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Carboni Bisso I, Ruiz V, Huespe IA, Rosciani F, Cantos J, Lockhart C, Fernández Ceballos I, Las Heras M. Bronchoscopy-guided percutaneous tracheostomy during the COVID-19 pandemic. Surgery 2023; 173:944-949. [PMID: 36621447 PMCID: PMC9771743 DOI: 10.1016/j.surg.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/17/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Assessment of the efficacy and complications associated with performing bronchoscopy-guided percutaneous tracheostomy in COVID-19 and non-COVID-19 patients. METHODS Prospective observational study conducted between March of 2020 and February of 2022. All adult patients who underwent elective bronchoscopy-guided percutaneous tracheostomy were included. The efficacy of the procedure was evaluated based either on the success rate in the execution or on the need for conversion to open technique. Percutaneous tracheostomy-related complications were registered during the procedure. We performed 6-month follow-up for identifying late complications. RESULTS During the study period, 312 bronchoscopy-guided percutaneous tracheostomies were analyzed. One hundred and eighty-three were performed in COVID-19 patients and 129 among non-COVID-19 patients. Overall, 64.1% (200) of patients were male, with a median age of 66 (interquartile range 54-74), and 65% (205) presented at least 1 comorbidity. Overall, oxygen desaturation was the main complication observed (20.8% [65]), being more frequent in the COVID-19 group occurring in 27.3% (50) with a statistically significant difference versus the non-COVID-19 patients' group (11.6% [15]); P < .01). Major complications such as hypotension, arrhythmias, and pneumothorax were more frequently observed among COVID-19 patients as well but with no significant differences. Percutaneous tracheostomy could be executed quickly and satisfactorily in all the patients with no need for conversion to the open technique. Likewise, no suspension of the procedure was required in any case. During 6-month follow-up, we found an incidence of 0.96% (n = 3) late complications, 2 tracheal granulomas, and 1 ostomal infection. CONCLUSION Bronchoscopy-guided percutaneous tracheostomy can be considered an effective and safe procedure in COVID-19 patients. Nevertheless, it is highly remarkable that in the series under study, a great number of COVID-19 patients presented oxygen desaturation during the procedure.
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Affiliation(s)
| | - Victoria Ruiz
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Argentina
| | | | - Foda Rosciani
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Argentina
| | - Joaquín Cantos
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Argentina
| | | | | | - Marcos Las Heras
- Intensive Care Unit, Hospital Italiano de Buenos Aires, Argentina
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Saraf¹ A, Manhas M, Manhas A, Ahmad R, Kalsotra P. Elective Tracheostomy During Covid-19 Pandemic- A Tertiary Care Centre Experience. Indian J Otolaryngol Head Neck Surg 2023:1-5. [PMID: 36684822 PMCID: PMC9838437 DOI: 10.1007/s12070-022-03381-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/07/2022] [Indexed: 01/11/2023] Open
Abstract
Aims and Objectives : The aim of our study was to present an experience of elective tracheostomy in COVID-19 patients at our institute. Materials and methods The present prospective study was conducted, after approval by Institutional Ethics Committee, in the Department of ENT, SMGS Hospital, GMC Jammu from May 2020 to March 2021 over 60 patients having need for prolonged mechanical ventilation and having tested positive for COVID-19 with nasopharyngeal swab on rtPCR assay testing. Detailed information regarding following aspects was gathered :Age, Gender, Comorbidities (Diabetes, Cardiovascular disease, Pulmonary disease, Malignancy), time of endotracheal intubation to tracheostomy, time to wean sedation after tracheostomy, time to wean mechanical ventilation after tracheostomy, surgical complications, mortality, any health care worker in operating team getting infected by SARS-CoV-2. All 60 patients underwent Elective Open Tracheostomy Bed-side in the ICU section of our institute. Results The mean age of presentation was 55.9 ± 2.34 years, with male preponderance. The most common indication for tracheostomy was ARDS (Acute Respiratory Distress Syndrome) (56.6%). Out of 60 patients, co-morbidities were present in 44 patients (73.3%). The mean time between endotracheal intubation and tracheostomy was 12.2 ± 4.9 days. The mean time to wean mechanical ventilation after tracheostomy was 10.4 ± 2.31 days. The mean time to wean sedation was 2.2 ± 0.83 days. There were no deaths during the procedure. Out of 60 patients, 5 patients (8.3%) died due to complications of COVID-19. Conclusion Our study provides important clinical data (such as timing of tracheostomy, pre-operative evaluation of patients, recommendations during procedure, outcomes of tracheostomy and postoperative care) on this threatening issue of tracheostomy in COVID-19 patients and might be of immense help to various Otorhinolaryngologists who are dealing with the same situation.
