarter of the COVID-19 patients, especially female, suffered from voice impairment during infection, and approximately 70 % of these dysphonic patients kept experiencing long-lasting voice sequelae, which should be noticed by global physicians.
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Affiliation(s)
- Chung-Wei Lin
- Department of Education, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Han Wang
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-En Li
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ting-Yi Chiang
- Department of Education, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Li-Wen Chiu
- Department of Education, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hsin-Ching Lin
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Business Management, Institute of Healthcare Management and Institute of Biomedical Science, National Sun Yat-sen University, Kaohsiung, Taiwan; Sleep Center, Robotic Surgery Center and Center for Quality Management, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Chun-Tuan Chang
- Department of Business Management, Institute of Healthcare Management and Institute of Biomedical Science, National Sun Yat-sen University, Kaohsiung, Taiwan
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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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5
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Bhasarkar A, Dolma K. Utility of Early Tracheostomy in Critically Ill Covid-19 Patients: A Systematic Review. Indian J Otolaryngol Head Neck Surg 2023; 75:1-11. [PMID: 37362113 PMCID: PMC10016177 DOI: 10.1007/s12070-022-03280-1] [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: 09/04/2022] [Accepted: 11/11/2022] [Indexed: 03/17/2023] Open
Abstract
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.
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Affiliation(s)
- Ashwin Bhasarkar
- Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Kunzes Dolma
- Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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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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7
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Faure M, Decavèle M, Morawiec E, Dres M, Gatulle N, Mayaux J, Stefanescu F, Caliez J, Similowski T, Delemazure J, Demoule A. Specialized Weaning Unit in the Trajectory of SARS-CoV-2 ARDS: Influence of Limb Muscle Strength on Decannulation and Rehabilitation. Respir Care 2022; 67:967-975. [PMID: 35640998 PMCID: PMC9994145 DOI: 10.4187/respcare.09602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with ARDS due to COVID-19 may require tracheostomy and transfer to a weaning center. To date, data on the outcome of these patients are scarce. The objectives of this study were to determine the factors associated with time to decannulation and limb-muscle strength recovery. METHODS This was an observational retrospective study of subjects with COVID-19-related ARDS requiring tracheostomy after prolonged ventilation, who were subsequently transferred to a weaning center from April 4, 2020-May 30, 2020. RESULTS Forty-three subjects were included. Median age (interquartile range) was 61 (48-66) y; 81% were men, and median body mass index (BMI) was 30 (26-35) kg/m2. Tracheostomy was performed after a median of 19 (12-27) d of mechanical ventilation, and the median ICU length of stay prior to transfer to the weaning center was 30 (21-46) d. On admission to the weaning center, the median Medical Research Council (MRC) score was 36 (27-44). Time to decannulation was 9 (7-18) d after admission to the weaning center. The only factor independently associated with early decannulation was the MRC score on admission to the weaning center (odds ratio 1.16 [95% CI 1.06-1.31], P = .005). Two factors were independently associated with MRC gain ≥ 10: BMI (odds ratio 0.88 [95% CI 0.76-0.99], P = .045) and MRC on admission (odds ratio 0.91 [95% CI 0.82-0.98], P = .03. Three months after admission to the weaning center, 40 subjects (93%) were weaned from mechanical ventilation and 36 (84%) had returned home. CONCLUSIONS MRC score at weaning center admission predicted both early decannulation and limb-muscle strength recovery.
