Outcomes After Tracheostomy in COVID-19 Patients

Optimal Timing of Tracheostomy in the Setting of COVID-19 and Associated Pneumothorax

Introduction At the beginning of the 2020 pandemic, no criteria were in place regarding the timing of tracheostomy placement in intubated COVID-19 patients, nor were there any data pertaining to pneumothorax incidence in this population. This study examines the timing of tracheostomy placement and its correlation with patient outcomes, along with pneumothorax incidence in COVID-19 patients who underwent a tracheostomy.  Methods We performed a multi-institutional retrospective study of intubated COVID-19 patients admitted to intensive care units (ICUs) in North and South Dakota between April 2020 and December 2020. The timing of the tracheostomy was assessed, with primary outcomes being mortality, successful ventilator weaning, discharge to a long-term care facility, and overall length of stay. Patients were grouped by age, gender, ethnicity, and comorbidities. Pre- and post-tracheostomy pneumothorax was extracted from this dataset. Results We identified 85 patients who were intubated with COVID-19 and underwent a tracheostomy. The timing of tracheostomy varied widely, ranging from five to 53 days with an average time to tracheostomy being 17.3 days. Thirty-four of the patients expired, 32 patients were discharged to a long-term care hospital (LTCH), and 11 patients were discharged to an inpatient rehabilitation facility. Only three patients were discharged home. Regression analysis did not reveal statistically significant differences between patients who survived (N = 51) and patients who expired (N = 34) for almost all variables analyzed. Sixteen of the 85 patients were diagnosed with pneumothorax during their hospital stay. Half of these patients were diagnosed after a tracheostomy was placed. Conclusion This study did not demonstrate statistically significant differences in overall mortality or incidence of pneumothorax when it pertains to the timing of placement of tracheostomy. Variation in mortality was identified, in which younger patients were more likely to survive than older patients, a finding that was echoed in other studies. Considering this evidence, we cannot conclude that an association between the timing of tracheostomy and mortality from COVID-19; therefore, tracheostomy in the setting of COVID-19 can be performed at the provider's discretion.

The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a chinese tertiary hospital

OBJECTIVES

The timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

One thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital.

METHODS

Tracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death.

RESULTS

In both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT.

CONCLUSIONS

In a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes.

TRIAL REGISTRATION

ChiCTR2100043905. Registered 05 March 2021. http://www.chictr.org.cn/listbycreater.aspx.

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.

TGRA-P: Task-driven model predicts 90-day mortality from ICU clinical notes on mechanical ventilation

BACKGROUND

With the outbreak and spread of COVID-19 worldwide, limited ventilators fail to meet the surging demand for mechanical ventilation in the ICU. Clinical models based on structured data that have been proposed to rationalize ventilator allocation often suffer from poor ductility due to fixed fields and laborious normalization processes. The advent of pre-trained models and downstream fine-tuning methods allows for learning large amounts of unstructured clinical text for different tasks. But the hardware requirements of large-scale pre-trained models and purposeless networks downstream have led to a lack of promotion in the clinical domain.

OBJECTIVE

In this study, an innovative architecture of a task-driven predictive model is proposed and a Task-driven Gated Recurrent Attention Pool model (TGRA-P) is developed based on the architecture. TGRA-P predicts early mortality risk from patients' clinical notes on mechanical ventilation in the ICU, which is used to assist clinicians in diagnosis and decision-making.

METHODS

Specifically, a Task-Specific Embedding Module is proposed to fine-tune the embedding with task labels and save it as static files for downstream calls. It serves the task better and prevents GPU overload. The Gated Recurrent Attention Unit (GRA) is proposed to further enhance the dependency of the information preceding and following the text sequence with fewer parameters. In addition, we propose a Residual Max Pool (RMP) to avoid ignoring words in common text classification tasks by incorporating all word-level features of the notes for prediction. Finally, we use a fully connected decoding network as a classifier to predict the mortality risk.

RESULT

The proposed model shows very promising results with an AUROC of 0.8245±0.0096, an AUPRC of 0.7532±0.0115, an accuracy of 0.7422±0.0028 and F1-score of 0.6612±0.0059 for 90-day mortality prediction using clinical notes of ICU mechanically ventilated patients on the MIMIC-III dataset, all of which are better than previous studies. Moreover, the superiority of the proposed model in comparison with other baseline models is also statistically validated through the calculated Cohen's d effect sizes.

