CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway management

Purpose The need for prolonged invasive mechanical ventilation in COVID-19 patients is placing the otorhinolaryngologist in front of an increasing request for tracheostomy. Nowadays, there is uncertainty regarding the timing of tracheostomy, the prognosis of these patients and the safety of healthcare workers. The aim of this study is to evaluate the efficacy and safety of tracheostomy placement in patients with COVID-19. Methods A retrospective cohort study on 23 COVID 19 patients, to analyse the timing of tracheostomy, the risk factors associated with in-hospital death and the infection of the involved health care workers. Early tracheostomy was defined as ≤ 10 days and late ones > 10 days. Results The mortality rate of COVID-19 patients admitted to ICU that underwent tracheostomy was 18%. The overall mortality of patients admitted to ICU was 53%. The univariate analysis revealed that early tracheostomy, SOFA score > 6, and D-dimer level > 4 were significantly associated with a greater risk of death. At the multivariate analysis SOFA score > 6 and D-dimer level > 4 resulted as significant factors for a higher risk of death. No health care workers associated with tracheostomy are confirmed to be infected by SARS-CoV2. Conclusion We suggest to wait at least 14 days to perform tracheostomy. In patients with SOFA score > 6 and D dimer > 4, tracheostomy should not be performed or should be postponed. Optimized procedures and enhanced personal protective equipment can make the tracheostomy safe and beneficial in COVID-19 patients.

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“…We performed the first tracheostomy on 10th March 2020 when no ENT guidelines on safe tracheostomy were already been published [23].…”

Section: Open Surgical Tracheostomy Proceduresmentioning

confidence: 99%

Elective tracheostomy during COVID-19 outbreak: to whom, when, how? Early experience from Venice, Italy

Volo¹,

Stritoni²,

Battel

et al. 2020

Eur Arch Otorhinolaryngol

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“…PDT is usually performed by intensivists at the bedside and guided by FFB or bedside ultrasound instead of transferring patients to the operating room, which can be cost-effective, and minimize the risk of viral transmission and disease progression in transit ( 41 , 42 ). However, in PDT, the ventilator circuit needs to be opened more often and produces more viral aerosols are produced ( 8 ), thus increasing the risk of exposure due to more extensive airway manipulation ( 42 ), especially in the case of FFB guidance.…”

Section: Discussionmentioning

confidence: 99%

A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study

Kang

Wang²,

Du³

et al. 2022

Front. Surg.

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ImportanceThe number of infections and deaths caused by the global epidemic of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) invasion is steadily increasing daily. In the early stages of outbreak, approximately 15%–20% of patients with coronavirus disease 2019 (COVID-19) inevitably developed severe and critically ill forms of the disease, especially elderly patients and those with several or serious comorbidities. These more severe forms of disease mainly manifest as dyspnea, reduced blood oxygen saturation, severe pneumonia, acute respiratory distress syndrome (ARDS), thus requiring prolonged advanced respiratory support, including high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), and invasive mechanical ventilation (IMV).ObjectiveThis study aimed to propose a safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19.DesignThis is a single center quality improvement study.ParticipantsTracheotomy is a necessary and important step in airway management for COVID-19 patients with prolonged endotracheal intubation, IMV, failed extubation, and ventilator dependence. Standardized third-level protection measures and bulky personal protective equipment (PPE) may hugely impede the implementation of tracheotomy, especially when determining the optimal pre-surgical positioning for COVID-19 patients with ambiguous surface position, obesity, short neck or limited neck extension, due to vision impairment, reduced tactile sensation and motility associated with PPE. Consequently, the aim of this study was to propose a safer and more practical tracheotomy, namely percutaneous dilated tracheotomy (PDT) with delayed endotracheal intubation withdrawal under the guidance of bedside ultrasonography without the conventional use of flexible fiberoptic bronchoscopy (FFB), which can accurately determine the optimal pre-surgical positioning, as well as avoid intraoperative damage of the posterior tracheal wall and prevent the occurrence of tracheoesophageal fistula (TEF).

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“…Following reports of poor survival and risks of health care worker exposure, 13 our institution and others originally advocated against elective aerosol-generating procedures for patients with COVID-19 disease. 11 This study is one of the first to describe a modified tracheostomy technique, in conjunction with outcomes for patients and health care personnel following adoption of that technique, that supports elective tracheostomy.…”

Section: Discussionmentioning

confidence: 99%

“…11,12 Aerosolized transmission raises significant infectious concerns for health care workers performing procedures on patients with COVID-19 and generates fear regarding the potential impact of frontline health care workers succumbing to the disease. 13,14 Finally, in an era of acute resource shortages, the procedure requires consumption of PPE, which may be scarce in supply.…”

mentioning

confidence: 99%

Controlled apneic tracheostomy in patients with coronavirus disease 2019 (COVID-19)

Weiss¹,

Coppolino²,

Wiener³

et al. 2021

JTCVS Techniques

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Objective The objective of this study was to develop a team-based institutional infrastructure for navigating management of a novel disease, to determine a safe and effective approach for performing tracheostomies in patients with COVID-19 respiratory failure, and to review outcomes of patients and healthcare personnel following implementation of this approach. Methods An interdisciplinary Task Force was constructed to develop innovative strategies for management of a novel disease. A single-institution prospective non-randomized cohort study was then conducted on patients with COVID-19 respiratory failure who underwent tracheostomy using an induced bedside apneic technique at a tertiary care academic institution between April 27th, 2020, and June 30th, 2020. Results 28 patients underwent tracheostomy with induced apnea. The median lowest procedural oxygen saturation was 95%. The median number of ventilated days following tracheostomy was 11. There were 3 mortalities (11%) due to sepsis and multiorgan failure; of 25 surviving patients, 100% were successfully discharged from the hospital and 76% are decannulated, with a median time of 26 days from tracheostomy to decannulation (range 12 - 57). There was no symptomatic disease transmission to healthcare personnel on the COVID-19 Tracheostomy Team. Conclusions Patients with respiratory failure from COVID-19 disease may benefit from tracheostomy. This can be completed effectively and safely, without viral transmission to healthcare personnel. Performing tracheostomies earlier in the course of disease may expedite patient recovery and improve ICU resource utilization. Creation of a collaborative Task Force is an effective strategic approach for management of novel disease.

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CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway management

Cited by 5 publications

References 9 publications

Elective tracheostomy during COVID-19 outbreak: to whom, when, how? Early experience from Venice, Italy

Elective tracheostomy during COVID-19 outbreak: to whom, when, how? Early experience from Venice, Italy

A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study

Controlled apneic tracheostomy in patients with coronavirus disease 2019 (COVID-19)

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