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Affiliation(s)
- Morgane Faure
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Maxens Decavèle
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France; and Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
| | - Elise Morawiec
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Martin Dres
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France; and Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Nicolas Gatulle
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Julien Mayaux
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - François Stefanescu
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Julien Caliez
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; and APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), Paris, France
| | - Julie Delemazure
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Alexandre Demoule
- APHP-6 Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France; and Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
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8
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Battaglini D, Premraj L, White N, Sutt AL, Robba C, Cho SM, Di Giacinto I, Bressan F, Sorbello M, Cuthbertson B, Bassi GL, Suen J, Fraser J, Pelosi P. Tracheostomy outcomes in critically ill COVID-19 patients: a systematic review, meta-analysis, and meta-regression. Br J Anaesth 2022; 129:679-692. [PMID: 36182551 PMCID: PMC9345907 DOI: 10.1016/j.bja.2022.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/12/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Background We performed a systematic review of mechanically ventilated patients with COVID-19, which analysed the effect of tracheostomy timing and technique (surgical vs percutaneous) on mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), decannulation from tracheostomy, duration of mechanical ventilation, and complications. Methods Four databases were screened between January 1, 2020 and January 10, 2022 (PubMed, Embase, Scopus, and Cochrane). Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Population or Problem, Intervention or exposure, Comparison, and Outcome (PICO) guidelines. Meta-analysis and meta-regression for main outcomes were performed. Results The search yielded 9024 potentially relevant studies, of which 47 (n=5268 patients) were included. High levels of between-study heterogeneity were observed across study outcomes. The pooled mean tracheostomy timing was 16.5 days (95% confidence interval [CI]: 14.7–18.4; I2=99.6%). Pooled mortality was 22.1% (95% CI: 18.7–25.5; I2=89.0%). Meta-regression did not show significant associations between mortality and tracheostomy timing, mechanical ventilation duration, time to decannulation, and tracheostomy technique. Pooled mean estimates for ICU and hospital LOS were 29.6 (95% CI: 24.0–35.2; I2=98.6%) and 38.8 (95% CI: 32.1–45.6; I2=95.7%) days, both associated with mechanical ventilation duration (coefficient 0.8 [95% CI: 0.2–1.4], P=0.02 and 0.9 [95% CI: 0.4–1.4], P=0.01, respectively) but not tracheostomy timing. Data were insufficient to assess tracheostomy technique on LOS. Duration of mechanical ventilation was 23.4 days (95% CI: 19.2–27.7; I2=99.3%), not associated with tracheostomy timing. Data were insufficient to assess the effect of tracheostomy technique on mechanical ventilation duration. Time to decannulation was 23.8 days (95% CI: 19.7–27.8; I2=98.7%), not influenced by tracheostomy timing or technique. The most common complications were stoma infection, ulcers or necrosis, and bleeding. Conclusions In patients with COVID-19 requiring tracheostomy, the timing and technique of tracheostomy did not clearly impact on patient outcomes. Systematic Review Protocol PROSPERO CRD42021272220.
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9
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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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10
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Evrard D, Jurcisin I, Assadi M, Patrier J, Tafani V, Ullmann N, Timsit JF, Montravers P, Barry B, Weiss E, Rozencwajg S. Tracheostomy in COVID-19 acute respiratory distress syndrome patients and follow-up: A parisian bicentric retrospective cohort. PLoS One 2021; 16:e0261024. [PMID: 34936655 PMCID: PMC8694414 DOI: 10.1371/journal.pone.0261024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Tracheostomy has been proposed as an option to help organize the healthcare system to face the unprecedented number of patients hospitalized for a COVID-19-related acute respiratory distress syndrome (ARDS) in intensive care units (ICU). It is, however, considered a particularly high-risk procedure for contamination. This paper aims to provide our experience in performing tracheostomies on COVID-19 critically ill patients during the pandemic and its long-term local complications. METHODS We performed a retrospective analysis of prospectively collected data of patients tracheostomized for a COVID-19-related ARDS in two university hospitals in the Paris region between January 27th (date of first COVID-19 admission) and May 18th, 2020 (date of last tracheostomy performed). We focused on tracheostomy technique (percutaneous versus surgical), timing (early versus late) and late complications. RESULTS Forty-eight tracheostomies were performed with an equal division between surgical and percutaneous techniques. There was no difference in patients' characteristics between surgical and percutaneous groups. Tracheostomy was performed after a median of 17 [12-22] days of mechanical ventilation (MV), with 10 patients in the "early" group (≤ day 10) and 38 patients in the "late" group (> day 10). Survivors required MV for a median of 32 [22-41] days and were ultimately decannulated with a median of 21 [15-34] days spent on cannula. Patients in the early group had shorter ICU and hospital stays (respectively 15 [12-19] versus 35 [25-47] days; p = 0.002, and 21 [16-28] versus 54 [35-72] days; p = 0.002) and spent less time on MV (respectively 17 [14-20] and 35 [27-43] days; p<0.001). Interestingly, patients in the percutaneous group had shorter hospital and rehabilitation center stays (respectively 44 [34-81] versus 92 [61-118] days; p = 0.012, and 24 [11-38] versus 45 [22-71] days; p = 0.045). Of the 30 (67%) patients examined by a head and neck surgeon, 17 (57%) had complications with unilateral laryngeal palsy (n = 5) being the most prevalent. CONCLUSIONS Tracheostomy seems to be a safe procedure that could help ICU organization by delegating work to a separate team and favoring patient turnover by allowing faster transfer to step-down units. Following guidelines alone was found sufficient to prevent the risk of aerosolization and contamination of healthcare professionals.
