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

Timing dilemma: a systematic review and meta-analysis of short-term mortality in patients with COVID-19 undergoing tracheostomy with varied timing, including 7, 10 and 14 days

OBJECTIVE

To analyse the effects of tracheostomy timing on COVID-19 outcomes by comparing mortality rates at different time points (7, 10 and 14 days).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library, Web of Science and Scopus were searched from 31 August 2023 to 6 September 2023.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was short-term mortality, defined as intensive care unit (ICU) mortality, hospital mortality and 28-day or 30-day mortality. The secondary outcomes included mechanical ventilation duration, ICU and hospital days.

RESULTS

Among 3465 patients from 12 studies, the 10-day subgroup analysis revealed higher mortality for earlier tracheostomy than for later tracheostomy (49.7% vs 32.6%, OR 1.91, 95% CI 1.37-2.65). No significant differences were observed at 7- and 14-day marks. Earlier tracheostomy was associated with shorter mechanical ventilation (mean difference=-7.35 days, 95% CI -11.63 to -0.38) and ICU stays (mean difference=-11.24 days, 95% CI -18.50 to -3.97) compared with later tracheostomy. Regarding hospital stay, the later tracheostomy group exhibited a trend towards longer-term inpatients, with no significant difference.

CONCLUSIONS

No significant difference in short-term mortality was observed between patients undergoing tracheostomy at 7 and 14 days; however, at 10 days, later tracheostomy resulted in a lower mortality rate. Accordingly, subtle timing differences may impact short-term results in COVID-19 patients. Considering that the later tracheostomy group had longer mechanical ventilation and ICU stays, additional research is required to determine an optimal timing that reduces mortality cost-effectively.

Tracheostomy is associated with decreased in-hospital mortality during severe COVID-19 infection

Objective

Tracheostomy is often performed in patients with a prolonged course of endotracheal intubation. This study sought to examine the clinical utility of tracheostomy during severe Coronavirus disease 2019 (COVID-19) infection.

Study Design

A retrospective single-system, multicenter observational cohort study was performed on patients intubated for COVID-19 infection. Patients who received intubation alone were compared with patients who received intubation and subsequent tracheostomy. Patient demographics, comorbidities, and hospital courses were analyzed.

Setting

The University of Pennsylvania Health System from 2020 to 2021.

Methods

Logistic regression analysis was performed on patient demographics and comorbidities. Kaplan-Meier survival curves were generated depending on whether patients received a tracheostomy.

Results

Of 777 intubated patients, 452 were male (58.2%) and 325 were female (41.8%) with a median age of 63 (interquartile range [IQR]: 54-73) years. One-hundred and eighty-five (23.8%) patients underwent tracheostomy. The mean time from intubation to tracheostomy was (17.3 ± 9.7) days. Patients who underwent tracheostomy were less likely to expire during their hospitalization than those who did not undergo tracheostomy (odds ratio [OR] = 0.31, P < 0.001), and patient age was positively associated with mortality (OR = 1.04 per year, P < 0.001). Likelihood of receiving tracheostomy was positively associated with being on extra-corporeal membranous oxygenation (ECMO) (OR = 101.10, P < 0.001), immunocompromised status (OR = 3.61, P = 0.002), and current tobacco smoking (OR = 4.81, P = 0.041). Tracheostomy was also associated with a significantly longer hospital length of stay ([57.5 ± 32.2] days vs. [19.9 ± 18.1] days, P < 0.001).

Conclusions

Tracheostomy was associated with reduced in-hospital mortality, despite also being associated with increased comorbidities. Tracheostomy should not be held back from patients with comorbidities for this reason alone and may even improve survival in high-risk patients.