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Affiliation(s)
- Aditiya Saraf¹
- Department of ENT and Head and Neck Surgery, SMGS Hospital, Government Medical College, Jammu, Jammu and Kashmir India
| | - Monica Manhas
- Department of Physiology, Government Medical College, Jammu, Jammu and Kashmir India
| | - Amit Manhas
- Department of Anaesthesia, Government Medical College, Jammu, Jammu and Kashmir India
| | - Raies Ahmad
- Department of ENT and Head and Neck Surgery, SMGS Hospital, Government Medical College, Jammu, Jammu and Kashmir India
| | - Parmod Kalsotra
- Department of ENT and Head and Neck Surgery, SMGS Hospital, Government Medical College, Jammu, Jammu and Kashmir India
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Standiford TC, Farlow JL, Brenner MJ, Blank R, Rajajee V, Baldwin NR, Chinn SB, Cusac JA, De Cardenas J, Malloy KM, McDonough KL, Napolitano LM, Sjoding MW, Stoneman EK, Washer LL, Park PK. COVID-19 Transmission to Health Care Personnel During Tracheostomy Under a Multidisciplinary Safety Protocol. Am J Crit Care 2022; 31:452-460. [PMID: 35953441 DOI: 10.4037/ajcc2022538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Tracheostomies are highly aerosolizing procedures yet are often indicated in patients with COVID-19 who require prolonged intubation. Robust investigations of the safety of tracheostomy protocols and provider adherence and evaluations are limited. OBJECTIVES To determine the rate of COVID-19 infection of health care personnel involved in COVID-19 tracheostomies under a multidisciplinary safety protocol and to investigate health care personnel's attitudes and suggested areas for improvement concerning the protocol. METHODS All health care personnel involved in tracheostomies in COVID-19-positive patients from April 9 through July 11, 2020, were sent a 22-item electronic survey. RESULTS Among 107 health care personnel (80.5%) who responded to the survey, 5 reported a positive COVID-19 test result (n = 2) or symptoms of COVID-19 (n = 3) within 21 days of the tracheostomy. Respondents reported 100% adherence to use of adequate personal protective equipment. Most (91%) were familiar with the tracheostomy protocol and felt safe (92%) while performing tracheostomy. Suggested improvements included creating dedicated tracheostomy teams and increasing provider choices surrounding personal protective equipment. CONCLUSIONS Multidisciplinary engagement in the development and implementation of a COVID-19 tracheostomy protocol is associated with acceptable safety for all members of the care team.
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Affiliation(s)
- Taylor C Standiford
- Taylor C. Standiford is a second-year resident, Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco
| | - Janice L Farlow
- Janice L. Farlow is a head and neck surgical oncology fellow, Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus
| | - Michael J Brenner
- Michael J. Brenner is an associate professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Ross Blank
- Ross Blank is an assistant professor, Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Venkatakrishna Rajajee
- Venkata-krishna Rajajee is a professor, Department of Neurosurgery, University of Michigan, Ann Arbor
| | - Noel R Baldwin
- Noel R. Baldwin is a registered nurse, Critical Care Medicine Unit, University of Michigan, Ann Arbor
| | - Steven B Chinn
- Steven B. Chinn is an assistant professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Jessica A Cusac
- Jessica A. Cusac is a respiratory therapist, clinical specialist, University Hospital/Cardiovascular Center, University of Michigan, Ann Arbor
| | - Jose De Cardenas
- Jose De Cardenas is an associate professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Kelly M Malloy
- Kelly M. Malloy is an associate professor, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Kelli L McDonough
- Kelli L. McDonough is a clinical research project manager, Department of Surgery, University of Michigan, Ann Arbor
| | - Lena M Napolitano
- Lena M. Napolitano is a professor, Department of Surgery, University of Michigan, Ann Arbor
| | - Michael W Sjoding
- Michael W. Sjoding is an assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Emily K Stoneman
- Emily K. Stoneman is an associate professor, Division of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor
| | - Laraine L Washer
- Laraine L. Washer is a professor, Division of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor
| | - Pauline K Park
- Pauline K. Park is a professor, Department of Surgery, University of Michigan, Ann Arbor
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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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Azmy MC, Pathak S, Schiff BA. The surgical airway in the COVID-19 era. OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY 2022; 33:134-140. [PMID: 35505952 PMCID: PMC9047482 DOI: 10.1016/j.otot.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Karna ST, Trivedi S, Singh P, Khurana A, Gouroumourty R, Dodda B, Saigal S, Sharma JP, Karna A, Shrivastava P, Hussain A, Gupta V, Behera G, Waindeskar V. Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study. Indian J Crit Care Med 2022; 26:85-93. [PMID: 35110850 PMCID: PMC8783235 DOI: 10.5005/jp-journals-10071-24080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Tracheostomy is integral in long-term intensive care of coronavirus disease-2019 (COVID-19) patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. Materials and methods We conducted a retrospective, single-center, observational study of severe COVID-19 patients who underwent elective tracheostomy (n = 65) during critical care in a tertiary care institute in Central India from May 1, 2020, to April 30, 2021. Data were collected from Medical records, ICU charts, and follow-up visits by patient. A primary objective was to study the clinical characteristics, tracheostomy complications, weaning outcomes, and mortality at 28 and 60 days of ICU admission. We categorized the cohort into two groups (deceased and survivor) and studied association of clinical parameters with 28-day mortality. Cox Proportional regression analysis was applied to calculate the hazard ratio among the predictors of mortality with p value <0.05 as significant. Results Elective tracheostomy was done in 69 of 436 (15.8%) patients on invasive mechanical ventilation, of which 65 were included. Tracheostomy was percutaneous in 45/65 (69%) and surgical in 20/65 (31%) with timing from intubation as early in 41/65 and late in 24/65 with most common indication as weaning failure followed by anticipated prolonged ventilation. Tracheostomy complications were present in 29/65 (45%) patients with no difference in complication rates between timing and type of tracheostomy. Downsizing, decannulation, and weaning were successful in 22%, 32 (49%), and 35/65 (54%) patients after tracheostomy. The 28-day mortality was 30/65 (46%). The fractional inspired oxygen concentration (FiO2) requirement in survivors was lower (0.4–0.6, p = 0.015) with a higher PaO2/FiO2 ratio (118–200, p = 0.033). Early tracheostomy within 7 days of intubation was not associated with weaning or survival benefit. Conclusions We suggest that tracheostomy should be delayed to after 7 days of intubation, especially till FiO2 reduces to 0.5 with improvement in PaO2/FiO2 for better outcomes and avoiding a wasted procedure (CTRI/2021/07/034768). Study Highlights Tracheostomy is integral in care of COVID-19 patients needing prolonged ventilation. There is no difference in complications in early/late or percutaneous dilatational/surgical technique. We observed successful weaning post-tracheostomy in 54% patients. Mortality at 28 days was 46%. Early tracheostomy within 7 days of intubation did not improve weaning or survival. How to cite this article Karna ST, Trivedi S, Singh P, Khurana A, Gouroumourty R, Dodda B, et al. Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study. Indian J Crit Care Med 2022;26(1):85–93.