CONCLUSION

The experimental results show that TGRA-P based on the innovative task-driven prognostic architecture obtains state-of-the-art performance. In future work, we will build upon the provided code and investigate its applicability to different datasets. The model balances performance and efficiency, not only reducing the cost of early mortality risk prediction but also assisting physicians in making timely clinical interventions and decisions. By incorporating textual records that are challenging for clinicians to utilize, the model serves as a valuable complement to physicians' judgment, enhancing their decision-making process.

Optimal timing and outcomes among COVID-19 patients undergoing tracheostomy

BACKGROUND

Patients who require mechanical ventilation secondary to severe COVID-19 infection have poor survival. It is unknown if the benefit of tracheostomy extends to COVID-19 patients. If so, what is the optimal timing?

METHODS

Retrospective cohort study within a large hospital system in the United States. The population included patients with COVID-19 from January 1, 2020 to September 30, 2020. In total, 93,918 cases were identified. They were excluded if no intubation or tracheostomy, underwent tracheostomy before intubation, <18 years old, hospice patients before admission, and bacterial pneumonia. In total, 5,911 patients met the criteria. Outcomes between patients who underwent endotracheal intubation only versus tracheostomy were compared. The primary outcome was inpatient mortality. All patients who underwent tracheostomy versus intubation only were compared. Three cohort analysis compared early (<10 days) versus late (>10 days) tracheostomy versus control. Eight cohort analysis compared days 0-2, days 3-6, days 7-10, days 11-14, days 15-18, days 19-22, and days 23+ to tracheostomy versus control.

RESULTS

There was an overall inpatient mortality rate of 37.5% in the tracheostomy cohort compared to 54.4% in the control group (P < .0001). There was an early tracheostomy group inpatient mortality rate of 44.7% (adjusted odds ratio 0.73, 95% confidence interval 0.52-1.01) compared to 33.1% (adjusted odds ratio 0.44, 95% confidence interval 0.34-0.58) in the late tracheostomy group.

CONCLUSION

COVID-19 patients with tracheostomy had a significantly lower mortality rate compared to intubated only. Optimal timing for tracheostomy placement for COVID-19 patients is 11 days or later. Future studies should focus on early tracheostomy patients.

Association between tracheostomy and survival in patients with coronavirus disease 2019 who require prolonged mechanical ventilation for more than 14 days: A multicenter cohort study

OBJECTIVE

Tracheostomy is a common procedure with potential prognostic advantages for patients who require prolonged mechanical ventilation (PMV). Early recommendations for patients with coronavirus disease 2019 (COVID-19) suggested delayed or limited tracheostomy considering the risk for viral transmission to clinicians. However, updated guidelines for tracheostomy with appropriate personal protective equipment have revised its indications. This study aimed to evaluate the association between tracheostomy and prognosis in patients with COVID-19 requiring PMV.

METHODS

This was a multicenter, retrospective cohort study using data from the nationwide Japanese Intensive Care PAtient Database. We included adult patients aged ≥16 years who were admitted to the intensive care unit (ICU) due to COVID-19 and who required PMV (for >14 days or until performance of tracheostomy). The primary outcome was hospital mortality, and the association between implementation of tracheostomy and patient prognosis was assessed using weighted Cox proportional hazards regression analysis with inverse probability of treatment weighting (IPTW) using the propensity score to address confounders.

RESULTS

Between January 2020 and February 2021, 453 patients with COVID-19 were observed. Data from 109 patients who required PMV were analyzed: 66 (60.6%) underwent tracheostomy and 38 (34.9%) died. After adjusting for potential confounders using IPTW, tracheostomy implementation was found to significantly reduce hospital mortality (hazard ratio [HR]: 0.316, 95% confidence interval [CI]: 0.163-0.612). Patients who underwent tracheostomy had a similarly decreased ICU and 28-day mortality (HR: 0.269, 95% CI: 0.124-0.581; HR 0.281, 95% CI: 0.094-0.839, respectively). A sensitivity analysis using different definitions of PMV duration consistently showed reduced mortality in patients who underwent tracheostomy.

