Utility of Tracheostomy in Patients With COVID-19 and Other Special Considerations

Low Molecular Weight Heparin Dosing in Relation to Postoperative Bleeding After Tracheotomy in Patients Infected With SARS-CoV-2-A Descriptive Study

Objective

The aim of this study was to analyze whether patients with SARS-CoV-2 who received surgical tracheotomy had a lower incidence of postoperative bleeding if their LMWH was postponed or canceled on the day of surgery.

Methods

Patients with SARS-CoV-2 admitted to the intensive care units who underwent surgical tracheotomy were assessed retrospectively through their medical records. Data on comorbidity, LMWH dose, and timing were collected. Bleedings < 72 h post surgery were noted as stomal or airway bleedings.

Results

All 101 patients included were on LMWH. Twenty-two patients had no change of dose of LMWH, 24 patients had their dose of LMWH postponed to post surgery, and 50 patients had their dose reduced to only the evening dose on the day of surgery. Twenty-six patients had a stomal bleeding, one patient had an airway bleeding, and four patients had both stomal and airway bleedings. No significant difference in the incidence of bleeding was identified between various groups of different LMWH doses or timing, reduced dose versus no change of dose, OR 1.29 (95% CI 0.42-3.92). Postponed dose versus no change of dose of LMWH, OR 1.03 (95% CI 0.28-3.75). Increasing age was correlated to a higher risk of bleeding post-surgery by an OR of 1.64 (95% CI 1.06-2.54, p = 0.026 for every 10 years added). No fatal bleeding related to surgical tracheotomy was observed.

Conclusion

Decreased doses of LMWH on the day of surgery were not associated with a risk reduction for post-surgical bleeding in patients with SARS-CoV-2 who received tracheotomy. Increasing age was a risk factor for post-surgical bleeding.

Level of Evidence

Retrospective, level 3.

Comparison of COVID-19 and Non-COVID-19 Tracheostomised Patients: Complications, Survival, and Mortality Risk Factors

Objectives: To compare the outcomes of tracheostomised COVID-19 patients with non-COVID-19 tracheostomised patients to identify factors influencing severity and mortality. Methods: A retrospective, single-centre cohort study was conducted on COVID-19 tracheostomised patients admitted from May 2020 to February 2022, compared with a cohort of non-COVID-19 tracheostomised patients. Results: COVID-19 tracheostomised patients had a higher mortality rate (50% vs. 27.3% in non-COVID-19 patients). Mortality risk factors in COVID-19 tracheostomised patients included female sex (HR 1.99, CI 1.09-3.61, p = 0.025), ischemic heart disease (HR 5.71, CI 1.59-20.53, p = 0.008), elevated pre-tracheostomy values of PEEP (HR 1.06, CI 1.01-1.11, p = 0.017) and INR (HR 1.04, CI 1.01-1.07, p = 0.004), and ventilatory complications (HR 8.63, CI 1.09-68.26, p = 0.041). No significant differences in complication rates were found based on Sars-CoV-2 infection or tracheostomy type. Conclusions: Tracheostomy technique did not impact complications, discharge circumstances, or mortality, supporting the safety of bedside percutaneous tracheostomies for COVID-19 patients. COVID-19 tracheostomised patients exhibited a higher mortality rate.

Characteristics and factors associated with mortality in tracheostomized patients with COVID-19: a retrospective cohort study in a hospital in Tacna, Peru

OBJECTIVE

We aimed to describe the main demographic, clinical, laboratory and therapeutic characteristics and to identify whether they are associated with mortality in tracheostomized patients.

MATERIAL AND METHODS.

Retrospective cohort study in adult patients diagnosed with COVID-19, admitted to ICU (Intensive Care Unit) and requiring tracheostomy. Demographic, clinical, laboratory and treatment data were obtained from the medical records of patients admitted to Hospital III Daniel Alcides Carrión in Tacna. The Cox proportional hazards model was used for survival analysis and hazard ratios (HR) with their 95% confidence intervals (95%CI) were calculated.

RESULTS.

We evaluated 73 patients, 72.6% were men, the most common comorbidities were obesity (68.5%), type 2 diabetes mellitus (35.6%), and arterial hypertension (34.2%). Thirty-seven percent of the participants died during their stay at the ICU. The median time from intubation to tracheostomy and the duration of tracheostomy was 17 (RIC: 15-21) and 21 (RIC: 3-39) days, respectively. Multivariate analysis showed that the factors associated with mortality were procalcitonin > 0.50 ng/dL at the time of tracheostomy (HRa: 2.40 95%CI: 1.03-5.59) and a PaO2/FiO2 ratio less than or equal to 150 mmHg (HRa: 4.44 95%CI: 1.56-12.60).

CONCLUSIONS.

The factors associated with mortality at the time of tracheostomy were procalcitonin > 0.50 ng/dL and a PaO2/FiO2 ratio less than or equal to 150 mmHg.

