Indications and timing for tracheostomy in patients with SARS CoV2-related

Abstract

Background The indications and timing for tracheostomy in patients with SARS CoV2-related are controversial. Purpose In a recent issue published in the European Archives of Otorhinolaryngology, Mattioli et al. published a short communication about tracheostomy timing in patients with COVID-19 (Coronavirus Disease 2019); they reported that the tracheostomy could allow early Intensive Care Units discharge and, in the context of prolonged Invasive Mechanical Ventilation, should be suggested within 7 and 14 days to avoid potential tracheal damages. In this Letter to the Editor we would like to present our experience with tracheostomy in a Hub Covid Hospital. Methods 8 patients underwent open tracheostomy in case of intubation prolonged over 14 days, bronchopulmonary overlap infections, and patients undergoing weaning. They were followed up and the number and timing of death were recorded. Results Two patients died after tracheostomy; the median time between tracheostomy and death was 3 days. A negative prognostic trend was observed for a shorter duration of intubation. Conclusion In our experience, tracheostomy does not seem to influence the clinical course and prognosis of the disease, in the face of possible risks of contagion for healthcare workers. The indication for tracheostomy in COVID-19 patients should be carefully evaluated and reserved for selected patients. Although it is not possible to define an optimal timing, it is our opinion that tracheostomy in a stable or clinically improved COVID-19 patient should not be proposed before the 20th day after orotracheal intubation.

Tracheostomy is Safe in Patients with Prolonged Intubation After Coronavirus Disease 2019 Infection

“…To date, only a few studies have examined COVID-19 patient outcomes after tracheostomy. One early study performed tracheostomies after 14 days of intubation in COVID-19 patients and found a mortality rate of 25%, leading them to conclude that a tracheostomy should not be performed until at least 21 days of mechanical ventilation 12 . Another study that waited longer, on average 20 days, had a much lower mortality rate of 11%.…”

The Role of Tracheotomy and Timing of Weaning and Decannulation in Patients Affected by Severe COVID-19

“…Even though data regarding this topic are lacking and timing has yet to be defined, some authors have addressed the issue of when to perform the procedure, and practices vary widely. 8 Only small cohorts of patients have been reported; therefore, it is inappropriate to draw conclusions with such small numbers. One has to balance between the advantages of tracheotomy and the possibility of viral transmission to medical/ nursing staff involved in surgical and decannulation procedure or taking care for the patients.…”

“…One of the first case series of 32 patients from Italy reported a mean intubation period of 15 days (range, 9-21 days) before performing tracheotomy. Ferri et al 8 suggested that tracheostomy should be performed in stable or clinically improved patients affected by COVID-19, not before the 20th day after orotracheal intubation. They argue that the subgroup of patients with shorter duration of intubation has a negative prognostic trend.…”

Surgical tracheotomy in COVID-19 patients: an Italian single centre experience

“…We decided to practice surgical tracheotomy to reduce risks of aerosol generation and to guarantee more safety to patients (less disconnection, shorter apnea time, less reduction in positive airway pressure, and less risk of bleeding in these deep heparinized patients). Optimal timing for tracheotomy is still debated in COVID-19 patients [ 23 , 24 ]. In fact, in such a complex and unpredictable situation, early tracheotomy may be futile while late tracheotomy is not likely to assist in ventilator weaning.…”