CONCLUSION

The implementation of tracheostomy was associated with favorable patient prognosis among patients with COVID-19 requiring PMV. Our findings support proactive tracheostomy in critically ill patients with COVID-19 requiring mechanical ventilation for >14 days.

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.

Utility of Early Tracheostomy in Critically Ill Covid-19 Patients: A Systematic Review

COVID 19 has proven itself to be an agent of cataclysm and caused an uproar worldwide due to consistent strain on the finite resources available to tackle the situation. With the rapidly mutating viral nature, resultant disease is becoming more severe over time, causing significant numbers of critical cases needing invasive ventilatory support. Available literature dictates that tracheostomy might reduce the stress over healthcare infrastructure. Our systematic review is aimed towards understanding the influence of tracheostomy timing, over the course of the illness, by analyzing the relevant literature, thus aiding in decision making while managing critical COVID 19 patients. With predefined inclusion and exclusion criteria, PubMed data was explored using search terms like 'timing', 'tracheotomy'/'tracheostomy' and 'COVID'/'COVID-19'/'SARS CoV2' and 26 articles were finalised for formal review. 26 studies (3527 patients) were systematically reviewed. 60.3% and 39.5% patients underwent percutaneous dilational tracheostomy and open surgical tracheostomy respectively. We report 7.62%, 21.3%, 56% and 46.53% as approximate estimates, of complication rate, mortality rate, rate of mechanical ventilation weaning and rate of decannulation following tracheostomy in COVID 19 patients, respectively taking into account underestimation of the data. Provided that appropriate preventive measures and safety guidelines are strictly followed, moderately early tracheostomy (between 10 and 14 days of intubation) can prove quite efficacious in management of critical COVID 19 patients. Also, early tracheostomy was associated with early weaning and decannulation, thus reducing the enormous competition for intensive care unit beds.

Percutaneous Dilatational Tracheostomy in Patients with COVID-19 Supported by Extracorporeal Membrane Oxygenation

Background

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 can cause acute respiratory distress syndrome, often requiring prolonged mechanical ventilation and eventually tracheostomy. Both procedures occur in isolation units where personal protective equipment is needed. Additionally, the high bleeding risk in patients with extracorporeal membrane oxygenation (ECMO) places a great strain on surgeons. We investigated the clinical characteristics and outcomes of percutaneous dilatational tracheostomy (PDT) in patients with coronavirus disease 2019 (COVID-19) supported by ECMO, and compared the outcomes of patients with and without ECMO.

Methods

This retrospective, single-center, observational study included patients with severe COVID-19 who underwent elective PDT (n=29) from April 1, 2020, to October 31, 2021. The patients were divided into ECMO and non-ECMO groups. Data were collected from electronic medical records at Ajou University Hospital in Suwon, Korea.

Results

Twenty-nine COVID-19 patients underwent PDT (24 men [82.8%] and 5 women [17.2%]; median age, 61 years; range, 26-87 years; interquartile range, 54-71 years). The mean procedure time was 17±10.07 minutes. No clinically or statistically significant difference in procedure time was noted between the ECMO and non-ECMO groups (16.35±7.34 vs. 18.25±13.32, p=0.661). Overall, 12 patients (41.4%) had minor complications; 10 had mild subdermal bleeding from the skin incision, which was resolved with local gauze packing, and 2 (6.9%) had dislodgement. No healthcare provider infection was reported.

Conclusion

Our PDT approach is safe for patients and healthcare providers. With bronchoscopy assistance, PDT can be performed quickly and easily even in isolation units and with acceptable risk, regardless of the hypo-coagulable condition of patients on ECMO.

Good outcome of tracheostomy in a COVID-19 child with Joubert syndrome-Case report

Pediatric tracheostomy in COVID-19 patients is a rarity. Joubert syndrome is a rare genetic disease, involving a lack of muscle control. We report the case of a child with Joubert syndrome and a severe form of COVID-19 infection, in whom we performed tracheostomy in order to replace prolonged intubation and mechanical ventilation; successful decannulation was performed after 12 months. Successful decannulation is still possible in a child with severe comorbidities (Joubert syndrome) even if it might take much longer than in patients without comorbidities.

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.