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Affiliation(s)
- Diane Evrard
- Department of Otorhinolaryngology, Bichat Hospital, Paris, France
| | - Igor Jurcisin
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Paris, France
| | - Maksud Assadi
- Department of Anesthesia and Surgical Intensive Care Unit, Bichat Hospital, Université de Paris, UFR Denis Diderot, INSERM UMR 1152, ANR10-LABX-17, Paris, France
| | | | - Victor Tafani
- Department of Otorhinolaryngology, Bichat Hospital, Paris, France
| | - Nicolas Ullmann
- Department of Oral and Maxillofacial surgery, Beaujon Hospital, Paris, France
| | | | - Philippe Montravers
- Department of Anesthesia and Surgical Intensive Care Unit, Bichat Hospital, Université de Paris, UFR Denis Diderot, INSERM UMR 1152, ANR10-LABX-17, Paris, France
| | - Béatrix Barry
- Department of Otorhinolaryngology, Bichat Hospital, Paris, France
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Paris, France
- Inserm UMR-S1149, Inserm et Université de Paris, Paris, France
| | - Sacha Rozencwajg
- Department of Anesthesia and Surgical Intensive Care Unit, Bichat Hospital, Université de Paris, UFR Denis Diderot, INSERM UMR 1152, ANR10-LABX-17, Paris, France
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11
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Long SM, Feit NZ, Chern A, Cooley V, Hill SS, Rajwani K, Schenck EJ, Stiles B, Tassler AB. Percutaneous and Open Tracheostomy in Patients With COVID-19: The Weill Cornell Experience in New York City. Laryngoscope 2021; 131:E2849-E2856. [PMID: 34037983 PMCID: PMC8242792 DOI: 10.1002/lary.29669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/09/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN Review of prospectively collected data. METHODS Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2849-E2856, 2021.
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Affiliation(s)
- Sallie M. Long
- Department of Otolaryngology—Head and Neck SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Noah Z. Feit
- Weill Cornell Medical CollegeNew YorkNew YorkU.S.A.
| | - Alexander Chern
- Department of Otolaryngology—Head and Neck SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Victoria Cooley
- Division of Biostatistics and EpidemiologyWeill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Shanna S. Hill
- Department of AnesthesiologyNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Kapil Rajwani
- Division of Pulmonary and Critical Care MedicineNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Edward J. Schenck
- Division of Pulmonary and Critical Care MedicineNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Brendon Stiles
- Department of Cardiothoracic SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
| | - Andrew B. Tassler
- Department of Otolaryngology—Head and Neck SurgeryNewYork‐Presbyterian Hospital/Weill Cornell MedicineNew YorkNew YorkU.S.A.
