Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients

Abstract

Purpose COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes. Methods We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway. Results At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO 2 at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89-3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p = 0.001) were independent variables associated with prolonged time to decannulation. Conclusion Higher FiO 2 at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.

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

“… Study Sample size Follow up period/day MV weaning %/days Decannulation % Deaths % Martin-Villares C. et al [ 9 ] 1890 a 30 days 842/1616 (52.1%) 683/1616 383/1616 (23.7%) Breik O. et al [ 10 ] 100 30 days 85/100 (85%) 84/100 mean 14 days 15/100 (15%) Angel L. et al [ 11 ] 98 Mean 11 (SD 6) 32/98 (33%) 8/98 (8%) 7/98 (7%) Yeung. et al [ 7 ] 72 Median 26 (IQR18.8–3) 44/72 61.1% median 10 days 25/72 7/72 (9.7%) Tornari C. et al [ 5 ] 78 b Median 21 (IQR 15–28) 46/69 (66.6%) 35/69 4/78 (5.1%) Picetti E. et al [ 8 ] 66 Retrospective study Mean 21.4 days (SD 7.2) N/A 15/66 (22.7%) Chao T.N. et al [ 12 ] 53 Minimum 14 days PT 30/53 (56.6%) 11.8 days (SD 6.9) 7/53 (13.2%) 16.6 days (SD 5.0) 6/53 (11.3%) Botti C. et al [ 13 ] 44 Median 22 days PI Median 35 days PI (18–79) Mean 36 (10–77) day PT 15/44 (34.1%) Floyd E. et al [ 14 ] 38 Minimum 14 days PT 21/38 (55.2%) median 10 days 7/38 (18.4%) median 14 days 2/38 (5.3%) Zuazua-Gonzalez A. et al [ 6 ] …”

“…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] ].…”

“…The estimated percentage of tracheostomies performed among patients with severe COVID-19 infection varies from 29.3% [ 5 ] to 36.1% [ 6 ], 40.9% [ 7 ] and 53% [ 8 ] as reported in the literature.…”

Tracheostomy in patients with COVID-19: predictors and clinical features

“…However, the results of our study show that SOFA at ICU admission, with a cut-off point of 4.5, was the only variable associated with the need for tracheostomy due to PMV. Tornari et al [ 29 ] found that higher FiO 2 (≥ 0.4) at tracheostomy and peak cough flow prior to tracheostomy were associated with delayed decannulation in COVID-19 patients. Different studies conducted in non-COVID-19 patients have been published assessing predictors of PMV, [ 30 ] showing that variables that evaluate the severity of critical illness, most of them included in the SOFA score, could predict the need for PMV and tracheostomy.…”

Timing of elective tracheotomy and duration of mechanical ventilation amongst patients admitted to intensive care with severe COVID-19: a multicentre prospective cohort study

“…Tornari and colleagues conducted an observational cohort study to understand the factors that influenced the trajectory from tracheotomy to decannulation to facilitate ICU capacity planning and improve outcomes. Higher FiO 2 at tracheotomy time and higher pre-tracheotomy peak cough flow were associated with longer delays in decannulation of COVID-19 tracheotomy patients (25).…”