Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic

Abstract

Purpose The COVID-19 pandemic is placing unprecedented demand upon critical care services for invasive mechanical ventilation. There is current uncertainty regarding the role of tracheostomy for weaning ventilated patients with COVID-19 pneumonia. This is due to a number of factors including prognosis, optimal healthcare resource utilisation, and safety of healthcare workers when performing such a high-risk aerosol-generating procedure. Methods Literature review and proposed practical guideline based on the experience of a tertiary healthcare institution with 195 critical care admissions for COVID-19 up until 4th April 2020. Results A synthesis of the current international literature and reported experience is presented with respect to prognosis, viral load and staff safety, thus leading to a pragmatic recommendation that tracheostomy is not performed until at least 14 days after endotracheal intubation in COVID-19 patients. Practical steps to minimise aerosol generation in percutaneous tracheostomy are outlined and we describe the process and framework for setting up a dedicated tracheostomy team. Conclusion In selected COVID-19 patients, there is a role for tracheostomy to aid in weaning and optimise healthcare resource utilisation. Both percutaneous and open techniques can be performed safely with careful modifications to technique and appropriate enhanced personal protective equipment. ORL-HNS surgeons can play a valuable role in forming tracheostomy teams to support critical care teams during this global pandemic.

Tracheostomy in 80 COVID-19 patients: a multicenter, retrospective, observational study

“…Sixty (69.0%) patients had chronic medical illnesses, and the most common illnesses were hypertension (40.0%), coronary heart disease (21.1%), diabetes (17.5%) and cerebrovascular disease (10.0%) ( Table 1). Thirty (37.5%) patients received tracheostomies within 14 days after intubation, and their median duration between intubation and tracheostomy was signi cantly shorter than that of the late tracheostomy group ( [11][12][13][14][15][16][17][18][19][20][21], p = 0.034) at ICU admission and lower APACHE II scores (13 (SD 4) vs 17 (SD 6), p = 0.010) before tracheostomy. Among all 80 patients, lymphocytopenia and hypoalbuminemia at hospital admission and hypoxemia at ICU admission were prominent (Table 2).…”

“…During the pandemic of COVID-19, it remains unclear whether early tracheostomy performance is bene cial to critically ill COVID-19 patients. Some guidelines [16][17][18] suggested that tracheostomy should be delayed until at least 14 days from endotracheal intubation because viral load in the upper and lower airway may be high in the early course of the infection in COVID-19 patients.…”

“…However, tracheostomies within 14 days of endotracheal intubation should be avoided. [4,7] 6 [4,9] 5 [4,7] 0.014 APACHE II score 12 [9,18] 15 [11,21] 11 [9,17] Data were presented as count (%).…”

Elective Tracheostomy During Mechanical Ventilation in Patients Affected by COVID‐19: Preliminary Case Series From Lombardy, Italy

“…4 Postoperative care represents another open issue that should be explored in the next few months, based on gradually evolving body of available data. 3,4 In our experience, circuit disconnections were strictly avoided, and only closed in-line suctioning was used.…”

Airway, voice and swallow outcomes following endotracheal intubation and mechanical ventilation for COVID-19 pneumonitis: preliminary results of a prospective cohort study

“…Data are limited regarding the proportion of mechanically ventilated COVID-19 positive patients requiring tracheostomy but preliminary data including that from our own tertiary institution suggests a range between <10%-19.3%, [9,10]. Most published guidelines have recommended late tracheostomy to minimise the risk of disease transmission [11,12].…”