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Affiliation(s)
- Sunaina Tejpal Karna
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Saurabh Trivedi
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Pooja Singh
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
- Pooja Singh, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India, Phone: +91 9340969292, e-mail:
| | - Alkesh Khurana
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Revadi Gouroumourty
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Brahmam Dodda
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Saurabh Saigal
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Jai Prakash Sharma
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Amit Karna
- Department of Anesthesiology and Critical Care, Chirayu Medical College and Hospital, Bhopal, Madhya Pradesh, India
| | - Pranav Shrivastava
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Aqeel Hussain
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Vikas Gupta
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Gankalyan Behera
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Vaishali Waindeskar
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Favier V, Lescroart M, Pequignot B, Grimmer L, Florentin A, Gallet P. Measurement of airborne particle emission during surgical and percutaneous dilatational tracheostomy COVID-19 adapted procedures in a swine model: Experimental report and review of literature. PLoS One 2022; 17:e0278089. [PMID: 36417482 PMCID: PMC9683587 DOI: 10.1371/journal.pone.0278089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Surgical tracheostomy (ST) and Percutaneous dilatational tracheostomy (PDT) are classified as high-risk aerosol-generating procedures and might lead to healthcare workers (HCW) infection. Albeit the COVID-19 strain slightly released since the vaccination era, preventing HCW from infection remains a major economical and medical concern. To date, there is no study monitoring particle emissions during ST and PDT in a clinical setting. The aim of this study was to monitor particle emissions during ST and PDT in a swine model. METHODS A randomized animal study on swine model with induced acute respiratory distress syndrome (ARDS) was conducted. A dedicated room with controlled airflow was used to standardize the measurements obtained using an airborne optical particle counter. 6 ST and 6 PDT were performed in 12 pigs. Airborne particles (diameter of 0.5 to 3 μm) were continuously measured; video and audio data were recorded. The emission of particles was considered as significant if the number of particles increased beyond the normal variations of baseline particle contamination determinations in the room. These significant emissions were interpreted in the light of video and audio recordings. Duration of procedures, number of expiratory pauses, technical errors and adverse events were also analyzed. RESULTS 10 procedures (5 ST and 5 PDT) were fully analyzable. There was no systematic aerosolization during procedures. However, in 1/5 ST and 4/5 PDT, minor leaks and some adverse events (cuff perforation in 1 ST and 1 PDT) occurred. Human factors were responsible for 1 aerosolization during 1 PDT procedure. ST duration was significantly shorter than PDT (8.6 ± 1.3 vs 15.6 ± 1.9 minutes) and required less expiratory pauses (1 vs 6.8 ± 1.2). CONCLUSIONS COVID-19 adaptations allow preventing for major aerosol leaks for both ST and PDT, contributing to preserving healthcare workers during COVID-19 outbreak, but failed to achieve a perfectly airtight procedure. However, with COVID-19 adaptations, PDT required more expiratory pauses and more time than ST. Human factors and adverse events may lead to aerosolization and might be more frequent in PDT.
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Affiliation(s)
- Valentin Favier
- Department of Otolaryngology-Head and Neck Surgery, Gui de Chauliac Hospital, University Hospital of Montpellier, Montpellier, France
- Montpellier Laboratory of Informatics, Robotics and Microelectonics (LIRMM), ICAR Team, French National Centre for Scientific Research (CNRS), Montpellier University, Montpellier, France
- * E-mail:
| | - Mickael Lescroart
- Intensive Care Unit Brabois, University Regional Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Benjamin Pequignot
- Intensive Care Unit Brabois, University Regional Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Léonie Grimmer
- Department of Hygiene, Environmental Risks and Healthcare Associated Risks, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Arnaud Florentin
- Department of Hygiene, Environmental Risks and Healthcare Associated Risks, University of Lorraine, Vandoeuvre-lès-Nancy, France
- Infection Prevention and Control Team, Regional University Hospital of Nancy, Vandœuvre-lès-Nancy, France
| | - Patrice Gallet
- ENT Department, Regional University Hospital of Nancy, University of Lorraine, Vandœuvre-lès-Nancy, France
- Virtual Hospital of Lorraine, University of Lorraine, Vandoeuvre-lès-Nancy, France
- NGERE, INSERM U1256 Lab, University of Lorraine, Vandoeuvre-lès-Nancy, France
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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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Protocol for percutaneous tracheostomy and prevention of COVID-19 transmission. Am J Otolaryngol 2021; 42:103090. [PMID: 34098456 PMCID: PMC8146471 DOI: 10.1016/j.amjoto.2021.103090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/22/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Currently we are faced with countless patients with prolonged invasive mechanical ventilation as a result of the COVID-19 pandemic, with the consequent increase in the need for tracheostomies and the risks that this includes for both patients and staff. OBJECTIVE It is necessary to establish a safety protocol for the performance of percutaneous tracheostomies in order to reduce the associated infections. MATERIAL AND METHODS 77 patients underwent tracheostomies between March 2020 and March 2021, evaluating the safety of the protocol and the rate of contagion among the staff. RESULTS Percutaneous tracheostomy was performed according to the protocol in 72 patients, 5 were excluded due to unfavorable anatomy or other reasons. There were no cases of SARS COVID-19 contagion among health personnel attributable to the procedure during the three-week follow-up period. There were no surgical complications in this series. CONCLUSION The authors recommend implementing security protocols such as the one discussed in this work, given its low contagion rate and ease of implementation.
