Tracheostomy for COVID-19 respiratory failure: timing, ventilatory characteristics, and outcomes

Abstract

Background: Whereas data from the pre-pandemic era have demonstrated that tracheostomy can accelerate liberation from the ventilator, reduce need for sedation, and facilitate rehabilitation, concerns for healthcare worker safety have led to disagreement on tracheostomy placement in COVID-19 patients. Data on COVID-19 patients undergoing tracheostomy may inform best practices. Thus, we report a retrospective institutional cohort experience with tracheostomy in ventilated patients with COVID-19, examining associations between time to tracheostomy and duration of mechanical ventilation in relation to patient characteristics, clinical course, and survival. Methods: Clinical data were extracted for all COVID-19 tracheostomies performed at a quaternary referral center from April-July 2020. Outcomes studied included mortality, adverse events, duration of mechanical ventilation, and time to decannulation. Results: Among 64 COVID-19 tracheostomies (13% of COVID-19 hospitalizations), patients were 64% male and 42% African American, with a median age of 54 (range, 20-89). Median time to tracheostomy was 22 days (range, 7-60) and median duration of mechanical ventilation was 39.4 days (range, 20-113). Earlier tracheostomy was associated with shortened mechanical ventilation (R 2 =0.4, P<0.01). Median decannulation time was 35.3 days (range, 7-79). There was 19% mortality and adverse events in 45%, mostly from bleeding in therapeutically anticoagulated patients.Conclusions: Tracheostomy was associated with swifter liberation from the ventilator and acceptable safety for physicians in this series of critically ill COVID-19 patients. Patient mortality was not increased relative to historical data on acute respiratory distress syndrome (ARDS). Future studies are required to establish conclusions of causality regarding tracheostomy timing with mechanical ventilation, complications, or mortality in COVID-19 patients.

The surgical airway in the COVID-19 era

“…12 Farlow et al found each additional day of intubation to be significantly associated with an additional 1.2 days to liberation from the ventilator. 19 After adjusting for demographics, every 1 day increase in time of intubation was also associated with a 3% decreased chance of discharge from the ICU, and 2.8% decreased chance in discharge from the hospital, although this was not statistically significant. 1 Another reason for supporting early tracheostomy was to address the increased demand for ventilators and ICU beds.…”

Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis

“…11,46 The high incidence of bleeding might be due to the use of therapeutic anticoagulation among COVID-19 patients, although data involving coagulation status were not reported in a standardized manner. 49 Only three studies compared the use of therapeutic anticoagulation in COVID-19 patients undergoing early or late tracheostomy. 15,18,21 Our meta-analysis found an overall tracheal bleeding rate of 16.5% among COVID-19 patients, with a similar incidence in those undergoing early and late tracheostomy.…”

“…Although the relationship between tracheostomy timing and VAP incidence among non-COVID-19 patients has been well assessed in several meta-analyses, 4,10 other known tracheostomy-related complications such as pneumothorax, pneumomediastinum, and local tracheal complications (ie, stomal infection, stenosis, fistula, and tracheomalacia) were not analyzed. 27,45,49,51,54 Only two studies described other tracheostomy complications (such as stoma infections, pneumothoraces, and VAP) among patients undergoing early or late tracheostomy; thus, a practical analysis could not be performed. 21,24 A meta-analysis of 17 RCTs involving 1212 non-COVID-19 patients demonstrated that percutaneous tracheostomy was associated with less risk of stomal infection (OR: 0.28) and bleeding (OR: 0.29) than open tracheostomy.…”

“…Additionally, PEEP (a respiratory parameter) during the peri-tracheostomy period that may be indicative of lung compliance, disease severity, and risk of perioperative pulmonary complications was comparable among COVID-19 patients in the early and late tracheostomy groups. 49,50 Other important factors, such as Sequential Organ Failure Assessment (SOFA) and APACHE II scores that are useful illness severity scores for critically ill patients, ventilator parameters (plateau pressure and tidal volume), fraction of inspired oxygen (FiO2), and partial pressure of arterial oxygen (fraction of inspired oxygen [PaO2:FiO2] ratio at the time of tracheostomy, which might affect tracheostomy timing, complications, and prolonged decannulation in COVID-19 patients), were inconsistently assessed in the studies included. 51 In five studies, the SOFA and APACHE II scores of COVID-19 patients undergoing early or late tracheostomy were obtained inconsistently by determining the mean score during ICU admission, on admission days or days before tracheostomy, or during the day of IMV or tracheostomy.…”

Outcomes of Surgical Tracheostomy on Mechanically Ventilated COVID-19 Patients Admitted to a Private Tertiary Hospital in Tanzania

“…Expert opinion on delayed tracheostomies is justified considering the reduced risk of transmission in the later course of illness [8,9]. Data on patients with COVID-19 undergoing tracheostomy indicating time and outcomes are very limited [10,11]. The few documented studies have yielded varying results with wide variations [10][11][12].…”