Bleeding Hazard of Percutaneous Tracheostomy in COVID-19 Patients Supported With Venovenous Extracorporeal Membrane Oxygenation: A Case Series

OBJECTIVES

Tracheostomy usually is performed to aid weaning from mechanical ventilation and facilitate rehabilitation and secretion clearance. Little is known about the safety of percutaneous tracheostomy in patients with severe COVID-19 supported on venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to investigate the bleeding risk of bedside percutaneous tracheostomy in patients with COVID-19 infection supported with VV-ECMO.

DESIGN

A Retrospective review of electronic data for routine care of patients on ECMO.

SETTING

Tertiary, university-affiliated national ECMO center.

PARTICIPANTS

Patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support.

INTERVENTIONS

No intervention was conducted during this study.

MEASUREMENTS AND MAIN RESULTS

Electronic medical records of 16 confirmed patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support, including patient demographics, severity of illness, clinical variables, procedural complications, and outcomes, were compared with 16 non-COVID-19 patients. The SPSS statistical software was used for statistical analysis. The demographic data were compared using the chi-square test, and normality assumption was tested using the Shapiro-Wilk test. The indications for tracheostomy in all the patients were prolonged mechanical ventilation and sedation management. None of the patients suffered a life-threatening procedural complication within 48 hours. Moderate-to-severe bleeding was similar in both groups. There was no difference in 30- and 90-days mortality between both groups. As per routine screening results, none of the staff involved contracted COVID-19 infection.

CONCLUSIONS

In this case series, percutaneous tracheostomy during VV-ECMO in patients with COVID-19 appeared to be safe and did not pose additional risks to patients or healthcare workers.

Clinical outcomes after tracheostomy in patients with coronavirus disease 2019: a single-center experience in Japan

PURPOSE

Many patients with coronavirus disease 2019 require mechanical ventilation and tracheostomy. However, the timing and indications for tracheostomy are controversial. This study assessed 11 patients with coronavirus disease 2019 who underwent tracheostomy with clinical information and retrospective analyses.

METHODS

A single-center retrospective observational study was performed on patients with coronavirus disease 2019 who underwent tracheostomy between 2020 and 2021.

RESULTS

Failure to wean was the most common indication for tracheostomy, followed by extracorporeal membrane oxygenation decannulation and the need for secretion management. After tracheostomy, six patients (54.5%) were liberated from the ventilator. The time from intubation to tracheostomy (21.1 ± 9.14 days) was correlated with the duration of ventilator dependency (36.83 ± 20.45 days, r² = 0.792, p = 0.018). The mean Acute Physiological and Chronic Health Evaluation II score was significantly lower in the ventilator-liberated group (23 ± 2.77) than in the non-ventilator-liberated group (31 ± 6.13, p = 0.0292). Furthermore, patients with Acute Physiological and Chronic Health Evaluation II scores of < 27 points achieved ventilator liberation and a long-term survival (p = 0.0006).

CONCLUSIONS

This study describes the outcomes of a cohort of patients who underwent tracheostomy after intubation for coronavirus disease 2019. The Acute Physiological and Chronic Health Evaluation II score predicted whether or not the patient could achieve ventilator liberation.

Outcomes of Percutaneous Tracheostomy for Patients With SARS-CoV-2 Respiratory Failure

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause severe respiratory failure leading to prolonged mechanical ventilation. Data are just emerging about the practice and outcomes of tracheostomy in these patients. We reviewed our experience with tracheostomies for SARS-CoV-2.

METHODS

We retrospectively reviewed the demographics, comorbidities, timing of mechanical ventilation, tracheostomy, and intensive care unit and hospital lengths of stay in SARS-CoV-2 patients who received tracheostomies performed by the interventional pulmonary team. A tertiary care, teaching hospital in Chicago, Illinois. From March 2020 to April 2021, our center had 473 patients intubated for SARS-CoV-2, and 72 (15%) had percutaneous bedside tracheostomy performed by the interventional pulmonary team.