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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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11
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Mahmood K, Cheng GZ, Van Nostrand K, Shojaee S, Wayne MT, Abbott M, Nettlow D, Parish A, Green CL, Safi J, Brenner MJ, De Cardenas J. Tracheostomy for COVID-19 Respiratory Failure: Multidisciplinary, Multicenter Data on Timing, Technique, and Outcomes. Ann Surg 2021; 274:234-239. [PMID: 34029231 PMCID: PMC8265239 DOI: 10.1097/sla.0000000000004955] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The aim of this study was to assess the outcomes of tracheostomy in patients with COVID-19 respiratory failure. SUMMARY BACKGROUND DATA Tracheostomy has an essential role in managing COVID-19 patients with respiratory failure who require prolonged mechanical ventilation. However, limited data are available on how tracheostomy affects COVID-19 outcomes, and uncertainty surrounding risk of infectious transmission has led to divergent recommendations and practices. METHODS It is a multicenter, retrospective study; data were collected on all tracheostomies performed in COVID-19 patients at 7 hospitals in 5 tertiary academic medical systems from February 1, 2020 to September 4, 2020. RESULT Tracheotomy was performed in 118 patients with median time from intubation to tracheostomy of 22 days (Q1-Q3: 18-25). All tracheostomies were performed employing measures to minimize aerosol generation, 78.0% by percutaneous technique, and 95.8% at bedside in negative pressure rooms. Seventy-eight (66.1%) patients were weaned from the ventilator and 18 (15.3%) patients died from causes unrelated to tracheostomy. No major procedural complications occurred. Early tracheostomy (≤14 days) was associated with decreased ventilator days; median ventilator days (Q1-Q3) among patients weaned from the ventilator in the early, middle and late groups were 21 (21-31), 34 (26.5-42), and 37 (32-41) days, respectively with P = 0.030. Compared to surgical tracheostomy, percutaneous technique was associated with faster weaning for patients weaned off the ventilator [median (Q1-Q3): 34 (29-39) vs 39 (34-51) days, P = 0.038]; decreased ventilator-associated pneumonia (58.7% vs 80.8%, P = 0.039); and among patients who were discharged, shorter intensive care unit duration [median (Q1-Q3): 33 (27-42) vs 47 (33-64) days, P = 0.009]; and shorter hospital length of stay [median (Q1-Q3): 46 (33-59) vs 59.5 (48-80) days, P = 0.001]. CONCLUSION Early, percutaneous tracheostomy was associated with improved outcomes compared to surgical tracheostomy in a multi-institutional series of ventilated patients with COVID-19.
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Affiliation(s)
- Kamran Mahmood
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Duke University, Durham, NC
| | - George Z Cheng
- Department of Medicine, Division of Pulmonary and Critical Care, University of California, San Diego, CA
| | - Keriann Van Nostrand
- Department of Medicine, Division of Pulmonary and Critical Care, Emory University, Atlanta, GA
| | - Samira Shojaee
- Department of Medicine, Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Max T Wayne
- Department of Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI
| | - Matthew Abbott
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Duke University, Durham, NC
| | - Darrell Nettlow
- Department of Medicine, Division of Pulmonary and Critical Care, University of California, San Diego, CA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Javeryah Safi
- Department of Medicine, Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Michael J Brenner
- Department of Otolaryngology- Head and Neck Surgery, University of Michigan, Ann Arbor, MI
- Global Tracheostomy Collaborative, Raleigh, NC
| | - Jose De Cardenas
- Department of Medicine, Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI
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12
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COVIDTrach: a prospective cohort study of mechanically ventilated patients with COVID-19 undergoing tracheostomy in the UK. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2021; 3:e000077. [PMID: 34282409 PMCID: PMC8275367 DOI: 10.1136/bmjsit-2020-000077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/09/2021] [Indexed: 12/23/2022] Open
Abstract
Objectives COVIDTrach is a UK multicentre prospective cohort study project that aims to evaluate the outcomes of tracheostomy in patients with COVID-19 receiving mechanical ventilation and record the incidence of SARS-CoV-2 infection among healthcare workers involved in the procedure. Design Data on patient demographic, clinical history and outcomes were entered prospectively and updated over time via an online database (REDCap). Clinical variables were compared with outcomes, with logistic regression used to develop a model for mortality. Participants recorded whether any operators tested positive for SARS-CoV-2 within 2 weeks of the procedure. Setting UK National Health Service departments involved in treating patients with COVID-19 receiving mechanical ventilation. Participants The cohort comprised 1605 tracheostomy cases from 126 UK hospitals collected between 6 April and 26 August 2020. Main outcome measures Mortality following tracheostomy, successful wean from mechanical ventilation and length of time from tracheostomy to wean, discharge from hospital, complications from tracheostomy, reported SARS-CoV-2 infection among operators. Results The median time from intubation to tracheostomy was 15 days (IQR 11, 21). 285 (18%) patients died following the procedure. 1229 (93%) of the survivors had been successfully weaned from mechanical ventilation at censoring and 1049 (81%) had been discharged from hospital. Age, inspired oxygen concentration, positive end-expiratory pressure setting, fever, number of days of ventilation before tracheostomy, C reactive protein and the use of anticoagulation and inotropic support independently predicted mortality. Six reports were received of operators testing positive for SARS-CoV-2 within 2 weeks of the procedure. Conclusions Tracheostomy appears to be safe in mechanically ventilated patients with COVID-19 and to operators performing the procedure and we identified clinical parameters that are predictive of mortality. Trial registration number The study is registered with ClinicalTrials.Gov (NCT04572438).