Impact of Tracheostomy on COVID-19 ICU Patients in Saudi Arabia: A Retrospective Analysis

Introduction The COVID-19 pandemic has prompted the development of novel medical interventions, including tracheostomy, a surgical procedure for a direct airway. This study investigates the intricacies of managing critically ill patients in the ICU, focusing on its debated utility in the global crisis. Methods The study assessed the impact of tracheostomy on COVID-19 patients at Al-Ahsa Hospital, Saudi Arabia, using a retrospective cohort design and data from electronic health records and databases. It aimed to provide insights into treatment outcomes and practices. Results The findings of this study shed light on the significant impact of tracheostomy on the course of ICU treatment for COVID-19 patients. Total number of participants were 1389. The study cohort consisted of predominantly non-pregnant individuals with an average body mass index reflective of the regional population. Among the COVID-19 patients, only a small percentage, 63 (4.5%), required tracheostomy, while the majority, 1326 (95.5%), did not undergo this procedure. Analysis of ICU outcomes revealed that a substantial proportion of patients, 223 (16.1%), achieved total cure, while the remaining patients did not. After a 28-day ICU stay, the majority of individuals, 1287 (92.7%), were discharged, while a smaller percentage remained in the ICU, with 77 (5.5%) still requiring mechanical ventilation. Notably, patients who underwent tracheostomy had a significantly longer ICU stay compared to those who did not, with an average of 59 days versus 19 days, respectively. Furthermore, the study found that tracheostomy did not significantly impact ICU discharge outcomes, including death, discharge home, and transfer to another facility. However, it did influence hospital discharge outcomes, with lower mortality rates and a higher rate of transfer to another facility among patients who underwent tracheostomy. These results provide valuable insights into the management and outcomes of critically ill COVID-19 patients in the ICU, particularly in relation to the use of tracheostomy as a treatment intervention. Conclusion The study highlights the dual benefits of tracheostomy in COVID-19 care, extending hospital stays but not increasing ICU discharge rates, emphasizing the need for tailored clinical strategies.

Early versus late tracheostomy in critically ill COVID-19 patients

BACKGROUND

The role of early tracheostomy as an intervention for critically ill COVID-19 patients is unclear. Previous reports have described prolonged intensive care stays and difficulty weaning from mechanical ventilation in critically ill COVID-19 patients, particularly in those developing acute respiratory distress syndrome. Pre-pandemic evidence on the benefits of early tracheostomy is conflicting but suggests shorter hospital stays and lower mortality rates compared to late tracheostomy.

OBJECTIVES

To assess the benefits and harms of early tracheostomy compared to late tracheostomy in critically ill COVID-19 patients.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register, which comprises CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv, as well as Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index) and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions. We conducted the searches on 14 June 2022.

SELECTION CRITERIA

We followed standard Cochrane methodology. We included randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) evaluating early tracheostomy compared to late tracheostomy during SARS-CoV-2 infection in critically ill adults irrespective of gender, ethnicity, or setting.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. To assess risk of bias in included studies, we used the Cochrane RoB 2 tool for RCTs and the ROBINS-I tool for NRSIs. We used the GRADE approach to assess the certainty of evidence for outcomes of our prioritized categories: mortality, clinical status, and intensive care unit (ICU) length of stay. As the timing of tracheostomy was very heterogeneous among the included studies, we applied GRADE only to studies that defined early tracheostomy as 10 days or less, which was chosen according to clinical relevance.

MAIN RESULTS

We included one RCT with 150 participants diagnosed with SARS-CoV-2 infection and 24 NRSIs with 6372 participants diagnosed with SARS-CoV-2 infection. All participants were admitted to the ICU, orally intubated and mechanically ventilated. The RCT was a multicenter, parallel, single-blinded study conducted in Sweden. Of the 24 NRSIs, which were mostly conducted in high- and middle-income countries, eight had a prospective design and 16 a retrospective design. We did not find any ongoing studies. RCT-based evidence We judged risk of bias for the RCT to be of low or some concerns regarding randomization and measurement of the outcome. Early tracheostomy may result in little to no difference in overall mortality (RR 0.82, 95% CI 0.52 to 1.29; RD 67 fewer per 1000, 95% CI 178 fewer to 108 more; 1 study, 150 participants; low-certainty evidence). As an indicator of improvement of clinical status, early tracheostomy may result in little to no difference in duration to liberation from invasive mechanical ventilation (MD 1.50 days fewer, 95%, CI 5.74 days fewer to 2.74 days more; 1 study, 150 participants; low-certainty evidence). As an indicator of worsening clinical status, early tracheostomy may result in little to no difference in the incidence of adverse events of any grade (RR 0.94, 95% CI 0.79 to 1.13; RD 47 fewer per 1000, 95% CI 164 fewer to 102 more; 1 study, 150 participants; low-certainty evidence); little to no difference in the incidence of ventilator-associated pneumonia (RR 1.08, 95% CI 0.23 to 5.20; RD 3 more per 1000, 95% CI 30 fewer to 162 more; 1 study, 150 participants; low-certainty evidence). None of the studies reported need for renal replacement therapy. Early tracheostomy may result in little benefit to no difference in ICU length of stay (MD 0.5 days fewer, 95% CI 5.34 days fewer to 4.34 days more; 1 study, 150 participants; low-certainty evidence). NRSI-based evidence We considered risk of bias for NRSIs to be critical because of possible confounding, study participant enrollment into the studies, intervention classification and potentially systematic errors in the measurement of outcomes. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases overall mortality (RR 1.47, 95% CI 0.43 to 5.00; RD 143 more per 1000, 95% CI 174 less to 1218 more; I2 = 79%; 2 studies, 719 participants) or duration to liberation from mechanical ventilation (MD 1.98 days fewer, 95% CI 0.16 days fewer to 4.12 more; 1 study, 50 participants), because we graded the certainty of evidence as very low. Three NRSIs reported ICU length of stay for 519 patients with early tracheostomy (≤ 10 days) as a median value, which we could not include in the meta-analyses. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases the ICU length of stay, because we graded the certainty of evidence as very low.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that early tracheostomy may result in little to no difference in overall mortality in critically ill COVID-19 patients requiring prolonged mechanical ventilation compared with late tracheostomy. In terms of clinical improvement, early tracheostomy may result in little to no difference in duration to liberation from mechanical ventilation compared with late tracheostomy. We are not certain about the impact of early tracheostomy on clinical worsening in terms of the incidence of adverse events, need for renal replacement therapy, ventilator-associated pneumonia, or the length of stay in the ICU. Future RCTs should provide additional data on the benefits and harms of early tracheostomy for defined main outcomes of COVID-19 research, as well as of comparable diseases, especially for different population subgroups to reduce clinical heterogeneity, and report a longer observation period. Then it would be possible to draw conclusions regarding which patient groups might benefit from early intervention. Furthermore, validated scoring systems for more accurate predictions of the need for prolonged mechanical ventilation should be developed and used in new RCTs to ensure safer indication and patient safety. High-quality (prospectively registered) NRSIs should be conducted in the future to provide valuable answers to clinical questions. This could enable us to draw more reliable conclusions about the potential benefits and harms of early tracheostomy in critically ill COVID-19 patients.