RESULTS

Median time from intubation to tracheostomy was 20 (interquartile range: 16 to 25) days. Demographics and comorbidities were similar between early and late tracheostomy, but early tracheostomy was associated with shorter intensive care unit lengths of stay and a shorter total duration of ventilation. To date, 39 (54%) patients have been decannulated, 17 (24%) before hospital discharge; median time to decannulation was 22 (IQR: 18 to 36) days. Patients that were decannulated were younger (56 vs. 69 y). The rate of decannulation for survivors was 82%. No providers developed symptoms or tested positive for SARS-CoV-2.

CONCLUSION

Tracheostomy enhances care for patients with prolonged respiratory failure from SARS-CoV-2 since early tracheostomy is associated with shorter duration of critical care, and decannulation rates are high for survivors. It furthermore appears safe for both patients and operators.

COVID-19 Tracheostomy Outcomes

OBJECTIVES

(1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration, overall length of stay (LOS), and intensive care unit (ICU) LOS for patients with COVID-19.

STUDY DESIGN

Case series with planned chart review.

SETTING

Single-institution tertiary care center.

METHODS

Patients with COVID-19 who were ≥18 years old and requiring invasive positive pressure ventilation (IPPV) met inclusion criteria. Patients were stratified into 2 cohorts: IPPV with tracheostomy and IPPV with intubation only. Cohorts were analyzed for the following primary outcome measures: mortality, LOS, ICU LOS, and IPPV duration.

RESULTS

An overall 258 patients with IPPV met inclusion criteria: 46 (18%) with tracheostomy and 212 (82%) without (66% male; median age, 63 years [interquartile range, 18.75]). Average LOS, time in ICU, and time receiving IPPV were longer in the tracheostomy cohort (P < .01). Ability to wean from IPPV was similar between cohorts (P > .05). The number of deaths in the nontracheostomy cohort (54%) was significantly higher than the tracheostomy cohort (29%, P < .01).

CONCLUSIONS

While tracheostomy placement in patients with COVID-19 did not shorten overall LOS, mechanical ventilation duration, or ICU LOS, patients with a tracheostomy experienced a significantly lower number of deaths vs those without. One goal for tracheostomy is improved pulmonary toilet with associated shortened IPPV requirements. Our study did not identify this advantage among the COVID-19 population. However, this study demonstrates that the need for tracheostomy in the COVID-19 setting does not portent a poor prognostic factor, as patients with a tracheostomy experienced a significantly higher survival rate than their nontracheostomy counterparts.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study

Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation).

DESIGN

International multi-institute retrospective cohort study.

SETTING

Thirteen hospitals in Bolivia, Brazil, Spain, and the United States.

PATIENTS

Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified.

CONCLUSIONS

COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Open Surgical Tracheostomy in COVID 19 Patients and Their Outcomes During the Second Wave in India: Experience at a Tertiary Referral Centre

Tracheostomy in COVID-19 is a debatable topic, with guidelines and recommendations evolving with every wave. Tracheostomy can help early weaning and potentially increase the availability of ICU beds. The aim of our study was to determine the outcomes of patients undergoing tracheostomy at different timings. This was an ambispective observational descriptive longitudinal study of patients confirmed to have COVID-19 by real- time reverse transcriptase polymerase chain reaction (RT-PCR) admitted in the ICU and needed intubation for mechanical ventilation and underwent tracheostomy at a tertiary referral centre. This study was over a period of two months from May to June 2021. A total of 169 patients were admitted to the ICU for COVID-19 from May to June 2021 out of which 27 patients underwent open surgical tracheostomy. Study included almost equal number of male and female patients. The most frequent comorbidities were hypertension and diabetes. The majority of patients were between 5th and 7th decades of life (59.2%; 16 patients). The common indications for tracheostomy were acute respiratory distress syndrome, failure to wean from ventilation, sedation management, difficult airway, and persistent airway oedema. Five patients (18.5%) underwent tracheostomy on day 8, the maximum number on a single day. The earliest tracheostomy was done on day 3 and the latest on day 17 with variable results. There were 6 survivors out of 27, youngest being a 27-year-old female and oldest a 60-year-old male. Our study showed that there was no association of age, sex of the patients and presence of comorbid conditions with the timing of intubation. Clinical outcome of the patients also was not affected by the any of the socio clinical variables viz. age, sex of the patient, presence of comorbid conditions and timing of intubation. Tracheostomy in COVID-19 is an aerosol generating procedure; strict recommendations and guidelines need to be followed.