Comparison Between Early and Late Tracheostomy in ICU Patients Including COVID-19 and Non-COVID-19 Patients: A Retrospective Cohort Study at a Tertiary Care Hospital

Background Tracheostomy is a common intervention for intensive care unit (ICU) patients for various reasons. The superiority of early versus late tracheostomy is still unfounded for non-COVID-19 cases. The COVID-19 pandemic complicated the matter, as little literature was available on the ideal timing of tracheostomy for patients with COVID-19. Research question This study aimed to establish the superiority of early or late tracheostomy for COVID-19 and non-COVID-19 cases by comparing outcomes, including ICU mortality, ventilation days after tracheostomy, and ICU length of stay (LOS). Study design and methods A single-center retrospective cohort study was conducted on ventilated ICU patients both with and without COVID-19 at a university hospital between January 2020 and December 2021. During the study period, 1,393 ventilated patients were scanned, and 156 were found to be tracheostomized. Tracheostomy was considered to be early when performed within 10 days of intubation, after which it was considered to be late. Results Tracheostomy was performed early for 84/156 (53.8%) of tracheostomized patients and late for 72/156 (46.2%) of patients. The overall mortality was 42.9% (36/84) versus 69.4% (50/72) (P=0.001, OR=3.03, 95% CI=1.563-5.874), 31.4% versus 65.5% in the non-COVID-19 group and 60.6% versus 72.1% (P=0.005, OR=2.640, 95% CI=1.345-5.181) in the COVID-19 group for the early and late tracheostomy groups, respectively. Ventilation days were higher for the late tracheostomy group than for the early tracheostomy group in the non-COVID-19 group (17.10 versus 9.18 days, P<0.001). However, it was almost the same for the early and late tracheostomy groups in the COVID-19 group (14.15 versus 13.86 days, P=0.821). The ICU LOS was greater for the late tracheostomy group for both the COVID-19 and non-COVID-19 groups. Multivariate analysis revealed that ICU mortality is significantly associated with age, ventilation days, and ICU LOS. Interpretation The results of this study indicate that early tracheostomy was associated with lower mortality, fewer ventilation days, and shorter LOS in both the COVID-19 and non-COVID-19 groups.

Impact of Tracheostomy on COVID-19 ICU Patients in Saudi Arabia: A Retrospective Analysis

Introduction The COVID-19 pandemic has prompted the development of novel medical interventions, including tracheostomy, a surgical procedure for a direct airway. This study investigates the intricacies of managing critically ill patients in the ICU, focusing on its debated utility in the global crisis. Methods The study assessed the impact of tracheostomy on COVID-19 patients at Al-Ahsa Hospital, Saudi Arabia, using a retrospective cohort design and data from electronic health records and databases. It aimed to provide insights into treatment outcomes and practices. Results The findings of this study shed light on the significant impact of tracheostomy on the course of ICU treatment for COVID-19 patients. Total number of participants were 1389. The study cohort consisted of predominantly non-pregnant individuals with an average body mass index reflective of the regional population. Among the COVID-19 patients, only a small percentage, 63 (4.5%), required tracheostomy, while the majority, 1326 (95.5%), did not undergo this procedure. Analysis of ICU outcomes revealed that a substantial proportion of patients, 223 (16.1%), achieved total cure, while the remaining patients did not. After a 28-day ICU stay, the majority of individuals, 1287 (92.7%), were discharged, while a smaller percentage remained in the ICU, with 77 (5.5%) still requiring mechanical ventilation. Notably, patients who underwent tracheostomy had a significantly longer ICU stay compared to those who did not, with an average of 59 days versus 19 days, respectively. Furthermore, the study found that tracheostomy did not significantly impact ICU discharge outcomes, including death, discharge home, and transfer to another facility. However, it did influence hospital discharge outcomes, with lower mortality rates and a higher rate of transfer to another facility among patients who underwent tracheostomy. These results provide valuable insights into the management and outcomes of critically ill COVID-19 patients in the ICU, particularly in relation to the use of tracheostomy as a treatment intervention. Conclusion The study highlights the dual benefits of tracheostomy in COVID-19 care, extending hospital stays but not increasing ICU discharge rates, emphasizing the need for tailored clinical strategies.