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12
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Dysphagia Severity and Management in Patients with COVID-19. CURRENT HEALTH SCIENCES JOURNAL 2021; 47:147-156. [PMID: 34765231 PMCID: PMC8551886 DOI: 10.12865/chsj.47.02.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022]
Abstract
COVID-19 has resulted in unprecedented numbers of patients treated at intensive care units (ICUs). Dysphagia is a key concern in critical illness survivors. We investigated the severity of dysphagia in COVID-19 and the need to adapt practices to provide efficient care. We reviewed the literature on COVID-19, post-critical-illness dysphagia, and dysphagia and tracheostomy guidelines during the pandemic. Critically ill COVID-19 patients present a high incidence of dysphagia, aggravated by respiratory distress, deconditioning, and neurological complications. Mechanical ventilation (MV), delirium, sedation and weakness are worse in COVID-19 than in other etiologies of critical care. In awake patients, respiratory compromise impairs breathing-swallowing-coughing coordination. Tracheostomy reduces laryngopharyngeal trauma, sedation, delirium, ICU stay and improves swallowing rehabilitation. Tracheostomy weaning and swallowing evaluation is complex in COVID-19 due to respiratory instability and a team discussion will guide adaptations. Patients assessed in the ICU were 67% recommended to be nil by mouth (were aspirating). Two months following hospital discharge, 83% of those who had undergone tracheostomy were managing a normal diet. Severely ill COVID-19 patients are expected to regain swallow function. Dysphagia care is based on adaptation of practices to the patients' multiple impairments.
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13
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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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14
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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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15
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Tsonas AM, Botta M, Horn J, Brenner MJ, Teng MS, McGrath BA, Schultz MJ, Paulus F, Serpa Neto A. Practice of tracheostomy in patients with acute respiratory failure related to COVID-19 - Insights from the PRoVENT-COVID study. Pulmonology 2021; 28:18-27. [PMID: 34836830 PMCID: PMC8450072 DOI: 10.1016/j.pulmoe.2021.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/30/2021] [Accepted: 08/04/2021] [Indexed: 01/16/2023] Open
Abstract
Objective Invasively ventilated patients with acute respiratory failure related to coronavirus disease 2019 (COVID–19) potentially benefit from tracheostomy. The aim of this study was to determine the practice of tracheostomy during the first wave of the pandemic in 2020 in the Netherlands, to ascertain whether timing of tracheostomy had an association with outcome, and to identify factors that had an association with timing. Methods Secondary analysis of the ‘PRactice of VENTilation in COVID–19’ (PRoVENT–COVID) study, a multicenter observational study, conducted from March 1, 2020 through June 1, 2020 in 22 Dutch intensive care units (ICU) in the Netherlands. The primary endpoint was the proportion of patients receiving tracheostomy; secondary endpoints were timing of tracheostomy, duration of ventilation, length of stay in ICU and hospital, mortality, and factors associated with timing. Results Of 1023 patients, 189 patients (18.5%) received a tracheostomy at median 21 [17 to 28] days from start of ventilation. Timing was similar before and after online publication of an amendment to the Dutch national guidelines on tracheostomy focusing on COVID–19 patients (21 [17–28] vs. 21 [17–26] days). Tracheostomy performed ≤ 21 days was independently associated with shorter duration of ventilation (median 26 [21 to 32] vs. 40 [34 to 47] days) and higher mortality in ICU (22.1% vs. 10.2%), hospital (26.1% vs. 11.9%) and at day 90 (27.6% vs. 14.6%). There were no patient demographics or ventilation characteristics that had an association with timing of tracheostomy. Conclusions Tracheostomy was performed late in COVID–19 patients during the first wave of the pandemic in the Netherlands and timing of tracheostomy possibly had an association with outcome. However, prospective studies are needed to further explore these associations. It remains unknown which factors influenced timing of tracheostomy in COVID–19 patients.