The Effect of Comorbidities and Complications on COVID-19 Mortality: A Detailed Retrospective Study in Western Romania

COVID-19 continues to impact global health systems even after being declared over, with some patients exhibiting severe complications linked to pre-existing conditions. This study aimed to investigate the association between comorbidities, complications, and survival outcomes among COVID-19 survivors in Western Romania. Our hypothesis posited that comorbidities and complications significantly influence survival rates. We conducted a retrospective analysis of 1948 COVID-19 survivors admitted from January to December 2021, with 192 selected for detailed analysis based on inclusion and exclusion criteria. The severity of COVID-19 was classified according to WHO guidelines, and conditions like hypertension and obesity were defined using criteria from the European Society of Hypertension (ESH), the European Society of Cardiology (ESC), and WHO, respectively. Among the 192 patients, 33 had mild, 62 had moderate, and 97 had severe COVID-19. The median age across the severity groups was 63.2 years. Patients undergoing tracheostomy had a mortality rate of 83.3% versus 22.2% for non-tracheostomy patients (p < 0.001) and presented with significantly higher lung injury, hospitalization duration, and complications. Remarkably, tracheostomized patients were 17.50 times more likely to succumb to the disease (95% CI 4.39-116.91, p < 0.001). Furthermore, pneumothorax increased the mortality risk significantly (OR 22.11, 95% CI 5.72-146.03, p < 0.001). Intriguingly, certain conditions like grade I hypertension and grade II obesity showed a protective effect against mortality, whereas type 2 diabetes mellitus increased mortality risk (univariate OR 2.89, p = 0.001). The presence of certain comorbidities and complications significantly impacts the survival rates of COVID-19 patients in Western Romania. Notably, tracheostomy, pneumothorax, and T2DM were associated with increased mortality. This study underscores the importance of personalized patient care and provides insights for healthcare policymakers in Western Romania to improve clinical management strategies.

Interdisciplinary assessment of tracheostomy care knowledge: An opportunity for quality improvement

PURPOSE

A 2013 AAOHNS consensus statement called for reduced variation in tracheostomy care. Multidisciplinary approaches and standardized protocols have been shown to improve tracheostomy outcomes. This study aims to identify inconsistencies in knowledge in order to design standardized education targeting these areas to improve quality of care.

MATERIALS AND METHODS

An online, multiple-choice tracheostomy care knowledge assessment was administered to nurses and respiratory therapists in ICUs, stepdown units, and regular nursing floors, as well as residents in otolaryngology, general surgery, and thoracic surgery. The survey was administered and data were recorded using the Select Survey online platform.

RESULTS

173 nurses, respiratory therapists, and residents participated in this study. Over 75 % of respondents identified correct answers to questions addressing basic tracheostomy care, such as suctioning and humidification. Significant variation was observed in identification and management of tracheostomy emergencies, and appropriate use of speaking valves. Only 47 % of all respondents identified all potential signs of tracheostomy tube displacement. Respiratory therapists with over 20 years of experience (p = 0.001), were more likely to answer correctly than those with less. Nurses were less likely than respiratory therapists to have received standardized tracheostomy education (p = 0.006) and were less likely than others to choose the appropriate scenario for speaking valve use (p = 0.042), highlighting the need for interdisciplinary education.

CONCLUSIONS

An interdisciplinary assessment of tracheostomy care knowledge demonstrates variation, especially in identification and management of tracheostomy emergencies and appropriate use of speaking valves. Design of a standardized educational program targeting these areas is underway.

Tracheal stenosis following tracheotomy in a COVID-19 patient

Hemodialyzed patients with COVID-19 are at risk for severe complications from acute respiratory distress syndrome, requiring admission to the intensive-care unit for invasive mechanical ventilation. Post tracheotomy stenosis can be a life-threatening condition that commonly occurs after iatrogenic injury secondary to tracheotomy or tracheal intubation. We report a case of a 44-year-old female patient on maintenance haemodialysis who presented a COVID-19-related ARDS that required mechanical ventilation for 4 weeks, followed by a persistent stridor and finally succumbed, 1 month after being discharged from intensive care unit, from a severe respiratory distress due to a tracheal stenosis. Our aim is to highlight the importance of the early recognition and management of post tracheotomy stenosis in patients with persistent respiratory difficulty as stridor after prolonged intubation requiring tracheotomy, in order to improve the prognosis of these patients.

Elective Tracheostomy During Covid-19 Pandemic- A Tertiary Care Centre Experience

Aims and Objectives

: The aim of our study was to present an experience of elective tracheostomy in COVID-19 patients at our institute.