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13
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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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14
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Caputo MP, Aziz S, Mifsud M. Early Tracheostomy in Morbidly Obese COVID-19 Patients: A Case Series and Discussion of Institutional Practices. Cureus 2021; 13:e14345. [PMID: 33972903 PMCID: PMC8105186 DOI: 10.7759/cureus.14345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Tracheostomies are often utilized in critically ill patients on prolonged mechanical ventilation, to enhance respiratory function and facilitate ventilator weaning. Many coronavirus disease 2019 (COVID-19) patients develop serious respiratory illness requiring ventilator management. In the early phase of this pandemic, the risk of disease spread lead to the development of conservative guidelines which advocated delaying tracheostomy at least two to three weeks from intubation and, preferably, with negative COVID-19 testing. The morbidly obese patient population, however, presents a unique scenario in which early tracheostomy may be beneficial. In this article, we discuss our institution's current practices along with clinical outcomes with reference to intensive care literature and propose that early tracheotomy in COVID-19 patients should be considered on a case by case basis.
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Affiliation(s)
- Mathew P Caputo
- Otolaryngology-Head and Neck Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Steven Aziz
- Otolaryngology-Head and Neck Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Matthew Mifsud
- Otolaryngology-Head and Neck Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
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15
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In Response. Anesth Analg 2021; 132:e58-e59. [PMID: 33323788 DOI: 10.1213/ane.0000000000005377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Amaya O, Arango E, Pabón S, Mejía S, Montoya MC, Madrid G. Is Surgical Tracheostomy Better Than Percutaneous Tracheostomy in Coronavirus Disease 2019-Positive Patients? Anesth Analg 2021; 132:e58. [PMID: 33323784 DOI: 10.1213/ane.0000000000005376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Oswaldo Amaya
- Department of Anesthesia, Fundación Santa Fe de Bogotá, Bogotá D.C., Colombia,
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17
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Ahmed Y, Cao A, Thal A, Shah S, Mehta V, Ow T, Smith R, Schiff BA. In Response to Improving the Safety and Science of COVID-19 Tracheostomy: Challenges and Opportunities. Laryngoscope 2021; 131:E2159. [PMID: 33724466 PMCID: PMC8250769 DOI: 10.1002/lary.29520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Yasmina Ahmed
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
| | - Angela Cao
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
| | - Arielle Thal
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
| | - Sharan Shah
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
| | - Vikas Mehta
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
| | - Thomas Ow
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
| | - Richard Smith
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
| | - Bradley A Schiff
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, New York, U.S.A
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18
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Ahmed Y, Cao A, Thal A, Shah S, Kinkhabwala C, Liao D, Li D, Parides M, Mehta V, Ow T, Smith R, Schiff BA. Tracheotomy Outcomes in 64 Ventilated COVID-19 Patients at a High-Volume Center in Bronx, NY. Laryngoscope 2021; 131:E1797-E1804. [PMID: 33410517 DOI: 10.1002/lary.29391] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES/HYPOTHESIS The COVID-19 pandemic has resulted in a dramatic increase in the number of patients requiring prolonged mechanical ventilation. Few studies have reported COVID-19 specific tracheotomy outcomes, and the optimal timing and patient selection criteria for tracheotomy remains undetermined. We delineate our outcomes for tracheotomies performed on COVID-19 patients during the peak of the pandemic at a major epicenter in the United States. METHODS This is a retrospective observational cohort study. Mortality, ventilation liberation rate, complication rate, and decannulation rate were analyzed. RESULTS Sixty-four patients with COVID-19 underwent tracheotomy between April 1, 2020 and May 19, 2020 at two tertiary care hospitals in Bronx, New York. The average duration of intubation prior to tracheotomy was 20 days ((interquartile range [IQR] 16.5-26.0). The mortality rate was 33% (n = 21), the ventilation liberation rate was 47% (n = 30), the decannulation rate was 28% (n = 18), and the complication rate was 19% (n = 12). Tracheotomies performed by Otolaryngology were associated with significantly improved survival (P < .05) with 60% of patients alive at the conclusion of the study compared to 9%, 12%, and 19% of patients undergoing tracheotomy performed by Critical Care, General Surgery, and Pulmonology, respectively. CONCLUSIONS So far, this is the second largest study describing tracheotomy outcomes in COVID-19 patients in the United States. Our early outcomes demonstrate successful ventilation liberation and decannulation in COVID-19 patients. Further inquiry is necessary to determine the optimal timing and identification of patient risk factors predictive of improved survival in COVID-19 patients undergoing tracheotomy. LEVEL OF EVIDENCE 4-retrospective cohort study Laryngoscope, 131:E1797-E1804, 2021.