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Affiliation(s)
- A M Tsonas
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands.
| | - M Botta
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands
| | - J Horn
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Amsterdam Neuroscience, Amsterdam UMC Research Institute, Amsterdam, the Netherlands
| | - M J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA; Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
| | - M S Teng
- Department of Otolaryngology-Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - B A McGrath
- Anaesthesia & Intensive Care Medicine, University NHS Foundation Trust, Manchester, UK
| | - M J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - F Paulus
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, the Netherlands
| | - A Serpa Neto
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, the Netherlands; Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
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16
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Benito DA, Bestourous DE, Tong JY, Pasick LJ, Sataloff RT. Tracheotomy in COVID-19 Patients: A Systematic Review and Meta-analysis of Weaning, Decannulation, and Survival. Otolaryngol Head Neck Surg 2021; 165:398-405. [PMID: 33399526 DOI: 10.1177/0194599820984780] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/09/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Daniel A Benito
- Division of Otolaryngology-Head & Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Daniel E Bestourous
- Division of Otolaryngology-Head & Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Jane Y Tong
- Department of Otolaryngology-Head & Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Luke J Pasick
- Department of Otolaryngology-Head & Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert T Sataloff
- Department of Otolaryngology-Head & Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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17
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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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18
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Carlson ER, Heidel RE, Houston K, Vahdani S, Winstead M. Tracheotomies in COVID-19 Patients: Protocols and Outcomes. J Oral Maxillofac Surg 2021; 79:1629-1642. [PMID: 33901449 PMCID: PMC7952266 DOI: 10.1016/j.joms.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/05/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Approximately 3-15% of COVID-19 patients will require prolonged mechanical ventilation thereby requiring consideration for tracheotomy. Guidelines for tracheotomy in this cohort of patients are therefore required with assessed outcomes of tracheotomies. PATIENTS AND METHODS A retrospective chart review was performed of COVID-19 patients undergoing tracheotomy. Inclusion criteria were the performance of a tracheotomy in COVID-19 positive patients between March 11 and December 31, 2020. Exclusion criteria were lack of consent, extubation prior to the performance of a tracheotomy, death prior to the performance of the tracheotomy, and COVID-19 patients undergoing tracheotomy who tested negative twice after medical treatment. The primary predictor variable was the performance of a tracheotomy in COVID-19 positive patients and the primary outcome variable was the time to cessation of mechanical ventilation with the institution of supplemental oxygen via trach mask. RESULTS Seventeen tracheotomies were performed between 4-25 days following intubation (mean = 17 days). Seven patients died between 4 and 16 days (mean = 8.7 days) following tracheotomy and 10 living patients realized cessation of mechanical ventilation from 4 hours to 61 days following tracheotomy (mean = 19.3 days). These patients underwent tracheotomy between 4 and 22 days following intubation (mean = 14 days). The 7 patients who died following tracheotomy underwent the procedure between 7 and 25 days following intubation (mean = 18.2 days). Seven patients underwent tracheotomy on or after 20 days of intubation and 3 survived (43%). Ten patients underwent tracheotomy before 20 days of intubation and 7 patients survived (70%). Significant differences between the mortality groups were detected for age (P = .006), and for P/F ratio at time of consult (P = .047) and the time of tracheotomy (P = .03). CONCLUSIONS Tracheotomies are safely performed in COVID-19 patients with a standardized protocol. The timing of tracheotomy in COVID-19 patients is based on ventilator parameters, P/F ratio, patient prognosis, patient advanced directives, and family wishes.
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Affiliation(s)
- Eric R Carlson
- Professor and Kelly L. Krahwinkel Chairman, Department of Oral and Maxillofacial Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN.
