Abstract and Introduction
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.
Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has taken a staggering toll around the world, with most of the mortality attributable to respiratory failure and acute respiratory distress syndrome (ARDS).[1,2] Approximately 10% to 15% of COVID-19 patients develop respiratory failure and require prolonged invasive mechanical ventilation.[1,3] Previous studies have shown that tracheostomy leads to decreased need for sedation, earlier weaning from mechanical ventilation, and decreased ventilator-associated pneumonia in patients with prolonged respiratory failure.[4,5] Tracheostomy also improves pulmonary hygiene, reduces intensive care unit (ICU) capacity strain, decreases risk of chronic laryngeal injury, and expedites rehabilitation. However, either performing tracheotomy or providing post-procedure patient care may lead to aerosolization of respiratory secretions that contain SARS-CoV-2, thereby posing a risk of infection to medical staff.
During the pandemic, multiple professional organizations and groups issued guidelines about the timing and performance of tracheostomy.[8–11] Many of the early guidelines recommended performing tracheostomy after 21 days of mechanical ventilation, based on the assumption that the delay would allow for lower viral load.[8,11] However, others supported the procedure after 10 days to leverage the anticipated advantages of early tracheostomy. The lack of evidence around the timing of tracheostomy is widely acknowledged, and some expert panel consensus statements have refrained from providing any specific recommendations. Controversy also exists about the preferred technique, with advocates divided between surgical and percutaneous methods.[12–14] Thus, institutions are following different guidelines, and the resulting variations in practice likely translate into overall lower quality care.[15,16] As the subsequent waves of the pandemic unfold, data remain limited about the best approach to manage prolonged COVID-19 respiratory failure. The aim of the present study was to assess tracheostomy-related practices in a multicenter cohort of COVID-19 patients in the United States (US). We also investigated whether different timing and techniques of tracheostomy were associated with better patient outcomes.
Annals of Surgery. 2021;274(2):234-239. © 2021 Lippincott Williams & Wilkins