Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study

Characteristics and factors associated with mortality in tracheostomized patients with COVID-19: a retrospective cohort study in a hospital in Tacna, Peru

OBJECTIVE

We aimed to describe the main demographic, clinical, laboratory and therapeutic characteristics and to identify whether they are associated with mortality in tracheostomized patients.

MATERIAL AND METHODS.

Retrospective cohort study in adult patients diagnosed with COVID-19, admitted to ICU (Intensive Care Unit) and requiring tracheostomy. Demographic, clinical, laboratory and treatment data were obtained from the medical records of patients admitted to Hospital III Daniel Alcides Carrión in Tacna. The Cox proportional hazards model was used for survival analysis and hazard ratios (HR) with their 95% confidence intervals (95%CI) were calculated.

RESULTS.

We evaluated 73 patients, 72.6% were men, the most common comorbidities were obesity (68.5%), type 2 diabetes mellitus (35.6%), and arterial hypertension (34.2%). Thirty-seven percent of the participants died during their stay at the ICU. The median time from intubation to tracheostomy and the duration of tracheostomy was 17 (RIC: 15-21) and 21 (RIC: 3-39) days, respectively. Multivariate analysis showed that the factors associated with mortality were procalcitonin > 0.50 ng/dL at the time of tracheostomy (HRa: 2.40 95%CI: 1.03-5.59) and a PaO2/FiO2 ratio less than or equal to 150 mmHg (HRa: 4.44 95%CI: 1.56-12.60).

CONCLUSIONS.

The factors associated with mortality at the time of tracheostomy were procalcitonin > 0.50 ng/dL and a PaO2/FiO2 ratio less than or equal to 150 mmHg.

Early versus late tracheostomy in critically ill COVID-19 patients

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Outcomes in Severe COVID-19 Patients Following Percutaneous Versus Open Surgical Tracheostomy: An Analysis of Clinical and Prognostic Indicators

Background and objective Tracheostomy in coronavirus disease 2019 (COVID-19) patients can be performed in cases of prolonged intubation or in patients with a known difficult airway. Tracheostomy is usually performed by two main approaches: open surgery or percutaneous endoscopic insertion. However, few studies have compared these two techniques in severe COVID-19 patients. The objective of the present study was to compare the efficacy of the two main methods of tracheostomy among patients with severe COVID-19 infection. We also aimed to investigate the impact of various lab data and medications on patient outcomes. Materials and methods We included all symptomatic severe COVID-19 patients in need of prolonged mechanical ventilation. We examined the patients' past medical history, arterial blood gas (ABG) analysis, laboratory workups, and medication history. We calculated the PaO₂/FiO₂ ratio as an index to evaluate the severity of acute respiratory distress syndrome (ARDS). Results During the study period, 72 patients with severe COVID-19 underwent tracheostomy tube insertion. The average age of participants was 58.93 ±15.27 years; 44 (61.1%) were male and 28 (38.9%) were female. Of note, 54 (75.0%) patients passed away and only 18 (25.0%) survived. Among the survivors, 13 (29.5%) were men and five (17.9%) were women. The study showed a significantly higher mortality rate (23, 92.0%) among patients who underwent open surgery compared to those who received percutaneous surgery (31, 65.9%) (p=0.01). Conclusion Based on our findings, percutaneous endoscopic tracheostomy seems to be the superior approach compared to open tracheostomy. Other predictive factors associated with patient outcomes included levels of HCO₃, FiO₂, PaCO₂, and PaO₂/FiO₂ ratio.

A 30-day Survival and Safety of Percutaneous Tracheostomy in Moderate-to-severe COVID-19 Pneumonia Patients: A Single-center Experience

Aims and objectives

In coronavirus disease-2019 (COVID-19) pneumonia, guidelines on timing and method of tracheostomy are evolving. The aim of the study was to analyze the outcomes of moderate-to-severe COVID-19 pneumonia patients who required tracheostomy and the safety with regard to the risk of transmission to the healthcare workers.

Materials and methods

We retrospectively analyzed 30-day survival outcome of a total of 70 moderate-to-severe COVID-19 pneumonia patients on a ventilator, wherein tracheostomy was performed only in 28 (tracheostomy group), and the remaining were with endotracheal intubation beyond 7 days (non-tracheostomy group). Besides demographics, comorbidities and clinical data including 30-day survival and complications of tracheostomy were analyzed in both groups with respect to the timing of tracheostomy from the day of intubation. Healthcare workers were monitored for COVID-19 symptoms by carrying out periodical COVID tests.

Results

The 30-day survival of the tracheostomy group was 75% as compared to 26.2% of the non-tracheostomy group. The majority of the patients (71.4%) had severe disease with PaO₂/FiO₂ (P/F ratio) <100. The first wave showed an 80% (4/5) while the second wave 100% (8/8) thirty days survival in the tracheostomy group performed before 13 days. All patients during the second wave underwent tracheostomy before 13 days with a median of 12th day from the day of intubation. These tracheostomies were performed percutaneously at the bedside, without any major complications and no transmission of disease to healthcare workers.

Conclusion

Early percutaneous tracheostomy within 13 days of intubation demonstrated a good 30-day survival rate in severe COVID-19 pneumonia patients.

How to cite this article

Shah M, Bhatuka N, Shalia K, Patel M. A 30-day Survival and Safety of Percutaneous Tracheostomy in Moderate-to-severe COVID-19 Pneumonia Patients: A Single-center Experience. Indian J Crit Care Med 2022;26(10):1120-1125.