Early versus late tracheostomy in critically ill COVID-19 patients

BACKGROUND

The role of early tracheostomy as an intervention for critically ill COVID-19 patients is unclear. Previous reports have described prolonged intensive care stays and difficulty weaning from mechanical ventilation in critically ill COVID-19 patients, particularly in those developing acute respiratory distress syndrome. Pre-pandemic evidence on the benefits of early tracheostomy is conflicting but suggests shorter hospital stays and lower mortality rates compared to late tracheostomy.

OBJECTIVES

To assess the benefits and harms of early tracheostomy compared to late tracheostomy in critically ill COVID-19 patients.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register, which comprises CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv, as well as Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index) and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions. We conducted the searches on 14 June 2022.

SELECTION CRITERIA

We followed standard Cochrane methodology. We included randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) evaluating early tracheostomy compared to late tracheostomy during SARS-CoV-2 infection in critically ill adults irrespective of gender, ethnicity, or setting.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. To assess risk of bias in included studies, we used the Cochrane RoB 2 tool for RCTs and the ROBINS-I tool for NRSIs. We used the GRADE approach to assess the certainty of evidence for outcomes of our prioritized categories: mortality, clinical status, and intensive care unit (ICU) length of stay. As the timing of tracheostomy was very heterogeneous among the included studies, we applied GRADE only to studies that defined early tracheostomy as 10 days or less, which was chosen according to clinical relevance.

MAIN RESULTS

We included one RCT with 150 participants diagnosed with SARS-CoV-2 infection and 24 NRSIs with 6372 participants diagnosed with SARS-CoV-2 infection. All participants were admitted to the ICU, orally intubated and mechanically ventilated. The RCT was a multicenter, parallel, single-blinded study conducted in Sweden. Of the 24 NRSIs, which were mostly conducted in high- and middle-income countries, eight had a prospective design and 16 a retrospective design. We did not find any ongoing studies. RCT-based evidence We judged risk of bias for the RCT to be of low or some concerns regarding randomization and measurement of the outcome. Early tracheostomy may result in little to no difference in overall mortality (RR 0.82, 95% CI 0.52 to 1.29; RD 67 fewer per 1000, 95% CI 178 fewer to 108 more; 1 study, 150 participants; low-certainty evidence). As an indicator of improvement of clinical status, early tracheostomy may result in little to no difference in duration to liberation from invasive mechanical ventilation (MD 1.50 days fewer, 95%, CI 5.74 days fewer to 2.74 days more; 1 study, 150 participants; low-certainty evidence). As an indicator of worsening clinical status, early tracheostomy may result in little to no difference in the incidence of adverse events of any grade (RR 0.94, 95% CI 0.79 to 1.13; RD 47 fewer per 1000, 95% CI 164 fewer to 102 more; 1 study, 150 participants; low-certainty evidence); little to no difference in the incidence of ventilator-associated pneumonia (RR 1.08, 95% CI 0.23 to 5.20; RD 3 more per 1000, 95% CI 30 fewer to 162 more; 1 study, 150 participants; low-certainty evidence). None of the studies reported need for renal replacement therapy. Early tracheostomy may result in little benefit to no difference in ICU length of stay (MD 0.5 days fewer, 95% CI 5.34 days fewer to 4.34 days more; 1 study, 150 participants; low-certainty evidence). NRSI-based evidence We considered risk of bias for NRSIs to be critical because of possible confounding, study participant enrollment into the studies, intervention classification and potentially systematic errors in the measurement of outcomes. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases overall mortality (RR 1.47, 95% CI 0.43 to 5.00; RD 143 more per 1000, 95% CI 174 less to 1218 more; I2 = 79%; 2 studies, 719 participants) or duration to liberation from mechanical ventilation (MD 1.98 days fewer, 95% CI 0.16 days fewer to 4.12 more; 1 study, 50 participants), because we graded the certainty of evidence as very low. Three NRSIs reported ICU length of stay for 519 patients with early tracheostomy (≤ 10 days) as a median value, which we could not include in the meta-analyses. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases the ICU length of stay, because we graded the certainty of evidence as very low.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that early tracheostomy may result in little to no difference in overall mortality in critically ill COVID-19 patients requiring prolonged mechanical ventilation compared with late tracheostomy. In terms of clinical improvement, early tracheostomy may result in little to no difference in duration to liberation from mechanical ventilation compared with late tracheostomy. We are not certain about the impact of early tracheostomy on clinical worsening in terms of the incidence of adverse events, need for renal replacement therapy, ventilator-associated pneumonia, or the length of stay in the ICU. Future RCTs should provide additional data on the benefits and harms of early tracheostomy for defined main outcomes of COVID-19 research, as well as of comparable diseases, especially for different population subgroups to reduce clinical heterogeneity, and report a longer observation period. Then it would be possible to draw conclusions regarding which patient groups might benefit from early intervention. Furthermore, validated scoring systems for more accurate predictions of the need for prolonged mechanical ventilation should be developed and used in new RCTs to ensure safer indication and patient safety. High-quality (prospectively registered) NRSIs should be conducted in the future to provide valuable answers to clinical questions. This could enable us to draw more reliable conclusions about the potential benefits and harms of early tracheostomy in critically ill COVID-19 patients.