Materials and methods

The present prospective study was conducted, after approval by Institutional Ethics Committee, in the Department of ENT, SMGS Hospital, GMC Jammu from May 2020 to March 2021 over 60 patients having need for prolonged mechanical ventilation and having tested positive for COVID-19 with nasopharyngeal swab on rtPCR assay testing. Detailed information regarding following aspects was gathered :Age, Gender, Comorbidities (Diabetes, Cardiovascular disease, Pulmonary disease, Malignancy), time of endotracheal intubation to tracheostomy, time to wean sedation after tracheostomy, time to wean mechanical ventilation after tracheostomy, surgical complications, mortality, any health care worker in operating team getting infected by SARS-CoV-2. All 60 patients underwent Elective Open Tracheostomy Bed-side in the ICU section of our institute.

Results

The mean age of presentation was 55.9 ± 2.34 years, with male preponderance. The most common indication for tracheostomy was ARDS (Acute Respiratory Distress Syndrome) (56.6%). Out of 60 patients, co-morbidities were present in 44 patients (73.3%). The mean time between endotracheal intubation and tracheostomy was 12.2 ± 4.9 days. The mean time to wean mechanical ventilation after tracheostomy was 10.4 ± 2.31 days. The mean time to wean sedation was 2.2 ± 0.83 days. There were no deaths during the procedure. Out of 60 patients, 5 patients (8.3%) died due to complications of COVID-19.

Conclusion

Our study provides important clinical data (such as timing of tracheostomy, pre-operative evaluation of patients, recommendations during procedure, outcomes of tracheostomy and postoperative care) on this threatening issue of tracheostomy in COVID-19 patients and might be of immense help to various Otorhinolaryngologists who are dealing with the same situation.

Outcomes and survival of tracheostomised patients during the COVID-19 pandemic in a third level hospital

PURPOSE

Analyse the evolution and outcomes of COVID-19 tracheostomised patients. Clarify if this cohort presents an increased risk of haemorrhagic complications and verify the correlation between some risk factors with increased mortality.

METHODS

A retrospective single-centre observational study of a prospective cohort of all COVID-19 patients admitted to our centre between March and April 2020. A control group was obtained from a historical cohort of patients who required tracheostomy due to prolonged invasive mechanical ventilation (IMV) before 2020.

RESULTS

A total of 1768 patients were included: 67 tracheostomised non-COVID-19 patients (historic cohort), 1371 COVID-19 patients that did not require ICU admission, 266 non-tracheostomised COVID-19 patients and 64 tracheostomised COVID-19 patients. Comparing the obesity prevalence, 54.69% of the tracheostomised COVID-19 patients were obese and 10.53% of the non-tracheostomised COVID-19 patients (p < 0.001). The median of ICU admission days was lower (p < 0.001) in the non-tracheostomised cohort (12.5 days) compared with the COVID-19 tracheostomised cohort (34 days). The incidence of haemorrhagic complications was significantly higher in tracheostomised COVID-19 patients (20.31%) compared with tracheostomised non-COVID-19 patients (5.97%) and presented a higher percentage of obesity, hypertension, diabetes and smoking, significantly different from the historic cohort (p < 0.001). A Cox model showed that tracheostomy had no statistically significant effect on mortality in COVID-19 patients.

CONCLUSION

Obesity and smoking may be risk factors for tracheostomy in COVID-19 patients, tracheostomised COVID-19 patients present a higher risk of bleeding complications than those admitted for other reasons and an elevated LDH and INR on ICU admission may be associated with increased mortality.

The value of tracheostomy of critically ill COVID-19 patients - A multicentral study

Purpose

Tracheostomy is an aerosol-generating procedure, thus performing it during the COVID-19 pandemic arises considerations such as the most appropriate timing and the patients to whom it is suitable. Medical teams lack sufficient data to assist determining whether or not to conduct tracheostomy, its short- and long-term implications are not fully understood. This study aims to shed light on the critically ill COVID-19 patients that require tracheostomy, and to investigate its value.

Methods

A retrospective multicentral case-control study of 157 hospitalized critically ill COVID-19 patients, among whom 30 patients went through tracheostomy and consisted of our study group.

Results

The mean age was similar between study and control groups (68.9 ± 12.7 years vs 70.5 ± 15.8 years, p = 0.57), as well as comorbidity prevalence (56.7% vs 67.7%, p = 0.25). Patients in the study group were hospitalized for longer duration until defined critically ill (5 ± 4.3 vs 3 ± 3.9 days; p = 0.01), until admitted to the intensive care unit (6 ± 6.6 vs 2.5 ± 3.7 days respectively; p = 0.005), and until discharged (24 ± 9.7 vs 10.7 ± 9.1 days, p < 0.001). Mortality rate was lower in the study group (30% vs 59.8%, p = 0.003). Kaplan Meier survival analysis revealed a statistically significant difference in survival time between groups (Log rank chi-sq = 20.91, p < 0.001) with mean survival time of 41 ± 3.1 days vs 21 ± 2.2 days. Survival was significantly longer in the study group (OR = 0.37, p = 0.004).

Conclusion

Tracheostomy allows for more prolonged survival for gradually deteriorating critically ill COVID-19 patients. This should be integrated into the medical teams' considerations when debating whether or not to conduct tracheostomy.

Tracheotomy Outcomes in 71 COVID-19 Patients: A Multi-Centric Study in Saudi Arabia

Since its outbreak in late 2019, the COVID-19 pandemic has seen a sharp rise in the demand for oxygen and ventilation facilities due to the associated extensive damage that it causes to the lungs. This study is considered the first and largest study in Saudi Arabia to evaluate the outcomes of tracheostomy in intubated COVID-19 patients. This is a retrospective, observational cohort study that was conducted at King Abdulaziz Medical City (KAMC) in Jeddah, Western Region, Saudi Arabia and King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. The findings of the study revealed that seventy-one patients with COVID-19 underwent tracheotomy between 1 March 2020 and 31 October 2020. The average period between intubation and tracheostomy was 9.97 days. Hypertension, diabetes, lung disease and obesity (BMI > 30) were significant risk factors of mortality. The overall 30-day mortality rate was 38.4%.

