Tracheostomy insertion in COVID-19: insertion practice and factors leading to unplanned tube exchange

Abstract

Background: Tracheostomy insertion in patients with Covid-19 presents unique challenges. Patients frequently have high ventilatory requirements, and as an aerosol generating procedure, tracheostomy insertion creates the potential for staff transmission. Problems with tracheostomies contribute to morbidity and mortality, and tracheostomy changes may increase risks of staff transmission. We sought to quantify the incidence of clinically necessitated tracheostomy changes, establish the indications for change and investigate the incidence of staff transmission. Methods: We conducted a single institution, retrospective, observational cohort study of all intensive care unit (ICU) patients with Covid-19 who had a tracheostomy between March 2020 and April 2021. The institution is a large tertiary referral centre in Ireland. Results: Forty-three patients had a tracheostomy during the study period. All were a Shiley™ Flexible Adult Taperguard or Shiley™ XLT Tracheostomy. 14 patients (33%) required a tracheostomy change, with the majority (57%) involving a change from a standard size to an extended length tracheostomy. Persistent leak was the most common indication for change (71.6%). Other indications included patient-ventilator dyssynchrony, persistent cough and accidental decannulation. No staff transmission of Covid-19 occurred during this study. Conclusions: The incidence of tracheostomy change was 33%, highlighting the importance of selecting the right tracheostomy for each patient. We discuss how key characteristics of tracheostomies such as type, size, length and inner diameter may impact flow, resistance and work of breathing, leading to unplanned tracheostomy change. No staff transmission occurred arising from tracheostomy insertion, adding to increasing evidence that tracheostomy insertion in Covid-19 appears safe with adherence to guidelines describing the correct use of personal protective equipment.

Indications of Tracheostomy in Patients Attending Baquba Teaching Hospital in Diyala, Iraq: A cross Sectional Study

“…As shown in Table 3, in 50 patients (71.5%), the trauma was the most common cause of prolonged ventilation indicator, while the viral cause was the least (1.5%). Total 50 100 As for the causes of upper airway obstruction, traumas were proven to be a cause in 15 patients (60%), while tumors were the second common cause that occurred in 10 patients (40 %), as shown in Table (5). Tracheostomy as part of another procedure with airway protection was seen in 5 cases of maxillofacial trauma.…”

“…Also, airflow resistance and labor associated with breathing should theoretically be less with a tracheostomy than for endotracheal tubes. However, such an effect has not been consistently demonstrated in patients after tracheostomy [4,5]. The occurrence of a tracheostomy motivates surgeons to be more aggressive in weaning attempts, especially if the tracheal hole in its place does not tolerate liberation from mechanical ventilation, which requires reconnection to the ventilator circuit [6].…”

Improving airway management and tracheostomy care through interprofessional collaboration: aligning timing, technique, and teamwork

“…In a recent issue of Journal of Thoracic Disease, McCauley and colleagues report on outcomes in ventilated patients with COVID-19. The study focused on unplanned t r a c h e o s t o m y t u b e e x c h a n g e a m o n g 4 3 p a t i e n t s undergoing tracheostomy (15). The need for an unplanned tracheostomy tube exchange suggests an extreme safety risk of respiratory compromise, partial dislodgment, accidental decannulation, or device-related pressure injury.…”