COVID-19 Transmission to Health Care Personnel During Tracheostomy Under a Multidisciplinary Safety Protocol

BACKGROUND

Tracheostomies are highly aerosolizing procedures yet are often indicated in patients with COVID-19 who require prolonged intubation. Robust investigations of the safety of tracheostomy protocols and provider adherence and evaluations are limited.

OBJECTIVES

To determine the rate of COVID-19 infection of health care personnel involved in COVID-19 tracheostomies under a multidisciplinary safety protocol and to investigate health care personnel's attitudes and suggested areas for improvement concerning the protocol.

METHODS

All health care personnel involved in tracheostomies in COVID-19-positive patients from April 9 through July 11, 2020, were sent a 22-item electronic survey.

RESULTS

Among 107 health care personnel (80.5%) who responded to the survey, 5 reported a positive COVID-19 test result (n = 2) or symptoms of COVID-19 (n = 3) within 21 days of the tracheostomy. Respondents reported 100% adherence to use of adequate personal protective equipment. Most (91%) were familiar with the tracheostomy protocol and felt safe (92%) while performing tracheostomy. Suggested improvements included creating dedicated tracheostomy teams and increasing provider choices surrounding personal protective equipment.

CONCLUSIONS

Multidisciplinary engagement in the development and implementation of a COVID-19 tracheostomy protocol is associated with acceptable safety for all members of the care team.

What Have We Learned About Transmission of COVID-19: Implications for PFT and Pulmonary Procedures

Because of the potential for high aerosol transmission during pulmonary function testing and pulmonary procedures, performing these tests and procedures must be considered carefully during the coronavirus disease-2019 (COVID-19) pandemic. Much has been learned about the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by aerosols and the potential for such transmission through pulmonary function tests and pulmonary procedures, and subsequently preventative practices have been enhanced and developed to reduce the risk of transmission of virus to patients and personnel. This article reviews what is known about the potential for transmission of SARS-CoV-2 during pulmonary function testing and pulmonary procedures and the recommended mitigation steps to prevent the spread of COVID-19.

A 30-day Survival and Safety of Percutaneous Tracheostomy in Moderate-to-severe COVID-19 Pneumonia Patients: A Single-center Experience

Aims and objectives

In coronavirus disease-2019 (COVID-19) pneumonia, guidelines on timing and method of tracheostomy are evolving. The aim of the study was to analyze the outcomes of moderate-to-severe COVID-19 pneumonia patients who required tracheostomy and the safety with regard to the risk of transmission to the healthcare workers.

Materials and methods

We retrospectively analyzed 30-day survival outcome of a total of 70 moderate-to-severe COVID-19 pneumonia patients on a ventilator, wherein tracheostomy was performed only in 28 (tracheostomy group), and the remaining were with endotracheal intubation beyond 7 days (non-tracheostomy group). Besides demographics, comorbidities and clinical data including 30-day survival and complications of tracheostomy were analyzed in both groups with respect to the timing of tracheostomy from the day of intubation. Healthcare workers were monitored for COVID-19 symptoms by carrying out periodical COVID tests.

Results

The 30-day survival of the tracheostomy group was 75% as compared to 26.2% of the non-tracheostomy group. The majority of the patients (71.4%) had severe disease with PaO₂/FiO₂ (P/F ratio) <100. The first wave showed an 80% (4/5) while the second wave 100% (8/8) thirty days survival in the tracheostomy group performed before 13 days. All patients during the second wave underwent tracheostomy before 13 days with a median of 12th day from the day of intubation. These tracheostomies were performed percutaneously at the bedside, without any major complications and no transmission of disease to healthcare workers.

Conclusion

Early percutaneous tracheostomy within 13 days of intubation demonstrated a good 30-day survival rate in severe COVID-19 pneumonia patients.

How to cite this article

Shah M, Bhatuka N, Shalia K, Patel M. A 30-day Survival and Safety of Percutaneous Tracheostomy in Moderate-to-severe COVID-19 Pneumonia Patients: A Single-center Experience. Indian J Crit Care Med 2022;26(10):1120-1125.

