Apneic Tracheostomy in COVID-19 Patients on Veno-Venous Extracorporeal Membrane Oxygenation

Outcomes for COVID-19 Patients Undergoing Tracheostomy With or Without Extracorporeal Membrane Oxygenation (ECMO)

Introduction The coronavirus disease 2019 (COVID-19) pandemic led to the more common use of venovenous (VV) extracorporeal membrane oxygenation (ECMO) for adults with acute respiratory distress syndrome (ARDS). While tracheostomy is generally understood to decrease the risks of prolonged endotracheal intubation, there is conflicting data regarding the benefit of tracheostomy in patients on ECMO. The purpose of this study is to determine whether ECMO cannulation before tracheostomy impacted patient outcomes. Methods This is a retrospective chart review of patients who underwent tracheostomy for COVID-19-related ARDS at a tertiary academic center from March 2020 through March 2022. Patients were separated into two groups based on whether they were cannulated for ECMO prior to tracheostomy. Fisher's exact test or Wilcoxon rank sum test was used to compare the two groups. Results A total of 24 patients were included in the study, with 13 in the ECMO group and 11 in the non-ECMO group. There was no significant difference in age, comorbidities, race, or gender between the groups. Patients on ECMO had a longer time from admission to intubation (seven days vs. three days, p=.002), were more likely to have multiple intubations (54% vs 9%, p= .033), had increased rates of postoperative bleeding (62% vs. 18%, p = .047), and had a higher mortality rate (39% vs. 0%, p= .041). Conclusions ECMO cannulation prior to tracheostomy for COVID-19-related ARDS is associated with poorer outcomes. It is unclear whether this is related to a more severe disease burden in these patients. Further study is needed to evaluate this and guide future management.

Tracheostomy in Critically Ill COVID-19 Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience

OBJECTIVES

Novel coronavirus-19 (COVID-19) has led to over 6 million fatalities globally. An estimated 75% of COVID-19 patients who require critical care admission develop acute respiratory distress syndrome (ARDS) needing invasive mechanical ventilation (IMV) and/or extracorporeal membrane oxygenation (ECMO). Due to prolonged ventilation requirements, these patients often also require tracheostomy. We performed a review of clinical outcomes in COVID-19 patients on ECMO at a high-volume tertiary care center in Hamilton, Ontario, Canada.

METHODOLOGY

We performed a retrospective case series, including 24 adult patients diagnosed with COVID-19 who required IMV, veno-venous (ECMO), and tracheostomy. All patients were included from April to December 2021. We extracted demographic and clinical variables pertaining to the tracheostomy procedure and ECMO therapy. We performed descriptive statistical analyses. This study was approved by the Hamilton Integrated Research Ethics Board (14217-C).

RESULTS

We included 24 consecutive patients with COVID-19 who required tracheostomy while undergoing ECMO therapy. The mean age was 49.4 years [standard deviation (SD): 7.33], the majority of patients were male (75%), with mean body mass index of 32 (SD: 8.81). Overall mortality rate was 33.3%. Percutaneous tracheostomy was performed most frequently (83.3%) and, similar to open tracheostomy, was associated with a low rate of perioperative bleeding complications. Within surviving patients, the mean time to IMV weaning and decannulation was 60.2 (SD: 24.6) and 49.4 days (SD: 21.8), respectively.

CONCLUSION

Percutaneous tracheostomy appears to be safe in COVID-19 patients on ECMO and holding anticoagulation 24 hours prior to and after tracheostomy may limit bleeding events in these patients.

Safety of tracheostomy during extracorporeal membrane oxygenation support: A single-center experience

BACKGROUND

Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients.

METHODS

This is a retrospective observational single-center study.

RESULTS

Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V-V ECMO support over an 8-year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3-40.1) vs 37.2 (26.5-53.2) days, p = 0.013] and a shorter ECMO-to-tracheostomy time [13.3 (8.5-19.7) vs 27.8 (16.3-36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V-V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID-19, who did not show significantly higher rates of major bleeding when compared to non-COVID-19 patients (p = 0.297). Within the COVID-19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0).

CONCLUSIONS

Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID-19 patients, if relevant clinical expertise is available.