Tracheostomy insertion in COVID-19: insertion practice and factors leading to unplanned tube exchange

Background

Tracheostomy insertion in patients with coronavirus disease 2019 (COVID-19) presents unique challenges. Patients frequently have high ventilatory requirements, and as an aerosol generating procedure, tracheostomy insertion creates the potential for staff transmission. Problems with tracheostomies contribute to morbidity and mortality, and tracheostomy changes may increase risks of staff transmission. We sought to quantify the incidence of clinically necessitated tracheostomy changes, establish the indications for change and investigate the incidence of staff transmission.

Methods

We conducted a single institution, retrospective, observational cohort study of all intensive care unit (ICU) patients with COVID-19 who had a tracheostomy between March 2020 and April 2021. The institution is a large tertiary referral centre in Ireland.

Results

Forty-three patients had a tracheostomy during the study period. All were a Shiley™ Flexible Adult Taperguard or Shiley™ XLT Tracheostomy. 14 patients (33%) required a tracheostomy change, with the majority (57%) involving a change from a standard size to an extended length tracheostomy. Persistent leak was the most common indication for change (71.6%). Other indications included patient-ventilator dyssynchrony, persistent cough and accidental decannulation. No staff transmission of COVID-19 occurred during this study.

Conclusions

The incidence of tracheostomy change was 33%, highlighting the importance of selecting the right tracheostomy for each patient. We discuss how key characteristics of tracheostomies such as type, size, length and inner diameter may impact flow, resistance and work of breathing, leading to unplanned tracheostomy change. No staff transmission occurred arising from tracheostomy insertion, adding to increasing evidence that tracheostomy insertion in COVID-19 appears safe with adherence to guidelines describing the correct use of personal protective equipment.

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

BACKGROUND

Health care professionals (HCPs) performing tracheostomies in patients with COVID-19 may be at increased risk of infection.

OBJECTIVE

To evaluate factors underlying HCPs' COVID-19 infection and determine whether tracheostomy providers report increased rates of infection.

METHODS

An anonymous international survey examining factors associated with COVID-19 infection was made available November 2020 through July 2021 to HCPs at a convenience sample of hospitals, universities, and professional organizations. Infections reported were compared between HCPs involved in tracheostomy on patients with COVID-19 and HCPs who were not involved.