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Affiliation(s)
- Yasmina Ahmed
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Angela Cao
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Arielle Thal
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Sharan Shah
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Corin Kinkhabwala
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - David Liao
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Daniel Li
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Michael Parides
- Department of Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Vikas Mehta
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Thomas Ow
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Richard Smith
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
| | - Bradley A Schiff
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, U.S.A
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19
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West TE, Schultz MJ, Ahmed HY, Shrestha GS, Papali A. Pragmatic Recommendations for Tracheostomy, Discharge, and Rehabilitation Measures in Hospitalized Patients Recovering From Severe COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:110-119. [PMID: 33534772 PMCID: PMC7957235 DOI: 10.4269/ajtmh.20-1173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/04/2021] [Indexed: 12/14/2022] Open
Abstract
New studies of COVID-19 are constantly updating best practices in clinical care. However, research mainly originates in resource-rich settings in high-income countries. Often, it is impractical to apply recommendations based on these investigations to resource-constrained settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for tracheostomy, discharge, and rehabilitation measures in hospitalized patients recovering from severe COVID-19 in LMICs. We recommend that tracheostomy be performed in a negative pressure room or negative pressure operating room, if possible, and otherwise in a single room with a closed door. We recommend using the technique that is most familiar to the institution and that can be conducted most safely. We recommend using fit-tested enhanced personal protection equipment, with the fewest people required, and incorporating strategies to minimize aerosolization of the virus. For recovering patients, we suggest following local, regional, or national hospital discharge guidelines. If these are lacking, we suggest deisolation and hospital discharge using symptom-based criteria, rather than with testing. We likewise suggest taking into consideration the capability of primary caregivers to provide the necessary care to meet the psychological, physical, and neurocognitive needs of the patient.
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Affiliation(s)
- T. Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Marcus J. Schultz
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Hanan Y. Ahmed
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gentle S. Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - for the COVID-LMIC Task Force and the Mahidol-Oxford Research Unit (MORU)
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
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20
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Sun BJ, Wolff CJ, Bechtold HM, Free D, Lorenzo J, Minot PR, Maggio PG, Spain DA, Weiser TG, Forrester JD. Modified percutaneous tracheostomy in patients with COVID-19. Trauma Surg Acute Care Open 2020; 5:e000625. [PMID: 34192161 PMCID: PMC7736959 DOI: 10.1136/tsaco-2020-000625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/16/2020] [Indexed: 01/12/2023] Open
Abstract
Background Patients hospitalized with COVID-19 are at risk of developing hypoxic respiratory failure and often require prolonged mechanical ventilation. Indication and timing to perform tracheostomy is controversial in patients with COVID-19. Methods This was a single-institution retrospective review of tracheostomies performed on patients admitted for COVID-19 between April 8, 2020 and August 1, 2020 using a modified percutaneous tracheostomy technique to minimize hypoxia and aerosolization. Results Twelve tracheostomies were performed for COVID-related respiratory failure. Median patient age was 54 years (range: 36–76) and 9 (75%) were male. Median time to tracheostomy was 17 days (range: 10–27), and 5 (42%) patients had failed attempts at extubation prior to tracheostomy. There were no intraprocedural complications, including hypoxia. Post-tracheostomy bleeding was noted in two patients. Eight (67%) patients have been discharged at the time of this study, and there were four patient deaths unrelated to tracheostomy placement. No healthcare worker transmissions resulted from participating in the tracheostomy procedure. Conclusions A modified percutaneous tracheostomy is feasible and can be safely performed in patients infected with COVID-19. Level of evidence Level V, case series.
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Affiliation(s)
- Beatrice J Sun
- Department of Surgery, Stanford University, Stanford, California, USA
| | | | | | - Dwayne Free
- Bronchoscopy and Respiratory Care Services, Stanford University, Stanford, California, USA
| | - Javier Lorenzo
- Anesthesiology, Stanford University, Stanford, California, USA
| | - Patrick R Minot
- Anesthesiology, Stanford University, Stanford, California, USA
| | - Paul G Maggio
- Department of Surgery, Stanford University, Stanford, California, USA
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA
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21
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Open Tracheostomy for Critically Ill Patients with COVID-19. Int J Otolaryngol 2020; 2020:8861013. [PMID: 34966431 PMCID: PMC8711016 DOI: 10.1155/2020/8861013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/10/2020] [Accepted: 11/18/2020] [Indexed: 12/11/2022] Open
Abstract
Background COVID-19 is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy can shorten ICU length of stay and help weaning. Aims/Objectives. To describe the long-term evolution of the critically patient with COVID-19 and the need for invasive mechanical ventilation and orotracheal intubation (OTI), with or without tracheostomy. Material and Methods. A prospective study was performed including all patients admitted to the ICU due to COVID-19 from 10th March to 30th April 2020. Epidemiological data, performing a tracheostomy or not, mean time of invasive mechanical ventilation until tracheotomy, mean time from tracheotomy to weaning, and final outcome after one month of minimum follow-up were recorded. The Otolaryngology team was tested for COVID-19 before and after the procedures. Results Out of a total of 1612 hospital admissions for COVID-19, only 5.8% (93 patients) required ICU admission and IOT. Twenty-seven patients (29%) underwent a tracheostomy. After three months, within the group of tracheotomized patients, 29.6% died and 48.15% were extubated in a mean time of 28.53 days. In the nontracheostomized patients, the mortality was 42.4%. Conclusions Tracheostomy is a safe procedure for COVID-19 and helps weaning of prolonged OTI. Mortality after tracheostomy was less common than in nontracheostomized patients.
