Percutaneous Dilational Tracheostomy for Coronavirus Disease 2019 Patients Requiring Mechanical Ventilation*

Abstract

OBJECTIVES: To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN: Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING: Critical care units at two large metropolitan hospitals in New York City. PATIENTS: Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS: Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS: Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7–12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16–24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34–5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06–0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01–2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, –15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS: In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.

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

“…Unfortunately, most guidelines were published at the beginning of the pandemic without data to sustain them. This year, several studies have attempted to investigate how ET affects COVID-19 outcomes [21][22][23]. However, whether ET improves COVID-19 outcomes is still controversial [24][25][26].…”

Application of POCUS in patients with COVID-19 for acute respiratory distress syndrome management: a narrative review

“…Considering that patients with COVID-19 typically have longer periods of ventilation than patients with other viral pneumonias [ 60 ], the use of tracheostomy to aid weaning from ventilatory support should be considered [ 61 ], which may ease the burden upon critical care resources [ 62 ]. Angel et al showed that early tracheostomy in COVID-19 patients can be performed with improved patient prognosis [ 63 ]. Reported rates of tracheostomies during the coronavirus pandemic were significantly higher than those of pre-pandemic [ 61 , 64 , 65 ].…”

Managing Scarcity: Innovation and Resilience During the COVID-19 Pandemic

“…None of the eight providers performing the tracheostomies had any symptoms of COVID-19 infection or tested positive for the virus following the procedures. A later propensity score matched analysis of 205 patients at our institution who underwent tracheostomy (195 via our novel PDT protocol) compared patients who underwent early tracheostomy (median = 9 days of MV), late tracheostomy (median = 19 days of MV), or no tracheostomy (14). Compared to patients who did not require tracheostomy, early PDT was associated with more days of MV but higher probability of being liberated from the ventilator and lower mortality.…”