Outcomes of Percutaneous Tracheostomy for Patients with SARS-CoV-2 Respiratory Failure

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

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

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).

SARS-CoV-2 viral load assessment in lung transplantation

In the era of COVID-19 pandemic, organ transplantation programs were facing serious challenges. The lung transplantation donor pool was extremely limited and SARS-CoV-2 viral load assessment has become a crucial part of selecting an optimal organ donor. Since COVID-19 is a respiratory disease, the viral load is thought to be more important in lung transplantations as compared to other solid organ transplantations. We present two challenging cases of potential lung donors with a questionable COVID-19 status. Based on these cases, we suggest that the cycle threshold (Ct) value should always be requested from the laboratory and the decision whether to proceed with transplantation should be made upon complex evaluation of diverse criteria, including the nasopharyngeal swab and bronchoalveolar lavage PCR results, the Ct value, imaging findings and the medical history. However, as the presence of viral RNA does not ensure infectivity, it is still to be clarified which Ct values are associated with the viral viability. Anti-SARS-CoV-2 IgA antibodies may support the diagnosis and moreover, novel methods, such as quantifying SARS-CoV-2 nucleocapsid antigen in serum may provide important answers in organ transplantations and donor selections.