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Takhar A, Tornari C, Amin N, Wyncoll D, Tricklebank S, Arora A, Ahmad I, Simo R, Surda P. Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation. J Laryngol Otol 2020; 134:1-10. [PMID: 33143760 PMCID: PMC7729174 DOI: 10.1017/s0022215120002303] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT-anaesthetics department led tracheostomy team. METHOD A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020. RESULTS Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13-20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23-40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7-16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related. CONCLUSION Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.
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Affiliation(s)
- A Takhar
- Department of Otolaryngology and Head and Neck Surgery, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - C Tornari
- Department of Otolaryngology and Head and Neck Surgery, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - N Amin
- Department of Otolaryngology and Head and Neck Surgery, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - D Wyncoll
- Department of Critical Care, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - S Tricklebank
- Department of Critical Care, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - A Arora
- Department of Otolaryngology and Head and Neck Surgery, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - I Ahmad
- Department of Anaesthesia, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - R Simo
- Department of Otolaryngology and Head and Neck Surgery, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - P Surda
- Department of Otolaryngology and Head and Neck Surgery, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
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23
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Yeung E, Hopkins P, Auzinger G, Fan K. Challenges of tracheostomy in COVID-19 patients in a tertiary centre in inner city London. Int J Oral Maxillofac Surg 2020; 49:1385-1391. [PMID: 32912655 PMCID: PMC7451123 DOI: 10.1016/j.ijom.2020.08.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/14/2020] [Accepted: 08/17/2020] [Indexed: 01/08/2023]
Abstract
The rapid global spread of SARS-CoV-2, the causative agent of COVID-19, has dominated healthcare services, with exponential numbers requiring mechanical ventilation in the intensive care unit (ICU). Tracheostomy facilitates respiratory and sedative weaning but risks potential viral transmission. This study reviewed the tracheostomy provision, techniques, and outcomes for a single-centre prospective cohort during the resource-pressured COVID-19 period. Seventy-two of 176 patients underwent tracheostomy at a median 17 days: 44 surgical (open), 28 percutaneous. Their median age was 58 years, the male to female ratio was 2.4:1, 75.1% were of BAME backgrounds, 76% had a BMI≥25kg/m2, and 65% had ≥2 major co-morbidities. Seventy-nine percent of patients were weaned from sedation at a median 2 days, 61% were weaned from mechanical ventilation at a median 10 days, 39% were discharged from the ICU at a median 11.5 days, and 19.4% were discharged home at a median 24 days. All patients survived the procedure. The mortality rate was 9.7% at a median 12 days. No clinician reported COVID-19 symptoms within 14 days of the procedure. The role of tracheostomy in COVID-19 is currently unclear. Delivery of tracheostomy by maxillofacial surgeons relieved the workload pressure from ICU clinicians. The choice of technique was influenced by the patient and resource factors, resulting in a mixed cohort of open and percutaneous tracheostomy in COVID-19 patients. Preliminary data suggest that open tracheostomy is as favourable as percutaneous tracheostomy for COVID-19 patients, and is safe for clinicians.
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Affiliation(s)
- E Yeung
- King's College London Hospital NHS Foundation Trust, Denmark Hill, London, SE1 9RT, UK
| | - P Hopkins
- King's College London Hospital NHS Foundation Trust, Denmark Hill, London, SE1 9RT, UK
| | - G Auzinger
- King's College London Hospital NHS Foundation Trust, Denmark Hill, London, SE1 9RT, UK
| | - K Fan
- King's College London Hospital NHS Foundation Trust, Denmark Hill, London, SE1 9RT, UK.
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24
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Takhar A, Surda P, Ahmad I, Amin N, Arora A, Camporota L, Denniston P, El-Boghdadly K, Kvassay M, Macekova D, Munk M, Ranford D, Rabcan J, Tornari C, Wyncoll D, Zaitseva E, Hart N, Tricklebank S. Timing of Tracheostomy for Prolonged Respiratory Wean in Critically Ill Coronavirus Disease 2019 Patients: A Machine Learning Approach. Crit Care Explor 2020; 2:e0279. [PMID: 33225305 PMCID: PMC7673767 DOI: 10.1097/cce.0000000000000279] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To propose the optimal timing to consider tracheostomy insertion for weaning of mechanically ventilated patients recovering from coronavirus disease 2019 pneumonia. We investigated the relationship between duration of mechanical ventilation prior to tracheostomy insertion and in-hospital mortality. In addition, we present a machine learning approach to facilitate decision-making. DESIGN Prospective cohort study. SETTING Guy's & St Thomas' Hospital, London, United Kingdom. PATIENTS Consecutive patients admitted with acute respiratory failure secondary to coronavirus disease 2019 requiring mechanical ventilation between March 3, 2020, and May 5, 2020. INTERVENTIONS Baseline characteristics and temporal trends in markers of disease severity were prospectively recorded. Tracheostomy was performed for anticipated prolonged ventilatory wean when levels of respiratory support were favorable. Decision tree was constructed using C4.5 algorithm, and its classification performance has been evaluated by a leave-one-out cross-validation technique. MEASUREMENTS AND MAIN RESULTS One-hundred seventy-six patients required mechanical ventilation for acute respiratory failure, of which 87 patients (49.4%) underwent tracheostomy. We identified that optimal timing for tracheostomy insertion is between day 13 and day 17. Presence of fibrosis on CT scan (odds ratio, 13.26; 95% CI [3.61-48.91]; p ≤ 0.0001) and Pao2:Fio2 ratio (odds ratio, 0.98; 95% CI [0.95-0.99]; p = 0.008) were independently associated with tracheostomy insertion. Cox multiple regression analysis showed that chronic obstructive pulmonary disease (hazard ratio, 6.56; 95% CI [1.04-41.59]; p = 0.046), ischemic heart disease (hazard ratio, 4.62; 95% CI [1.19-17.87]; p = 0.027), positive end-expiratory pressure (hazard ratio, 1.26; 95% CI [1.02-1.57]; p = 0.034), Pao2:Fio2 ratio (hazard ratio, 0.98; 95% CI [0.97-0.99]; p = 0.003), and C-reactive protein (hazard ratio, 1.01; 95% CI [1-1.01]; p = 0.005) were independent late predictors of in-hospital mortality. CONCLUSIONS We propose that the optimal window for consideration of tracheostomy for ventilatory weaning is between day 13 and 17. Late predictors of mortality may serve as adverse factors when considering tracheostomy, and our decision tree provides a degree of decision support for clinicians.