Percutaneous and Open Tracheostomy in Patients With COVID-19: The Weill Cornell Experience in New York City

OBJECTIVE

Report long-term tracheostomy outcomes in patients with COVID-19.

STUDY DESIGN

Review of prospectively collected data.

METHODS

Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge.

RESULTS

One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037).

CONCLUSION

Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2849-E2856, 2021.

Quantifying Viral Particle Aerosolization Risk During Tracheostomy Surgery and Tracheostomy Care

Importance

During respiratory disease outbreaks such as the COVID-19 pandemic, aerosol-generating procedures, including tracheostomy, are associated with the risk of viral transmission to health care workers.

Objective

To quantify particle aerosolization during tracheostomy surgery and tracheostomy care and to evaluate interventions that minimize the risk of viral particle exposure.

Design, Setting, and Participants

This comparative effectiveness study was conducted from August 2020 to January 2021 at a tertiary care academic institution. Aerosol generation was measured in real time with an optical particle counter during simulated (manikin) tracheostomy surgical and clinical conditions, including cough, airway nebulization, open suctioning, and electrocautery. Aerosol sampling was also performed during in vivo swine tracheostomy procedures (n = 4), with or without electrocautery. Fluorescent dye was used to visualize cough spread onto the surgical field during swine tracheostomy. Finally, 6 tracheostomy coverings were compared with no tracheostomy covering to quantify reduction in particle aerosolization.

Main Outcomes and Measures

Respirable aerosolized particle concentration.

Results

Cough, airway humidification, open suctioning, and electrocautery produced aerosol particles substantially above baseline. Compared with uncovered tracheostomy, decreased aerosolization was found with the use of tracheostomy coverings, including a cotton mask (73.8% [(95% CI, 63.0%-84.5%]; d = 3.8), polyester gaiter 79.5% [95% CI, 68.7%-90.3%]; d = 7.2), humidification mask (82.8% [95% CI, 72.0%-93.7%]; d = 8.6), heat moisture exchanger (HME) (91.0% [95% CI, 80.2%-101.7%]; d = 19.0), and surgical mask (89.9% [95% CI, 79.3%-100.6%]; d = 12.8). Simultaneous use of a surgical mask and HME decreased the particle concentration compared with either the HME (95% CI, 1.6%-12.3%; Cohen d = 1.2) or surgical mask (95% CI, 2.7%-13.2%; d = 1.9) used independently. Procedures performed with electrocautery increased total aerosolized particles by 1500 particles/m3 per 5-second interval (95% CI, 1380-1610 particles/m3 per 5-second interval; d = 1.8).

Conclusions and Relevance

The findings of this laboratory and animal comparative effectiveness study indicate that tracheostomy surgery and tracheostomy care are associated with significant aerosol generation, putting health care workers at risk for viral transmission of airborne diseases. Combined HME and surgical mask coverage of the tracheostomy was associated with decreased aerosolization, thereby reducing the risk of viral transmission to health care workers.

Emergent tracheostomy during the pandemic of COVID-19: Slovenian National Recommendations

PURPOSE

Emergent tracheostomy under local anaesthesia is a reliable method of airway management when orotracheal intubation is not possible. COVID-19 is spread through aerosol making the emergent tracheostomy a high-risk procedure for surgeons. The surgical establishment of the air conduit in emergency scenarios must be adjusted for safety reasons.

METHODS

To establish the Slovenian National Guidelines for airway management in cannot intubate-cannot ventilate situations in COVID-19 positive patients.

RESULTS

Good communication and coordination between surgeon and anaesthesiologist is absolutely necessary. Deep general anaesthesia, full muscle relaxation and adequate preoxygenation without intubation are initial steps. The surgical cricothyrotomy is performed quickly, the thin orotracheal tube is inserted, the cuff is inflated and ventilation begins. Following patient stabilisation, the conversion to the tracheostomy is undertaken with the following features: skin infiltration with vasoconstrictor, a vertical incision, avoidance of electrical devices in favour of classical manners of haemostasis, the advancement of the tube towards the carina, performing the tracheal window in complete apnoea following adequate oxygenation, the insertion of non-fenestrated canulla attached to a heat and moisture exchanger, the fixation of canulla with stitches and tapes, and the cricothyrotomy entrance closure. Appropriate safety equipment is equally important.

CONCLUSION

The goal of the guidelines is to make the procedure safer for medical teams, without harming the patients. Further improvements of the guidelines will surely appear as COVID-19 is a new entity and there is not yet much experience in handling it.

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review

OBJECTIVE

In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

DATA SOURCES

PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents.

REVIEW METHODS

Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

CONCLUSIONS

Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel.

IMPLICATIONS FOR PRACTICE

Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

Elective open "Shield Tracheostomy" in patients with COVID-19

Purpose

To prevent the consequences of long-term endotracheal intubation, patients undergo tracheostomies. However, as COVID-19 is highly contagious, its existence has made the tracheostomy a high-risk procedure. Tracheostomy procedures must, therefore, be adjusted for safety reasons. The aim is to present the adjustments that should be made to the surgical technique.

Methods

Both the medical charts and surgical reports of patients with COVID-19 who were subjected to elective open tracheostomies were reviewed.

