Percutaneous tracheostomy for long-term ventilated COVID-19-patients: rationale and first clinical-safe for all-experience

Abstract

Background COVID-19 infection has resulted in thousands of critically ill patients admitted to ICUs and treated with mechanical ventilation. Percutaneous tracheostomy is a well-known technique utilised as a strategy to wean critically ill patients from mechanical ventilation. Worldwide differences exist in terms of methods, operators, and settings, and questions remain regarding timing and indications. If tracheostomy is to be performed in COVID-19 patients, a safe environment is needed for optimal care. Methods We present a guidewire dilating forceps tracheostomy procedure in COVID-19 patients that was optimised including apnoea-moments, protective clothing, checklists, and clear protocols. We performed a retrospective analysis of the outcome after tracheostomy in COVID-19 patients between March 2020 and May 2020. Results The follow-up of the first 16 patients, median age 62 years, revealed a median intubation time until tracheostomy of 18 days and median cannulation time of 20 days. The overall perioperative complication rate and complication rate while cannulated was 19%, mainly superficial bleeding. None of the healthcare providers involved in performing the procedure developed any symptoms of the disease. Conclusions This COVID-19-centred strategy based on flexibility, preparation, and cooperation between healthcare providers with different backgrounds facilitated percutaneous tracheostomy in COVID-19 patients without an increase in the overall complication rate or evidence of risk to healthcare providers. Our findings provide initial evidence that tracheostomy can be performed safely as a standard of care for COVID-19 patients requiring prolonged mechanical ventilation as was standard practice in ICU patients prior to the COVID-19 pandemic to promote ventilator weaning and patient recovery.

Therapeutic and Interventional Bronchoscopy Performed in Critically ill COVID-19 patients: A Systematic Review

“…Technical problem and difficulty in swallowing two complications of bronchoscope observed in two studies, both used disposable bronchoscopes [25]. Complications were more often due to PDT and tracheostomy leading to major or minor bleeding, delayed complications, cellulitis, infection and pneumothorax [71, 27, 80, 69, 81-84, 73]. Events valve migration, ETT dislodgement in patients was not associated to bronchoscopy [85, 49].…”

“…While interventional procedures like reduction in lung volume, hemostasis of active bleeding, intubation, extubation, tracheostomy, FBA, surfactant delivery, and decannulation provided positive outcome for the ICU patients under prolonged mechanical ventilation [13,26]. Percutaneous tracheostomy (PT) in the ICU patients is widely used to facilitate weaning from mechanical ventilation, to anticipate prolonged mechanical ventilation, to aid in the management of respiratory secretions and protect the airway in patients at risk of aspiration, to prevent laryngeal injury, and to minimize sedatives [27]. The therapeutic bronchoscopic procedure lasted for maximum 10 minutes, while guided PDT lasted for around 25-30 minutes for most of the COVID-19 patients [28][29][30].…”

Bleeding Complications of a Tracheostomy Stoma Covid-19 Patients Related to Therapy Heparin

“…Manfaat trakeostomi pada intubasi lama adalah mengurangi volume dead space, menurunkan resistensi saluran pernafasan, menghindari terjadinya kerusakan laring, pita suara dan stenosis glotis dan subglotis (Murphy et al, 2021). Disamping itu memudahkan perawatan, memudahkan suction lendir, memudahkan transportasi dan kenyamanan pasien, lebih mudah berbicara kembali dan memberi sarana diet secara oral (Jonckheere et al, 2021).…”

Outcomes of Percutaneous Tracheostomy for Patients With SARS-CoV-2 Respiratory Failure

“… 9 Several smaller studies from earlier in the pandemic reported lower decannulation rates, ranging from 8% to 13%. 1 , 3 , 4 However, one of the largest systematic review and meta-analysis comprising over 3000 patients found an average decannulation rate of 34.9%. 7 One potential explanation for differences is lack of availability and willingness of long-term acute care hospital (LTACH) facilities to accept SARS-CoV-2 infected patients, wanting to wait for viral clearance before accepting patients for transfer.…”

“…At the onset of the pandemic there were questions regarding the safety and value of tracheostomy for SARS-CoV-2 patients with prolonged respiratory failure. Tracheostomy has since been described and safely performed in these patients, and several societal guidelines support performing tracheostomy with proper personal protective equipment and precautions 1–6…”