Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection

Abstract

BackgroundSince the outset of the coronavirus disease 2019 (COVID-19) pandemic, published tracheostomy guidelines have generally recommended deferral of the procedure beyond the initial weeks of intubation given high mortality as well as concerns about transmission of the infection to providers. It is unclear whether tracheostomy in patients with COVID-19 infection facilitates ventilator weaning, and long-term outcomes are not yet reported in the literature.MethodsThis is a retrospective study of tracheostomy outcomes in patients with COVID-19 infection at a single-center academic tertiary referral intensive care unit. Patients underwent percutaneous tracheostomy at the bedside; the procedure was performed with limited staffing to reduce risk of disease transmission.ResultsBetween March 1 and June 30, 2020, a total of 206 patients with COVID-19 infection required mechanical ventilation and 26 underwent tracheostomy at a mean of 25±5 days after initial intubation. Overall, 81% of tracheostomy patients were liberated from the ventilator at a mean of 9±6 days postprocedure, and 54% were decannulated prior to hospital discharge at a mean of 21±10 days postprocedure. Sedation and pain medication requirements decreased significantly in the week after the procedure. In-hospital mortality was 15%. Among tracheostomy survivors, 68% were discharged to a facility.DiscussionThe management of patients with COVID-19 related respiratory failure can be challenging due to prolonged ventilator dependency. In our initial experience, outcomes post-tracheostomy in this population are encouraging, with short time to liberation from the ventilator, a high rate of decannulation prior to hospital discharge, and similar mortality to tracheostomy performed for other indications. Barriers to weaning ventilation in this cohort may be high sedation needs and ventilator dyssynchrony.Level of evidenceLevel V—Therapeutic/care management.

Sedation and Analgesia in Patients Undergoing Tracheostomy in COVID-19, a Multi-Center Registry

“…Early tracheostomy in the literature has been defined as less than ten days, and sometimes even less than 96 h. 20 Decannulation (46.8%) and mortality (22.7%) rates are also in line with data reported from other centers. 24,33 We did not see a significant difference in decannulation or mortality in the early versus late groups. We suspect this is related to the variability of critical illness and our relatively small cohort of patients.…”

“…22,23 Small, single-center studies in COVID-19 have shown decreased sedation medication pre- and post-tracheostomy. 24,25 As we gained a firm understanding of safe procedure performance, the COVID-19 pandemic provided a unique opportunity to assess outcomes in tracheostomy given the increased tracheostomy volume.…”

SARS‐CoV‐2 transmission risk to healthcare workers performing tracheostomies: a systematic review

“…A subgroup of patients with COVID‐19‐related severe acute respiratory failure may require prolonged periods of mechanical ventilation (MV) in the intensive care unit (ICU). Performing tracheostomies in such patients may decrease sedation requirements, facilitate ventilator weaning, and early rehabilitation 1 . However, ongoing concerns remain surrounding the transmission of SARS‐CoV‐2 from patients to healthcare workers (HCWs) during the tracheostomy procedure.…”

“…Performing tracheostomies in such patients may decrease sedation requirements, facilitate ventilator weaning, and early rehabilitation. 1 However, ongoing concerns remain surrounding the transmission of SARS‐CoV‐2 from patients to healthcare workers (HCWs) during the tracheostomy procedure.…”

Small Steps Towards Better Tracheostomy Care During the Evolving COVID-19 Pandemic

“…Prior to the pandemic, the outcomes of early versus late tracheostomy were investigated in several randomized clinical trials, and the pandemic added new urgency to question of optimal timing. 3–5 The data demonstrate that earlier tracheostomy can bring several important benefits to the patient and the healthcare system: tracheostomy reduces sedation requirements, 6 decreases requirement for invasive ventilation, 7 shortens ICU length of stay, 8 decrease incidence ventilator-associated pneumonia, 9 and alleviates risk of laryngeal injury associated with prolonged trans-laryngeal intubation of the trachea. 10 Notably, tracheostomy also eases the burden on critical care resources during surges.…”