| | - R Eric Heidel
- Associate Professor of Biostatistics, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - Kyle Houston
- Chief Resident, Department of Oral and Maxillofacial Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - Soheil Vahdani
- Fellow, Oral/Head and Neck Oncologic Surgery, Department of Oral and Maxillofacial Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - Michael Winstead
- Chief Resident, Department of Oral and Maxillofacial Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
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19
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Kaushal D, Goyal S, Nair NP, Soni K, Choudhury B, Kumari M, Chhabra S, Goyal A. Tips and Pearls for Tracheostomy during the Covid-19 Pandemic. Int Arch Otorhinolaryngol 2021; 25:e459-e462. [PMID: 34377185 PMCID: PMC8321648 DOI: 10.1055/s-0041-1731723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/28/2021] [Indexed: 11/22/2022] Open
Abstract
The number of critically-ill coronavirus disease 2019 (Covid-19) patients requiring mechanical ventilation is on the rise. Most guidelines suggest keeping the patient intubated and delay elective tracheostomy. Although the current literature does not support early tracheostomy, the number of patients undergoing it is increasing. During the pandemic, it is important that surgeons and anesthesiologists know the different aspects of tracheostomy in terms of indication, procedure, tube care and complications. A literature search was performed to identify different guidelines and available evidence on tracheostomy in Covid-19 patients. The purpose of the present article is to generate an essential scientific evidence for life-saving tracheostomy procedures.
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Affiliation(s)
- Darwin Kaushal
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shilpa Goyal
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Nithin Prakasan Nair
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Kapil Soni
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Bikram Choudhury
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Meena Kumari
- Department of Anesthesiology and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Swati Chhabra
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Amit Goyal
- Department of Otorhinolaryngology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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20
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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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21
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Šifrer R, Urbančič J, Piazza C, van Weert S, García-Purriños F, Benedik J, Tancer I, Aničin A. Emergent tracheostomy during the pandemic of COVID-19: Slovenian National Recommendations. Eur Arch Otorhinolaryngol 2021; 278:2209-2217. [PMID: 32889621 PMCID: PMC7473826 DOI: 10.1007/s00405-020-06318-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/21/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Emergent tracheostomy under local anaesthesia is a reliable method of airway management when orotracheal intubation is not possible. COVID-19 is spread through aerosol making the emergent tracheostomy a high-risk procedure for surgeons. The surgical establishment of the air conduit in emergency scenarios must be adjusted for safety reasons. METHODS To establish the Slovenian National Guidelines for airway management in cannot intubate-cannot ventilate situations in COVID-19 positive patients. RESULTS Good communication and coordination between surgeon and anaesthesiologist is absolutely necessary. Deep general anaesthesia, full muscle relaxation and adequate preoxygenation without intubation are initial steps. The surgical cricothyrotomy is performed quickly, the thin orotracheal tube is inserted, the cuff is inflated and ventilation begins. Following patient stabilisation, the conversion to the tracheostomy is undertaken with the following features: skin infiltration with vasoconstrictor, a vertical incision, avoidance of electrical devices in favour of classical manners of haemostasis, the advancement of the tube towards the carina, performing the tracheal window in complete apnoea following adequate oxygenation, the insertion of non-fenestrated canulla attached to a heat and moisture exchanger, the fixation of canulla with stitches and tapes, and the cricothyrotomy entrance closure. Appropriate safety equipment is equally important. CONCLUSION The goal of the guidelines is to make the procedure safer for medical teams, without harming the patients. Further improvements of the guidelines will surely appear as COVID-19 is a new entity and there is not yet much experience in handling it.
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Affiliation(s)
- Robert Šifrer
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia.