RESULTS

Of the 361 respondents (from 33 countries), 50% (n = 179) had performed tracheostomies on patients with COVID-19. Performing tracheostomies on patients with COVID-19 was not associated with increased infection in either univariable (P = .06) or multivariable analysis (odds ratio, 1.48; 95% CI, 0.90-2.46; P = .13). Working in a low- or middle-income country (LMIC) was associated with increased infection in both univariable (P < .001) and multivariable analysis (odds ratio, 2.88; CI, 1.50-5.53; P = .001).

CONCLUSIONS

Performing tracheostomy was not associated with COVID-19 infection, suggesting that tracheostomies can be safely performed in infected patients with appropriate precautions. However, HCPs in LMICs may face increased infection risk.

Coronavirus disease tracheostomy complications: a scoping review

BACKGROUND

Coronavirus disease 2019 increased the numbers of patients requiring prolonged mechanical ventilation, with a subsequent increase in tracheostomy procedures. Coronavirus disease 2019 patients are high risk for surgical complications. This review examines open surgical and percutaneous tracheostomy complications in coronavirus disease 2019 patients.

METHODS

Medline and Embase databases were searched (November 2021), and the abstracts of relevant articles were screened. Data were collected regarding tracheostomy technique and complications. Complication rates were compared between percutaneous and open surgical tracheostomy.

RESULTS

Percutaneous tracheostomy was higher risk for bleeding, pneumothorax and false passage. Surgical tracheostomy was higher risk for peri-operative hypoxia. The most common complication for both techniques was post-operative bleeding.

CONCLUSION

Coronavirus disease 2019 patients undergoing tracheostomy are at higher risk of bleeding and peri-operative hypoxia than non-coronavirus disease patients. High doses of anti-coagulants may partially explain this. Reasons for higher bleeding risk in percutaneous over open surgical technique remain unclear. Further research is required to determine the causes of differences found and to establish mitigating strategies.

Outcomes of Surgical Tracheostomy on Mechanically Ventilated COVID-19 Patients Admitted to a Private Tertiary Hospital in Tanzania

OBJECTIVES

 The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in the number of patients necessitating prolonged mechanical ventilation. Data on patients with COVID-19 undergoing tracheostomy indicating timing and outcomes are very limited. Our study illustrates--- outcomes for surgical tracheotomies performed on COVID-19 patients in Tanzania.

METHODS

 This was a retrospective observational study conducted at the Aga Khan Hospital in Dar es Salaam, Tanzania.

RESULTS

 Nineteen patients with COVID-19 underwent surgical tracheotomy between 16^th March and 31^st December 2021. All surgical tracheostomies were performed in the operating theatre. The average duration of intubation prior to tracheotomy and tracheostomy to ventilator liberation was 16 days and 27 days respectively. Only five patients were successfully liberated from the ventilator, decannulated, and discharged successfully.

CONCLUSIONS

 This is the first and largest study describing tracheotomy outcomes in COVID-19 patients in Tanzania. Our results revealed a high mortality rate. Multicenter studies in the private and public sectors are needed in Tanzania to determine optimal timing, identification of patients, and risk factors predictive of improved outcomes.

Inflammatory biomarkers and cardiac injury in COVID-19 patients

Introduction

Cardiac injury has received considerable attention due to the higher risk of morbidity and mortality associated with coronavirus disease. However, in a developing country, there is a scarcity of data on cardiac injury in COVID-19 patients related to inflammatory biomarkers.

Methods

Therefore, the present research retrospectively analyzes data from three territorial hospitals in Pakistan's Punjab province to investigate the potential impact of the cardiac injury on the mortality and severity of COVID-19-infected patients. We evaluated 2,051 patients between January 16 and April 18, 2022, with confirmed COVID-19. The in-hospital mortality recorded for the selected sample size was about 16.28%.

