Short-term Outcomes for Patients and Providers After Elective Tracheostomy in COVID-19–Positive Patients

• Published in: The Journal of surgical research Vol. 260; pp. 38 - 45
• Main Authors: Murphy, Patrick, Holler, Emma, Lindroth, Heidi, Laughlin, Michelle, Simons, Clark J., Streib, Erik W., Boustani, Malaz, Ortiz, Damaris
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2021
• Subjects: Adult; Aged; Airway Extubation - statistics & numerical data; Bronchoscopy - adverse effects; Bronchoscopy - instrumentation; Bronchoscopy - methods; Bronchoscopy - standards; Coronavirus; COVID-19; COVID-19 - diagnosis; COVID-19 - mortality; COVID-19 - therapy; COVID-19 - transmission; COVID-19 Nucleic Acid Testing - statistics & numerical data; Critical care; Female; Follow-Up Studies; Hospital Mortality; Humans; Infectious Disease Transmission, Patient-to-Professional - prevention & control; Infectious Disease Transmission, Patient-to-Professional - statistics & numerical data; Intensive Care Units - standards; Intensive Care Units - statistics & numerical data; Male; Middle Aged; Postoperative Complications - epidemiology; Postoperative Complications - etiology; Respiration, Artificial - adverse effects; Respiration, Artificial - instrumentation; Respiration, Artificial - methods; Respiration, Artificial - statistics & numerical data; Retrospective Studies; SARS-CoV-2 - isolation & purification; Severity of Illness Index; Shock/Sepsis/Trauma/Critical Care; Time Factors; Tracheostomy; Tracheostomy - adverse effects; Tracheostomy - instrumentation; Tracheostomy - methods; Tracheostomy - standards; Treatment Outcome; COVID-19; Critical care; Tracheostomy; Coronavirus
• ISSN: 0022-4804; 1095-8673; 1095-8673
• DOI: 10.1016/j.jss.2020.10.013

Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit. This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications. From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.