Results

The retrospective study included 25 patients. Our adjustments include the timing of tracheostomies, ideally putting them at 21 days after the onset of COVID-19, the advancement of an endotracheal tube to 26–28 cm from the upper-alveolar ridge, surgery being carried out in the intensive care unit with appropriately modified positions of the patient and providers, tracheo-cutaneous sutures, and intentionally making the small tracheal flap and the tracheal window the same shape as a medieval shield.

Conclusions

A tracheostomy performed in this way is now referred to as the Shield Tracheostomy. Further improvements to the surgical technique are expected in the future.

Assessment of SARS-CoV-2 in the Cerumen of COVID-19-Positive Patients

OBJECTIVE

To evaluate the presence of SARS-CoV-2 virus in the cerumen of patients with COVID-19.

METHODS

A prospective study was conducted in a tertiary care pandemic hospital. Sixty COVID-19 patients with cerumen in their external auditory canals were included in the study. Swabs were taken from the external auditory canal of the patients by an experienced otolaryngologist with the test swab. Sampling was done by rotating the sample swab 360° 10 times in each external auditory canal for a total of 20 times. After collection, swabs were placed into 2 mL of the sterile viral transport medium (various manufacturers), then transported and tested as soon as possible after collection.

RESULTS

SARS-CoV-2 was not detected in the cerumen polymerase chain reaction (PCR) samples of any of the 60 patients with positive nasopharyngeal/oropharyngeal swabs.

CONCLUSION

Cerumen cleaning is one of the most common procedures performed by otolaryngologists, and care should be taken during the procedure or due to the possibility of infection from the resulting contaminants. The cerumen contains the secretions of the glands in the external auditory canal and may contain certain pathogens that are actively found in the body. The presence of hepatitis B virus in the cerumen was examined and isolated in the cerumen. In our study, the presence of SARS-CoV-2 virus in the cerumen was evaluated in SARS-CoV-2 PCR-positive patients. SARS-CoV-2 virus was not detected in the cerumen samples of any of the patients.

Bronchoscopy in COVID-19 patients: When, how and why. Experience in clinical practice

Severe Acute Respiratory Syndrome due to Coronavirus-19 (SARS-CoV-2) is caused by combined alveolar-capillary lung damage, with bilateral pneumonia and thrombosis, which often causes respiratory failure. Proper COVID-19 management requires high skills in airway control and the need to perform aerosol-generating procedures such as bronchoscopy, which can increase the possibility of virus spreading among healthcare professionals. In an epidemiologically delicate moment, the multidisciplinary decision on "WHEN, HOW and WHY" to perform bronchoscopies minimizing the risk of COVID-19 transmission, represented a great challenge for all specialists engaged in bronchoscopic procedures. In this work authors want to share all technical aspects of 87 videobronchoscopies performed in confirmed or suspected COVID-19 patients, from 3rd to 6th January 2020, describing the reason, the organizational and operational model and patients characteristics. Was also evaluated the impact of high-risk procedures such as bronchoscopy on the personnel involved. The disclosure of all technical details, represents, in the opinion of the authors, an important contribution, capable of providing support to all physicians engaged in bronchoscopy procedures in confirmed or suspected COVID-19 patients.

Pragmatic Recommendations for Tracheostomy, Discharge, and Rehabilitation Measures in Hospitalized Patients Recovering From Severe COVID-19 in Low- and Middle-Income Countries

New studies of COVID-19 are constantly updating best practices in clinical care. However, research mainly originates in resource-rich settings in high-income countries. Often, it is impractical to apply recommendations based on these investigations to resource-constrained settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for tracheostomy, discharge, and rehabilitation measures in hospitalized patients recovering from severe COVID-19 in LMICs. We recommend that tracheostomy be performed in a negative pressure room or negative pressure operating room, if possible, and otherwise in a single room with a closed door. We recommend using the technique that is most familiar to the institution and that can be conducted most safely. We recommend using fit-tested enhanced personal protection equipment, with the fewest people required, and incorporating strategies to minimize aerosolization of the virus. For recovering patients, we suggest following local, regional, or national hospital discharge guidelines. If these are lacking, we suggest deisolation and hospital discharge using symptom-based criteria, rather than with testing. We likewise suggest taking into consideration the capability of primary caregivers to provide the necessary care to meet the psychological, physical, and neurocognitive needs of the patient.

Open Tracheostomy for Critically Ill Patients with COVID-19

Background

COVID-19 is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy can shorten ICU length of stay and help weaning. Aims/Objectives. To describe the long-term evolution of the critically patient with COVID-19 and the need for invasive mechanical ventilation and orotracheal intubation (OTI), with or without tracheostomy. Material and Methods. A prospective study was performed including all patients admitted to the ICU due to COVID-19 from 10^th March to 30^th April 2020. Epidemiological data, performing a tracheostomy or not, mean time of invasive mechanical ventilation until tracheotomy, mean time from tracheotomy to weaning, and final outcome after one month of minimum follow-up were recorded. The Otolaryngology team was tested for COVID-19 before and after the procedures.

Results

Out of a total of 1612 hospital admissions for COVID-19, only 5.8% (93 patients) required ICU admission and IOT. Twenty-seven patients (29%) underwent a tracheostomy. After three months, within the group of tracheotomized patients, 29.6% died and 48.15% were extubated in a mean time of 28.53 days. In the nontracheostomized patients, the mortality was 42.4%.

Conclusions

Tracheostomy is a safe procedure for COVID-19 and helps weaning of prolonged OTI. Mortality after tracheostomy was less common than in nontracheostomized patients.