Results

The majority of the participants were identified as male (64%) with a median age of 65 years. Also, fever, fatigue, and dyspnea were reported as common symptoms. An aggregate of 623 patients (30.38%) had a cardiac injury, and when these patients are compared to those without cardiac injury, the participants were significantly older and had more comorbidities with higher leukocyte counts, elevated levels of C-reactive protein, interleukin-6, procalcitonin, myohemoglobin, creatinine kinase-myocardial band, serum creatinine, high-sensitivity troponin-I, N-terminal pro-B-type natriuretic peptide had a significant amount of multiple ground-glass opacity and bilateral pulmonary infiltration in radiographic results. Participants with heart injury required more non-invasive or invasive mechanical respiration than those who did not have a cardiac injury. Individuals with cardiac injury had higher rates of sepsis, acute respiratory distress syndrome (ARDS), d-dimer concentration, and respiratory failure than those without cardiac injury. Patients who had had a cardiac injury died at a higher rate than those who had not suffered cardiac damage. In the multivariable logistic regression analysis, participants with cardiac injury showed greater odds of COVID-19 mortality and were found associated with older age (OR = 1.99, 95% CI = 0.04-3.19), elevated cardiac troponin I (OR = 18.64, 95% CI = 13.16-23.01), the complication of sepsis (OR = 10.39, 95% CI = 7.41-13.39) and ARDS (OR = 6.65, 95% CI = 4.04-8.91).

Conclusion

Cardiac injury is a frequent complication among patients with coronavirus-induced infection in Punjab, Pakistan, and it is significantly linked to a greater risk of in-hospital mortality.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study

Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation).

DESIGN

International multi-institute retrospective cohort study.

SETTING

Thirteen hospitals in Bolivia, Brazil, Spain, and the United States.

PATIENTS

Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified.

CONCLUSIONS

COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Tracheostomy outcomes in critically ill patients with COVID-19: a systematic review, meta-analysis, and meta-regression

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.

The Impact of Different Ventilatory Strategies on Clinical Outcomes in Patients with COVID-19 Pneumonia

Introduction: The aim was to investigate the impact of different ventilator strategies (non-invasive ventilation (NIV); invasive MV with tracheal tube (TT) and with tracheostomy (TS) on outcomes (mortality and intensive care unit (ICU) length of stay) in patients with COVID-19. We also assessed the impact of timing of percutaneous tracheostomy and other risk factors on mortality. Methods: The retrospective cohort included 868 patients with severe COVID-19. Demographics, MV parameters and duration, and ICU mortality were collected. Results: MV was provided in 530 (61.1%) patients, divided into three groups: NIV (n = 139), TT (n = 313), and TS (n = 78). Prevalence of tracheostomy was 14.7%, and ICU mortality was 90.4%, 60.2%, and 30.2% in TT, TS, and NIV groups, respectively (p < 0.001). Tracheostomy increased the chances of survival and being discharged from ICU (OR 6.3, p < 0.001) despite prolonging ICU stay compared to the TT group (22.2 days vs. 10.7 days, p < 0.001) without differences in survival rates between early and late tracheostomy. Patients who only received invasive MV had higher odds of survival compared to those receiving NIV in ICU prior to invasive MV (OR 2.7, p = 0.001). The odds of death increased with age (OR 1.032, p < 0.001), obesity (1.58, p = 0.041), chronic renal disease (1.57, p = 0.019), sepsis (2.8, p < 0.001), acute kidney injury (1.7, p = 0.049), multiple organ dysfunction (3.2, p < 0.001), and ARDS (3.3, p < 0.001). Conclusions: Percutaneous tracheostomy compared to MV via TT significantly increased survival and the rate of discharge from ICU, without differences between early or late tracheostomy.

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

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

Tracheostomy care and communication during COVID-19: Global interprofessional perspectives

Objective

Investigate healthcare providers, caregivers, and patient perspectives on tracheostomy care barriers during COVID-19.