Tracheostomy Practices and Outcomes in Patients With COVID-19 Supported by Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry

OBJECTIVES

The use of extracorporeal membrane oxygenation (ECMO) in patients with COVID-19 has been supported by major healthcare organizations, yet the role of specific management strategies during ECMO requires further study. We sought to characterize tracheostomy practices, complications, and outcomes in ECMO-supported patients with acute respiratory failure related to COVID-19.

DESIGN

Retrospective cohort study.

SETTING

ECMO centers contributing to the Extracorporeal Life Support Organization Registry.

PATIENTS

Patients 16 years or older receiving venovenous ECMO for respiratory support for: 1) COVID-19 in 2020 and 2021 (through October 2021) and 2) pre-COVID-19 viral pneumonia in 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 7,047 patients who received ECMO support for acute respiratory failure related to COVID-19. A total of 32% of patients were recorded as having a tracheostomy procedure during ECMO, and 51% had a tracheostomy at some point during hospitalization. The frequency of tracheostomy was similar in pre-COVID-19 viral pneumonia, but tracheostomies were performed 3 days earlier compared with patients with COVID-19 (median 6.7 d [interquartile range [IQR], 3.0-12.0 d] vs 10.0 d [IQR, 5.0-16.5 d]; p < 0.001). More patients were mobilized with pre-COVID-19 viral pneumonia, but receipt of a tracheostomy during ECMO was associated with increased mobilization in both cohorts. More bleeding complications occurred in patients who received a tracheostomy, with 9% of patients with COVID-19 who received a tracheostomy reported as having surgical site bleeding.

CONCLUSIONS

Tracheostomies are performed in COVID-19 patients receiving ECMO at rates similar to practices in pre-COVID-19 viral pneumonia, although later during the course of ECMO. Receipt of a tracheostomy was associated with increased patient mobilization. Overall mortality was similar between those who did and did not receive a tracheostomy.

Quality tracheotomy care can be maintained for non-COVID patients during the COVID-19 pandemic

Objectives

To analyze changes in tracheotomy practices at the onset of the COVID-19 pandemic, and determine if quality patient care was maintained.

Methods

This was a single institution retrospective study that included patients undergoing tracheotomy from May 2019 to January 2021. Patients were divided into two groups, pre-COVID and post-COVID. Only three patients tested positive for COVID-19, and they were excluded from the study. Data were collected from the electronic medical record. Statistical analyses were performed using 2-tailed independent t tests, Wilcoxon Rank Sum tests, Chi-Square tests, and Kaplan-Meier curves.

Results

There were 118 patients in the pre-COVID group and 91 patients in the post-COVID group. The main indication for tracheotomy in both groups was prolonged intubation. There were no significant differences in overall length of stay, time to tracheotomy, duration of tracheotomy procedure, or time to initial tracheotomy change between the two groups. Due to protocols implemented at our institution to limit viral transmission, there were significant increases in the percent of tracheotomies performed in the OR (p = .02), and those performed via open technique (p = .04). Additionally, the median time to decannulation significantly decreased in the post-COVID group (p = .02).

Conclusion

Several variables regarding the timing of patient care showed no significant differences between groups which demonstrates that quality patient care was maintained. It is important to note that this data was collected early in the Pandemic, and additional trends may become apparent over time.

Level of evidence

4.

Special Procedures for Pulmonary Disease in the Emergency Department

In the emergency department, there are infrequent but essential procedures related to pulmonary diseases that emergency physicians must be able to perform. These include thoracentesis, chest tube thoracostomy, tracheostomy manipulation, and fiberoptic intubation.

Tracheostomy outcomes in critically ill COVID-19 patients: a systematic review, meta-analysis, and meta-regression

Background

We performed a systematic review of mechanically ventilated patients with COVID-19, which analysed the effect of tracheostomy timing and technique (surgical vs percutaneous) on mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), decannulation from tracheostomy, duration of mechanical ventilation, and complications.

Methods

Four databases were screened between January 1, 2020 and January 10, 2022 (PubMed, Embase, Scopus, and Cochrane). Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Population or Problem, Intervention or exposure, Comparison, and Outcome (PICO) guidelines. Meta-analysis and meta-regression for main outcomes were performed.

