Safety and 30-day outcomes of tracheostomy for COVID-19: a prospective observational cohort study

Abstract

Background: The role of tracheostomy in coronavirus disease 2019 (COVID-19) is unclear, with several consensus guidelines advising against this practice. We developed both a dedicated airway team and coordinated education programme to facilitate ward management of tracheostomised COVID-19 patients. Here, we report outcomes in the first 100 COVID-19 patients who underwent tracheostomy at our institution. Methods: This was a prospective observational cohort study of patients confirmed to have COVID-19 who required mechanical ventilation at Queen Elizabeth Hospital, Birmingham, UK. The primary outcome measure was 30-day survival, accounting for severe organ dysfunction (Acute Physiology and Chronic Health [APACHE]-II score>17). Secondary outcomes included duration of ventilation, ICU stay, and healthcare workers directly involved in tracheostomy care acquiring COVID-19. Results: A total of 164 patients with COVID-19 were admitted to the ICU between March 9, 2020 and April 21, 2020. A total of 100 patients (mean [standard deviation] age: 55 [12] yr; 29% female) underwent tracheostomy; 64 (age: 57 [14] yr; 25% female) did not undergo tracheostomy. Despite similar APACHE-II scores, 30-day survival was higher in 85/100 (85%) patients after tracheostomy, compared with 27/64 (42%) non-tracheostomised patients {relative risk: 3.9 (95% confidence intervals [CI]: 2.3e6.4); P<0.0001}. In patients with APACHE-II scores !17, 68/100 (68%) tracheotomised patients survived, compared with 12/64 (19%) non-tracheotomised patients (P<0.001). Tracheostomy within 14 days of intubation was associated with shorter duration of ventilation (mean difference: 6.0 days [95% CI: 3.1e9.0]; P<0.0001) and ICU stay (mean difference: 6.7 days [95% CI: 3.7e9.6]; P<0.0001). No healthcare workers developed COVID-19. Conclusion: Independent of the severity of critical illness from COVID-19, 30-day survival was higher and ICU stay shorter in patients receiving tracheostomy. Early tracheostomy appears to be safe in COVID-19.

Assessment of the harms and potential benefits of tracheostomy in COVID-19 patients: Narrative review of outcomes and recommendations

“…Experts in the field suggest that applying the essential infection-control measures would lessen the viral transmissibility. As evidenced by this review, in all the tracheostomies carried out in multiple centres worldwide, regardless of the timing or the technique, none of the health care workers or hospital staff involved in the procedure, be it surgeons, anaesthesiologists or nurses, reported any symptoms and/or demonstrated seroconversion within 2 weeks of this procedure, provided that they all followed the guidelines and committed to the use of appropriate PPE and adhered to strict donning and doffing procedures [ [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] ].…”

Management of tracheostomy in COVID-19 patients: The Japanese experience

“…Therefore, a multidisciplinary team has to consider the appropriateness of embarking on tracheostomy [7] , [8] , [9] . Queen Elizabeth Hospital Birmingham COVID-19 airway team reported a total of 164 patients with COVID-19 admitted to the ICU between March 9, 2020 and April 21, 2020 [10] . Despite similar Acute Physiology and Chronic Health Evaluation (APACHE)-II scores, the 30-day survival was higher in 85/100 (85%) patients after tracheostomy, compared with 27/64 (42%) non-tracheostomised patients {relative risk: 3.9 (95% confidence intervals [CI]: 2.3–6.4); P < 0.0001}.In patients with APACHE-II scores ≥17, 68/100 (68%) tracheotomised patients survived, compared with 12/64 (19%) non-tracheotomised patients ( P < 0.001).…”

“…Again, no health-care worker transmission resulted from the procedures. In the Birmingham experience, a total of 100 patients underwent tracheostomy [10] . Nine patients underwent tracheostomy before 10 days, 55 between 10 and 14 days, and 36 after 14 days of intubation.…”

“…This is one of the early recommendations. Table 3 shows parameters to guide selection for tracheostomy in the Birmingham study recently published [10] . They stated that delaying the tracheostomy over concerns for health-care personnel safety may prolong patients’ time on a ventilator and ICU stay, without any benefit of improved safety for either the clinicians involved, or the patient.…”

“…They stated that delaying the tracheostomy over concerns for health-care personnel safety may prolong patients’ time on a ventilator and ICU stay, without any benefit of improved safety for either the clinicians involved, or the patient. Health-care personnel infection during tracheostomy procedures was prevented to a great extent by appropriate PPE and appropriate surgical procedures with highly experienced surgical teams according to previous reports [4 , 8 , 10 , 21 , 22] . An international tracheostomy consensus working group suggests that tracheostomy be delayed until at least day 10 of mechanical ventilation and should be considered only when patients are showing signs of clinical improvement [8] .…”