Pilot Study of Trans-oral Robotic-Assisted Needle Direct Tracheostomy Puncture in Patients Requiring Prolonged Mechanical Ventilation

COVID-19 can induce severe respiratory problems that need prolonged mechanical ventilation in the intensive care unit. While Open Tracheostomy (OT) is the preferred technique due to the excellent visualization of the surgical field and structures, Percutaneous Tracheostomy (PT) has proven to be a feasible minimally invasive alternative. However, PT's limitation relates to the inability to precisely enter the cervical trachea at the exact spot since the puncture is often performed based on crude estimation from anatomical laryngeal surface landmarks. Besides, there is no absolute control of the trajectory and force required to make the percutaneous puncture into the trachea, resulting in inadvertent injury to the cricoid ring, cervical esophagus, and vessels in the neck. Therefore, we hypothesize that a flexible mini-robotic system, incorporating the robotic needling technology, can overcome these challenges by allowing the trans-oral robotic instrument of the cervical trachea. This approach promises to improve current PT technology by making the initial trachea puncture from an “inside-out” approach, rather than an “outside-in” manner, fraught with several technical uncertainties.

Minimising risk to thoracic surgical teams in an era of COVID-19: exploring possible preventative measures

The demands of curtailing the impact of the coronavirus disease 2019 (COVID-19) global pandemic have disrupted the world’s ability to care for patients with thoracic pathologies. Those who undergo thoracic surgical therapeutic procedures are a high-risk category, likely to have impaired lung function but also high risk for exposing clinical teams to aerosolised viral loads. In light of this global pandemic, thorough pre-procedural planning, adequate personal protective equipment (PPE), experienced personnel and judicious anaesthetic and intra-operative measures will serve to be instrumental in ensuring positive patient outcomes whilst still protecting the safety of healthcare workers.

Dissemination of Information During Public Health Crises: Early COVID-19 Data From The Laryngoscope

OBJECTIVES

During a public health crisis, it is important for medical journals to share information in a timely manner while maintaining a robust peer-review process. This review reports and analyzes The Laryngoscope's publication trends and practices during the COVID-19 pandemic, before the COVID-19 pandemic, and during previous pandemics.

METHODS

Comprehensive review of two databases (PubMed and The Laryngoscope) was performed. COVID-19 manuscripts (published in The Laryngoscope during the first 4 months of the pandemic) were identified and compared to manuscripts pertaining to historic pandemics (published in The Laryngoscope during the first 2 years of each outbreak). Keywords included "Laryngoscope", "flu", "pandemic", "influenza", "SARS", "severe acute respiratory syndrome", "coronavirus", "COVID-19", and "SARS-CoV-2". Data were obtained from The Laryngoscope to characterize publication trends during and before the COVID-19 pandemic.

RESULTS

From March 1, 2020 to June 30, 2020, The Laryngoscope had 203 COVID-19 submissions. As of July 8, 2020, 20 (9.9%) were accepted, 117 (57.6%) under review, and 66 (32.5%) rejected. During the first 4 months of the pandemic, 18 COVID-19 manuscripts were published. The mean number of days from submission to online publication was 45, compared to 170 in 2018 and 196 in 2019. A total of 4 manuscripts concerning previous pandemics were published during the initial 2 years of each outbreak.

CONCLUSIONS

The Laryngoscope rapidly disseminated quality publications during the COVID-19 pandemic by upholding a robust peer-review process while expediting editorial steps, highlighting relevant articles online, and providing open access to make COVID-19-related publications available as quickly as possible. Laryngoscope, 130:2508-2515, 2020.

Challenges of tracheostomy in COVID-19 patients in a tertiary centre in inner city London

The rapid global spread of SARS-CoV-2, the causative agent of COVID-19, has dominated healthcare services, with exponential numbers requiring mechanical ventilation in the intensive care unit (ICU). Tracheostomy facilitates respiratory and sedative weaning but risks potential viral transmission. This study reviewed the tracheostomy provision, techniques, and outcomes for a single-centre prospective cohort during the resource-pressured COVID-19 period. Seventy-two of 176 patients underwent tracheostomy at a median 17 days: 44 surgical (open), 28 percutaneous. Their median age was 58 years, the male to female ratio was 2.4:1, 75.1% were of BAME backgrounds, 76% had a BMI≥25kg/m2, and 65% had ≥2 major co-morbidities. Seventy-nine percent of patients were weaned from sedation at a median 2 days, 61% were weaned from mechanical ventilation at a median 10 days, 39% were discharged from the ICU at a median 11.5 days, and 19.4% were discharged home at a median 24 days. All patients survived the procedure. The mortality rate was 9.7% at a median 12 days. No clinician reported COVID-19 symptoms within 14 days of the procedure. The role of tracheostomy in COVID-19 is currently unclear. Delivery of tracheostomy by maxillofacial surgeons relieved the workload pressure from ICU clinicians. The choice of technique was influenced by the patient and resource factors, resulting in a mixed cohort of open and percutaneous tracheostomy in COVID-19 patients. Preliminary data suggest that open tracheostomy is as favourable as percutaneous tracheostomy for COVID-19 patients, and is safe for clinicians.

Critical Care Guidance for Tracheostomy Care During the COVID-19 Pandemic: A Global, Multidisciplinary Approach

PURPOSE

Critical care nurses caring for patients with a tracheostomy are at high risk because of the predilection of SARS-CoV-2 for respiratory and mucosal surfaces. This review identifies patient-centered practices that ensure safety and reduce risk of infection transmission to health care workers during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Consensus statements, guidelines, institutional recommendations, and scientific literature on COVID-19 and previous outbreaks were reviewed. A global interdisciplinary team analyzed and prioritized findings via electronic communications and video conferences to develop consensus recommendations.