| | - Jure Urbančič
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
| | - Cesare Piazza
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, National Cancer Institute of Milan, Via Giacomo Venezian 1, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Via Festa del Perdono 7, Milan, Italy
| | - Stijn van Weert
- Department of Otolaryngology - Head and Neck Surgery, Amsterdam UMC, Locatie VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Francisco García-Purriños
- Servicio de Otorrinolaringología, Hospital Universitario Los Arcos del Mar Menor, Paraje Torre Octavio 54, 30739, Pozo Aledo, Murcia, Spain
| | - Janez Benedik
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
- Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Ivana Tancer
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Aleksandar Aničin
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
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22
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Sancho J, Ferrer S, Lahosa C, Posadas T, Bures E, Bañuls P, Fernandez-Presa L, Royo P, Blasco ML, Signes-Costa J. Tracheostomy in patients with COVID-19: predictors and clinical features. Eur Arch Otorhinolaryngol 2021; 278:3911-3919. [PMID: 33386436 PMCID: PMC7775730 DOI: 10.1007/s00405-020-06555-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/08/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Around 20% of patients hospitalized for COVID-19 need mechanical ventilation (MV). MV may be prolonged, thus warranting tracheostomy. METHODS Observational cohort study enrolling patients admitted due to COVID-19. Demographic and clinical data at hospital and ICU admission were collected. The primary endpoint was to identify parameters associated with a need for tracheostomy; secondary endpoints were to analyze the clinical course of patients who needed tracheostomy. RESULTS 118 patients were enrolled; 37 patients (31.5%) were transferred to ICU, of which 11 (29.72%) needed a tracheostomy due to prolonged MV. Sequential Organ Failure Assessment (SOFA) score at ICU admission (OR 0.65, 95% CI 0.47-0.92, p 0.015) was the only variable found to be associated with increased risk of the need for tracheostomy, with a cut-off point of 4.5 (sensitivity 0.72, specificity 0.73, positive predictive value 0.57 and negative predictive value 0.85). The main complications were nosocomial infection (100%), supraventricular cardiac arrhythmia (45.5%), agitation (54.5%), pulmonary thromboembolism (9.1%) and depression (9.1%). All patients presented with hypoalbuminemia and significant critical illness polyneuropathy. CONCLUSION SOFA at ICU admission is associated with an increased risk of tracheostomy in patients with COVID-19. Moreover, they present clinical features similar to those with chronic critical illness and suffer SARS-CoV-2-related complications.
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Affiliation(s)
- Jesus Sancho
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain. .,Institue of Health Research INCLIVA, Valencia, Spain.
| | - Santos Ferrer
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
| | - Carolina Lahosa
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
| | - Tomas Posadas
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
| | - Enric Bures
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
| | - Pilar Bañuls
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
| | - Lucia Fernandez-Presa
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
| | - Pablo Royo
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
| | - Mª Luisa Blasco
- Institue of Health Research INCLIVA, Valencia, Spain.,Intensive Care Unit, Hospital Clínico Universitario, Valencia, Spain
| | - Jaime Signes-Costa
- Respiratory Medicine Department, Hospital Clínico Universitario, Avd Blasco Ibañez 17, 46010, Valencia, Spain.,Institue of Health Research INCLIVA, Valencia, Spain
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23
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Meister KD, Pandian V, Hillel AT, Walsh BK, Brodsky MB, Balakrishnan K, Best SR, Chinn SB, Cramer JD, Graboyes EM, McGrath BA, Rassekh CH, Bedwell JR, Brenner MJ. Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review. Otolaryngol Head Neck Surg 2020; 164:984-1000. [PMID: 32960148 DOI: 10.1177/0194599820961990] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. DATA SOURCES PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents. REVIEW METHODS Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. CONCLUSIONS Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel. IMPLICATIONS FOR PRACTICE Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.
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Affiliation(s)
- Kara D Meister
- Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA.,Center for Pediatric Voice and Swallowing Disorders, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University, Baltimore, Maryland, USA.,Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Brian K Walsh
- Department of Health Sciences, Liberty University, Lynchburg, Virginia, USA
| | - Martin B Brodsky
- Outcomes After Critical Illness and Surgery Research Group, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Physical and Rehabilitation, Johns Hopkins University, Baltimore, Maryland, USA.,Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Karthik Balakrishnan
- Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA.,Center for Pediatric Voice and Swallowing Disorders, Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Lucile Packard Children's Hospital, Stanford Children's Health, Palo Alto, California, USA
| | - Simon R Best
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Michigan, USA
| | - John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Hollings Cancer Center, Charleston, South Carolina, USA
| | - Brendan A McGrath
- University of Manchester, NHS Foundation Trust, National Tracheostomy Safety Project, Manchester, UK
| | - Christopher H Rassekh
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua R Bedwell
- Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Otolaryngology-Head and Neck Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA; Global Tracheostomy Collaborative, Raleigh, North Carolina, USA
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24
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Martin-Villares C, Perez Molina-Ramirez C, Bartolome-Benito M, Bernal-Sprekelsen M. Outcome of 1890 tracheostomies for critical COVID-19 patients: a national cohort study in Spain. Eur Arch Otorhinolaryngol 2020; 278:1605-1612. [PMID: 32749607 PMCID: PMC7399582 DOI: 10.1007/s00405-020-06220-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/15/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Cristina Martin-Villares
- Department of Otorhinolaryngology, Hospital Universitario El Bierzo, Médicos sin Fronteras s/n, 24401, Ponferrada, León, Spain. .,Department of Medicine, Surgery and Anatomy, University of León, León, Spain.