Study design

Cross-sectional anonymous survey

Setting

Global Tracheostomy Collaborative Learning Community

Methods

A 17-item questionnaire was electronically distributed, assessing demographic and occupational data; challenges in ten domains of tracheostomy care; and perceptions regarding knowledge and preparedness for navigating the COVID-19 pandemic.

Results

Respondents (n = 115) were from 20 countries, consisting of patients/caregivers (10.4%) and healthcare professionals (87.0%), including primarily otolaryngologists (20.9%), nurses (24.3%), speech-language pathologists (18.3%), respiratory therapists (11.3%), and other physicians (12.2%). The most common tracheostomy care problem was inability to communicate (33.9%), followed by mucus plugging and wound care. Need for information on how to manage cuffs and initiate speech trials was rated highly by most respondents, along with other technical and knowledge areas. Access to care and disposable supplies were also prominent concerns, reflecting competition between community needs for routine tracheostomy supplies and shortages in intensive care units. Integrated teamwork was reported in 40 to 67% of respondents, depending on geography. Forty percent of respondents reported concern regarding personal protective equipment (PPE), and 70% emphasized proper PPE use.

Conclusion

While safety concerns, centering on personal protective equipment and pandemic resources are prominent concerns in COVID-19 tracheostomy care, patient-centered concerns must also be prioritized. Communication and speech, adequate supplies, and care standards are critical considerations in tracheostomy. Stakeholders in tracheostomy care can partner to identify creative solutions for delays in restoring communication, supply disruptions, and reduced access to tracheostomy care in both inpatient and community settings.

Early versus standard tracheostomy in ventilated patients in neurosurgical intensive care unit: A randomized controlled trial

INTRODUCTION

Tracheostomy is performed in patients with prolonged mechanical ventilation, who suffered catastrophic neurologic insult or upper airway obstruction. Thus far, there is no consensus on the optimal timing in performing a tracheostomy. This study aims to test whether early tracheostomy in mechanically ventilated patients in a neurosurgical setting would be associated with a shorter time of mechanical ventilation as compared to standard tracheostomy.

METHODS

This single-center prospective randomized controlled trial was conducted at University Malaya Medical Centre from July 2019 to July 2021. The likelihood of prolonged ventilation was determined objectively using the TRACH score and the patient's clinical presentation. The outcomes measured were days of mechanical ventilation post-tracheostomy, days of neuro-intensive care unit stay, and days of hospital stay. Tracheostomy-related complications were collected. The data collected were analyzed using Statistical Package for the Social Sciences version 25 for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS

In all, 39 patients were randomly assigned. Of these, 20 were allocated to the early tracheostomy group (ET) and 19 were allocated to the standard tracheostomy group (ST). The demographic characteristics were similar between the groups. The primary outcome, mean (SD) days of mechanical ventilation post-tracheostomy, was statistically different in the 2 groups- early 11.9 (9.3) days, standard 18.9 (32.5) days; p = 0.014. There were comparable tracheostomy-related complications in both groups.

CONCLUSION

Early tracheostomy is associated with a shorter duration of mechanical ventilation in a neurosurgical intensive care unit setting.

Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis

BACKGROUND

The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients' outcomes.

METHODS

We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14 days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model.

RESULTS

Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV (2098 patients; MD - 9.08 days, 95% CI - 10.91 to - 7.26 days, p < 0.01) and duration of ICU stay (1224 patients; MD - 9.41 days, 95% CI - 12.36 to - 6.46 days, p < 0.01). Mortality was reported for 2343 patients and was comparable between groups (OR 1.09, 95% CI 0.79-1.51, p = 0.59).

CONCLUSIONS

The results of this meta-analysis suggest that, compared with late tracheostomy, early tracheostomy in COVID-19 patients was associated with shorter duration of IMV and ICU stay without modifying the mortality rate. These findings may have important implications to improve ICU availability during the COVID-19 pandemic. Trial registration The protocol was registered at INPLASY (INPLASY202180088).