Tracheostomy for COVID-19 Respiratory Failure

Multidisciplinary, Multicenter Data on Timing, Technique, and Outcomes

Kamran Mahmood, MD, MPH; George Z. Cheng, MD, PhD; Keriann Van Nostrand, MD; Samira Shojaee, MD, MPH; Max T. Wayne, MD; Matthew Abbott, MD; Darrell Nettlow, MD; Alice Parish, MSPH; Cynthia L. Green, PhD; Javeryah Safi, MD; Michael J. Brenner, MD; Jose De Cardenas, MD


Annals of Surgery. 2021;274(2):234-239. 

In This Article


During the study time frame, 2793 adult patients were admitted with COVID-19 to the seven hospitals in 5 academic medical systems, 966 (34.5%) were admitted to the intensive care units, and 668 (23.9%) required invasive mechanical ventilation. Tracheostomy was performed in 118 (4.2% of total admitted) mechanically ventilated patients. Patients on invasive mechanical ventilation who did not undergo tracheostomy either stayed on the ventilator for <2 weeks or died. Patient characteristics are shown in Table 1. Most patients were obese, with a median body mass index (BMI) of 32.6 (Q1–Q3: 27.9–37.4). Acute respiratory distress syndrome (ARDS) was present in all patients during the ICU admission, and based on Berlin definition,[17] 63.6% of patients met criteria for severe ARDS. Thirty patients (25%) were treated with extracorporeal membrane oxygenation (ECMO). Median time from intubation to tracheostomy was 22 days (Q1–Q3: 18–25), and only 9 (7.6%) patients had tracheostomy within 14 days (Table 2). Percutaneous technique was used for 78.0% of procedures, whereas the remainder were performed with open surgical technique—primarily because of anatomical concerns that precluded percutaneous approach. Tracheostomy was performed with standard percutaneous and surgical techniques, with addition of personal protective equipment and measures to decrease aerosolization.[4,9] Most of the tracheostomies (61.0%) were performed by interventional pulmonologists. Five (4.2%) surgical tracheostomies were done in the operating room, mainly due to complexity of the patient airway and surgeon preference.

Seventy-eight (66.1%) patients were weaned from the ventilator by the time of last data review, with a median of 36 days (Q1–Q3: 30–41) on ventilator (Table 3). The median sedation days, defined as days with Richmond Agitation-Sedation Scale (RASS) <0, were 18 days (Q1–Q3: 14–22) pre-tracheostomy versus 7 days (Q1–Q3: 3–13) post-tracheostomy (P < 0.001). Tracheostomy tubes were decannulated in 40 (33.9%) patients. Ninety-eight patients (83.8%) were discharged from ICU, with median ICU length of stay of 35.5 days (Q1–Q3: 28–45.5). Ultimately, 100 patients (84.7%) were discharged from the hospital, with median length of stay of 49 days (Q1–Q3: 37–61). Eighteen (15.3%) patients died in the hospital, and no deaths were attributable to tracheostomy. Non–life-threatening complications seen with tracheostomy are listed in Table 3. There were no significant differences in complications when stratified by timing, technique of tracheostomy, or patient BMI. Seventy-five (63.6%) patients had ventilator-associated pneumonia (VAP) defined as clinical suspicion of ventilator associated pneumonia with positive respiratory cultures that necessitated antibiotic administration. Most VAPs were caused by gram-negative bacilli (39.8%) followed by Staphylococcus aureus (22.9%).

For comparing the effect of timing of tracheostomy to outcomes, we classified the timing of tracheostomy into early (≤14 days), middle (15–21 days), and late (>21 days) groups, as shown in Figure 1 and Table 4. This classification was based on the range of timing for performing tracheostomy recommended in protocols at the participating institutions as well as guidelines and publications.[8–10,18–21] Among the patients who were weaned from the ventilator, the early tracheostomy group had fewer days on ventilator; 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. Different patient factors like age, BMI, diabetes, and ARDS were not associated with ventilator duration, as shown in Supplemental Table 1,

Figure 1.

Flow diagram of tracheostomy technique and timing.

Comparing percutaneous vs. surgical technique, 92 patients (78.0%) had percutaneous tracheostomy, and 26 patients (22.0%) had surgical tracheostomy (Figure 1 and Table 5). Among the patients weaned, compared to those who underwent surgical tracheostomies, patients with percutaneous tracheostomies had decreased ventilator days [median (Q1–Q3): 34 (29–39) vs 39 (34–51) days; P = 0.038] and fewer ventilator-associated pneumonias (58.7% vs 80.8%; P = 0.039). Among patients who were discharged, compared to surgical patients, percutaneous tracheostomy patients had shorter ICU length of stay [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]. There was no significant difference in the BMI between percutaneous and surgical groups (P = 0.827).