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Affiliation(s)
- Arunjit Takhar
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pavol Surda
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Imran Ahmad
- Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Kings College London, United Kingdom
| | - Nikul Amin
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Asit Arora
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Luigi Camporota
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Poppy Denniston
- Department of Respiratory Medicine, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kariem El-Boghdadly
- Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Kings College London, United Kingdom
| | - Miroslav Kvassay
- Department of Informatics, Faculty of Management Science and Informatics, University of Zilina, Zilina, Slovakia
| | - Denisa Macekova
- Department of Informatics, Faculty of Management Science and Informatics, University of Zilina, Zilina, Slovakia
| | - Michal Munk
- Department of Informatics, Constantine the Philosopher University, Nitra, Slovakia
| | - David Ranford
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jan Rabcan
- Department of Informatics, Faculty of Management Science and Informatics, University of Zilina, Zilina, Slovakia
| | - Chysostomos Tornari
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Duncan Wyncoll
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Elena Zaitseva
- Department of Informatics, Constantine the Philosopher University, Nitra, Slovakia
| | - Nicholas Hart
- Lane Fox Respiratory Unit, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Kings College London, United Kingdom
| | - Stephen Tricklebank
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
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25
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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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26
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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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27
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Snyderman CH, Gardner PA. Endonasal drilling may be employed safely in the COVID-19 era. Int Forum Allergy Rhinol 2020; 10:1118-1119. [PMID: 32515081 PMCID: PMC7300827 DOI: 10.1002/alr.22642] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 01/11/2023]
Affiliation(s)
- Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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28
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Papathanakos G, Andrianopoulos I, Zikou X, Papathanasiou A, Koulouras V. Tracheostomy in the COVID-19 Era: The Apneic Approach. Otolaryngol Head Neck Surg 2020; 163:1283-1284. [PMID: 32600179 DOI: 10.1177/0194599820940652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Mattioli F, Marudi A, Ghirelli M, Molteni G, Sgarbi N, Valerini S, Girardis M, Presutti L, Fermi M. Reply to "Indications and timing for tracheostomy in patients with SARS CoV2-related" by Ferri et al. Eur Arch Otorhinolaryngol 2020; 277:2405-2406. [PMID: 32556782 PMCID: PMC7297929 DOI: 10.1007/s00405-020-06134-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Francesco Mattioli
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Andrea Marudi
- Department of Anesthesiology, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Michael Ghirelli
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Gabriele Molteni
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Verona, Piazzale Aristide Stefani, 41100, Verona, Italy
| | - Nicola Sgarbi
- Department of Anesthesiology, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Sara Valerini
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Massimo Girardis
- Department of Anesthesiology, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Livio Presutti
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Matteo Fermi
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy.
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30
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Choi SY, Shin J, Park W, Choi N, Kim JS, Choi CI, Ko JH, Chung CR, Son YI, Jeong HS. Safe surgical tracheostomy during the COVID-19 pandemic: A protocol based on experiences with Middle East Respiratory Syndrome and COVID-19 outbreaks in South Korea. Oral Oncol 2020; 109:104861. [PMID: 32590297 PMCID: PMC7298512 DOI: 10.1016/j.oraloncology.2020.104861] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/12/2020] [Accepted: 06/13/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND A subset of patients with COVID-19 require intensive respiratory care and tracheostomy. Several guidelines on tracheostomy procedures and care of tracheostomized patients have been introduced. In addition to these guidelines, further details of the procedure and perioperative care would be helpful. The purpose of this study is to describe our experience and tracheostomy protocol for patients with MERS or COVID-19. MATERIALS AND METHODS Thirteen patients with MERS were admitted to the ICU, 9 (69.2%) of whom underwent surgical tracheostomy. During the COVID-19 outbreak, surgical tracheostomy was performed in one of seven patients with COVID-19. We reviewed related documents and collected information through interviews with healthcare workers who had participated in designing a tracheostomy protocol. RESULTS Compared with previous guidelines, our protocol consisted of enhanced PPE, simplified procedures (no limitation in the use of electrocautery and wound suction, no stay suture, and delayed cannula change) and a validated screening strategy for healthcare workers. Our protocol allowed for all associated healthcare workers to continue their routine clinical work and daily life. It guaranteed safe return to general patient care without any related complications or nosocomial transmission during the MERS and COVID-19 outbreaks. CONCLUSION Our protocol and experience with tracheostomies for MERS and COVID-19 may be helpful to other healthcare workers in building an institutional protocol optimized for their own COVID-19 situation.
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Affiliation(s)
- Sung Yong Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joongbo Shin
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Woori Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nayeon Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Sei Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chan I Choi
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine and Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young-Ik Son
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Han-Sin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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