Early Tracheostomy for Managing ICU Capacity During the COVID-19 Outbreak

Abstract

BACKGROUND: During the first wave of the COVID-19 pandemic, shortages of ventilators and ICU beds overwhelmed health-care systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ICU stay is controversial.RESEARCH QUESTION: Can failure-free day outcomes focused on ICU resources help to decide the optimal timing of tracheostomy in overburdened health-care systems during viral epidemics? STUDY DESIGN AND METHODS: This retrospective cohort study included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, when ICU occupancy modified clinician criteria to perform tracheostomy in Patients with COVID-19. We compared ventilator-free days at 28 and 60 days and ICU-and hospital bed-free days at 28 and 60 days in propensity score-matched cohorts who underwent tracheostomy at different timings (# 7 days, 8-10 days, and 11-14 days after intubation).RESULTS: Of 1,939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (# 7 days vs > 7 days [116 patients included in the analysis]: median, 9 days [interquartile range (IQR), 0-15 days] vs 3 days [IQR,[0][1][2][3][4][5][6][7]; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs > 10 days [222 patients analyzed]: 6 days [IQR, 0-10 days] vs 0 days [IQR, 0-6 days]; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs > 14 days [318 patients analyzed]: 4 days [IQR, 0-9 days] vs 0 days [IQR, 0-2 days]; difference, 3 days; 95% CI, 2.1-3.9 days). Except hospital bed-free days at 28 days, all other end points were better with early tracheostomy.INTERPRETATION: Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on a ventilator in particular may improve ICU availability.

Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis

“…Figure 1 shows the flow diagram of study selection process. A total of 14 studies [ 21 – 23 , 31 – 41 ] (11 peer-reviewed and 3 preprints; 6 prospectively conducted and 8 retrospectively conducted; 8 single-center studies and 6 multicenter studies) from Asia, Europe and America, involving 2371 tracheostomized COVID-19 patients (938 in the ET group vs. 1433 in the LT group), were incorporated in our meta-analysis. The majority of the studies were conducted during the first wave of COVID-19 pandemic.…”

“…Nine studies [ 21 – 23 , 31 , 32 , 34 , 35 , 37 , 40 ] provided data on duration of IMV. Substantial statistical heterogeneity was observed ( I 2 = 57%).…”

“…Thirteen studies [ 21 – 23 , 31 – 33 , 35 – 41 ] provided data on overall mortality. Mortality was reported at 30 days following tracheostomy [ 33 ], at 30 days following ICU admission [ 32 , 35 ], at 60 days following intubation [ 39 ], at ICU [ 21 , 40 , 41 ] and hospital discharge [ 23 , 31 , 36 , 38 ] and at an undefined time point [ 22 , 37 ]. Moderate statistical heterogeneity was detected ( I 2 = 41%).…”

“…This year, several studies have attempted to investigate how ET affects COVID-19 outcomes [ 21 – 23 ]. However, whether ET improves COVID-19 outcomes is still controversial [ 24 – 26 ].…”

Soporte ventilatorio en pacientes críticos con COVID-19:a 18 meses de la pandemia en Chile

“…Múltiples series han demostrado que la técnica percutánea (con o sin apoyo broncoscópico) es segura y eficiente en este contexto [65]. Si bien la discusión en la literatura ha estado enfocada en identificar los beneficios de la traqueostomía precoz versus tardía en el contexto CoviD-19 [66]- [68], creemos que hay que replantear el foco de la pregunta. Más allá de determinar la mejor temporalidad del procedimiento, hay que intentar identificar aquellos pacientes en que el procedimiento maximizará sus chances de liberarse del ventilador mecánico y de sobrevida.…”