| | - Carmen Perez Molina-Ramirez
- Department of Otorhinolaryngology, Complejo Universitario Hospitalario de Segovia, University of Valladolid, Segovia, Spain
| | - Margarita Bartolome-Benito
- Department of Otorhinolaryngology, Hospital Infantil Universitario Niño Jesús, Autonomous University of Madrid, Madrid, Spain
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25
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Tornari C, Surda P, Takhar A, Amin N, Dinham A, Harding R, Ranford DA, Archer SK, Wyncoll D, Tricklebank S, Ahmad I, Simo R, Arora A. Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients. Eur Arch Otorhinolaryngol 2020; 278:1595-1604. [PMID: 32740720 PMCID: PMC7395208 DOI: 10.1007/s00405-020-06187-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/03/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. METHODS We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. RESULTS At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO2 at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89-3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p = 0.001) were independent variables associated with prolonged time to decannulation. CONCLUSION Higher FiO2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.
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Affiliation(s)
- Chrysostomos Tornari
- Department of ENT - Head & Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - Pavol Surda
- Department of ENT - Head & Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Arunjit Takhar
- Department of ENT - Head & Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Nikul Amin
- Department of ENT - Head & Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Alison Dinham
- Department of Head & Neck Physiotherapy, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Rachel Harding
- Department of Head & Neck Physiotherapy, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - David A Ranford
- Department of ENT - Head & Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Sally K Archer
- Department of Speech & Language Therapy, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Duncan Wyncoll
- Department of Intensive Care Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Stephen Tricklebank
- Department of Intensive Care Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Imran Ahmad
- Department of Anaesthetics, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ricard Simo
- Department of ENT - Head & Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Asit Arora
- Department of ENT - Head & Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Rovira A, Dawson D, Walker A, Tornari C, Dinham A, Foden N, Surda P, Archer S, Lonsdale D, Ball J, Ofo E, Karagama Y, Odutoye T, Little S, Simo R, Arora A. Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline. Eur Arch Otorhinolaryngol 2020; 278:313-321. [PMID: 32556788 PMCID: PMC7299456 DOI: 10.1007/s00405-020-06126-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022]
Abstract
Purpose Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. Methods This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. Results Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. Conclusion COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.
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Affiliation(s)
- Aleix Rovira
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK.
| | - Deborah Dawson
- Department of Critical Care, St George's Hospital NHS Foundation Trust, London, UK
| | - Abigail Walker
- Department of Otorhinolaryngology Head and Neck Surgery, University Hospital Lewisham, London, UK
| | - Chrysostomos Tornari
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Alison Dinham
- Department of Physiotherapy, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Neil Foden
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Pavol Surda
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Sally Archer
- Speech and Language Therapy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dagan Lonsdale
- Critical Care Unit, St George's Hospital NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - Jonathan Ball
- Critical Care Unit, St George's Hospital NHS Foundation Trust, London, UK
| | - Enyi Ofo
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Yakubu Karagama
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Tunde Odutoye
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Sarah Little
- Department of Otorhinolaryngology Head and Neck Surgery, St George's Hospital NHS Foundation Trust, London, UK
| | - Ricard Simo
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
| | - Asit Arora
- Department of Otorhinolayngology Head and Neck Surgery, Guy's and St Thomas Hospital NHS Foundation Trust, London, UK
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