RESULTS

Aerosol-generating procedures are commonly performed by nurses and other health care workers, most notably during suctioning, tracheostomy tube changes, and stoma care. Patient repositioning, readjusting circuits, administering nebulized medications, and patient transport also present risks. Standard personal protective equipment includes an N95/FFP3 mask with or without surgical masks, gloves, goggles, and gown when performing aerosol-generating procedures for patients with known or suspected COVID-19. Viral testing of bronchial aspirate via tracheostomy may inform care providers when determining the protective equipment required. The need for protocols to reduce risk of transmission of infection to nurses and other health care workers is evident.

CONCLUSION

Critical care nurses and multidisciplinary teams often care for patients with a tracheostomy who are known or suspected to have COVID-19. Appropriate care of these patients relies on safeguarding the health care team. The practices described in this review may greatly reduce risk of infectious transmission.

Airway Management of COVID-19 Positive Patients Aboard USNS COMFORT Mission to New York City

During the USNS Comfort mobilization to New York City in response to the pandemic, the ship's medical team cared for over 35 mechanically ventilated corona virus disease 2019 (COVID-19) infected patients. Due to the better than expected mortality rates of these patients, tracheotomy for prolonged intubation or other indicated interventional bronchoscopies were performed on 7 COVID positive patients, as well as 2 with negative screening tests. No member of the health care team subsequently became symptomatic or tested positive for COVID-19. This was in part due to the formation of a dedicated surgical airway team, use of standardized procedural techniques and personal protective equipment (PPE), and construction of a negative pressure operating room within the COVID-19 isolation ward on the ship. This experience shows that tracheotomies and other aerosolizing procedures can be performed with due concern for patient and provider safety, regardless of patient's COVID status.

Impact de l’épidémie de Coronavirus-19 sur l’activité chirurgicale en ORL

But

Le but de cette étude est d’évaluer l’impact de la pandémie de la COVID-19 sur l’activité chirurgicale de trois services d’ORL d’Île-de-France, une région fortement touchée par l’épidémie.

Matériel et méthodes

Le nombre et la nature des interventions chirurgicales a été recueilli au sein de trois services d’ORL franciliens universitaires du 17/03/2020 au 17/04/2020 et du 18/03/2019 au 18/04/2019. Le centre 1 est un service adulte généraliste à orientation otologique. Le centre 2 est un service adulte généraliste à orientation cancérologique. Le 3^e centre est exclusivement pédiatrique. Une analyse comparative de la baisse de l’activité chirurgicale a été effectuée entre 2019 et 2020.

Objectif

Analyser la baisse de l’activité chirurgicale.

Résultats

Les 3 centres ont opéré 540 patients en 2019, versus 89 en 2020, soit une baisse de 84 %. Cette diminution est de 89 % dans le centre 1, de 61 % dans le centre 2, et 95 % dans le centre pédiatrique. L’activité otologique a baissé de 97 %, endonasale de 91 %, cervicale de 54 %, plastique de 82 %, et transorale de 85 %. Le nombre de chirurgies pour cancer cutané a diminué (24 contre 9), alors que le nombre total de cervicotomies pour cancer est resté stable (18 contre 22). Le nombre de trachéotomies programmées est passé de 8 à 22.

Conclusion

Le nombre d’interventions chirurgicales en ORL a chuté de 84 % pendant le premier mois de l’épidémie de la COVID-19. Cette baisse d’activité est principalement aux dépens de la chirurgie fonctionnelle. L’activité oncologique a pu être préservée. Les structures hospitalières devront absorber un surplus d’activité majeur lors de l’après-crise.

Impact of the COVID-19 epidemic on ENT surgical volume

Purpose

The purpose of this study was to assess the impact of the COVID-19 pandemic on the surgical volume of three ENT departments in Ile-de-France, a region severely affected by the epidemic.

Materials and methods

The number and nature of surgeries was collected from three university hospital ENT departments from 17/03/2020 to 17/04/2020 and from 18/03/2019 to 18/04/2019. Centre 1 is a general adult ENT department specialized in otology, centre 2 is a general adult ENT department specialized in cancer and centre 3 is a paediatric ENT department. Comparative analysis of the decreased surgical volume was conducted between 2019 and 2020.

Objective

To analyse the reduction of ENT surgical volume.

Results

The three centres operated on 540 patients in 2019, versus 89 in 2020, i.e. an 84% decrease: 89% in Centre 1, 61% in Centre 2, and 95% in the paediatric centre. Otological surgery decreased by 97%, endonasal surgery decreased by 91%, head and neck surgery decreased by 54%, plastic surgery decreased by 82%, and transoral surgery decreased by 85%. The number of surgical operations for skin cancer decreased (24 vs. 9), while the total number of head and neck cancer surgeries remained stable (18 vs. 22). The number of planned tracheostomies increased from 8 to 22.

Conclusion

The number of ENT surgeries decreased by 84% during the first month of the COVID-19 epidemic. This decreased surgical volume mainly concerned functional surgery, while the level of cancer surgery remained stable. Hospital units will need to absorb a marked excess surgical volume after the epidemic.

Misconceptions About Negative Pressure Rooms and Their Impact Aboard USNS Comfort in New York City

The outbreak of novel coronavirus disease 2019 (COVID-19) has had a momentous impact on the field of otolaryngology due to the high number of aerosol-generating procedures involving the upper aerodigestive tract. These procedures bear significant risk to the provider and clinical environment due to the possibility of viral aerosolization. While significant attention has been appropriately paid to personal protective equipment during this pandemic, an understanding of industrial hygiene is also necessary for the safe delivery of health care to mitigate the risk of exposure to other patients and health care workers. We provide a review of air ventilation practices and their role in reducing pathogen spread. In addition, we share our experiences with effectively treating COVID-19-positive patients aboard the USNS Comfort through proper environment control measures.