Results

The search yielded 9024 potentially relevant studies, of which 47 (n=5268 patients) were included. High levels of between-study heterogeneity were observed across study outcomes. The pooled mean tracheostomy timing was 16.5 days (95% confidence interval [CI]: 14.7–18.4; I²=99.6%). Pooled mortality was 22.1% (95% CI: 18.7–25.5; I²=89.0%). Meta-regression did not show significant associations between mortality and tracheostomy timing, mechanical ventilation duration, time to decannulation, and tracheostomy technique. Pooled mean estimates for ICU and hospital LOS were 29.6 (95% CI: 24.0–35.2; I²=98.6%) and 38.8 (95% CI: 32.1–45.6; I²=95.7%) days, both associated with mechanical ventilation duration (coefficient 0.8 [95% CI: 0.2–1.4], P=0.02 and 0.9 [95% CI: 0.4–1.4], P=0.01, respectively) but not tracheostomy timing. Data were insufficient to assess tracheostomy technique on LOS. Duration of mechanical ventilation was 23.4 days (95% CI: 19.2–27.7; I²=99.3%), not associated with tracheostomy timing. Data were insufficient to assess the effect of tracheostomy technique on mechanical ventilation duration. Time to decannulation was 23.8 days (95% CI: 19.7–27.8; I²=98.7%), not influenced by tracheostomy timing or technique. The most common complications were stoma infection, ulcers or necrosis, and bleeding.

Conclusions

In patients with COVID-19 requiring tracheostomy, the timing and technique of tracheostomy did not clearly impact on patient outcomes.

Systematic Review Protocol

PROSPERO CRD42021272220.

Design of a Classifier to Determine the Optimal Moment of Weaning of Patients undergoing to the T-tube Test

Weaning from mechanical ventilation in the intensive care unit is a complex and relevant clinical problem. Prolonged mechanical ventilation leads to a variety of medical complications that increase hospital stay and costs, in addition to contributing the morbidity and mortality, affecting long-term quality of life. This work presents a methodology to establish the optimal moment of extubation of a patient connected to a mechanical ventilator, submitted to the T-Tube test. 133 patients are analyzed, classified into two groups: successful group (94 patients) and failed group (39 patients). The behaviour of the respiratory function is characterized through the mean, standard deviation, kurtosis, skewness, interquartile range and coefficient of interval of the respiratory flow time series. To classify these patients, neural networks (NN) and support vector machines (SVM) classifier are used, considering time intervals of the 450s, 600s and 900s. According to the results, the best classification is obtained using the SVM. Clinical Relevance-The paper determines the optimal moment for weaning a patient connected to a mechanical ventilator using machine learning techniques.

A Cost-Utility Analysis of Remote Pulse-Oximetry Monitoring of Patients With COVID-19

OBJECTIVES

Since 2020, COVID-19 has infected tens of millions and caused hundreds of thousands of fatalities in the United States. Infection waves lead to increased emergency department utilization and critical care admission for patients with respiratory distress. Although many individuals develop symptoms necessitating a ventilator, some patients with COVID-19 can remain at home to mitigate hospital overcrowding. Remote pulse-oximetry (pulse-ox) monitoring of moderately ill patients with COVID-19 can be used to monitor symptom escalation and trigger hospital visits, as needed.

METHODS

We analyzed the cost-utility of remote pulse-ox monitoring using a Markov model with a 3-week time horizon and daily cycles from a US health sector perspective. Costs (US dollar 2020) and outcomes were derived from the University Hospitals' real-world evidence and published literature. Costs and quality-adjusted life-years (QALYs) were used to determine the incremental cost-effectiveness ratio at a cost-effectiveness threshold of $100 000 per QALY. We assessed model uncertainty using univariate and probabilistic sensitivity analyses.

RESULTS

Model results demonstrated that remote monitoring dominates current standard care, by reducing costs ($11 472 saved) and improving outcomes (0.013 QALYs gained). There were 87% fewer hospitalizations and 77% fewer deaths among patients with access to remote pulse-ox monitoring. The incremental cost-effectiveness ratio was not sensitive to uncertainty ranges in the model.

CONCLUSIONS

Patient with COVID-19 remote pulse-ox monitoring increases the specificity of those requiring follow-up care for escalating symptoms. We recommend remote monitoring adoption across health systems to economically manage COVID-19 volume surges, maintain patients' comfort, reduce community infection spread, and carefully monitor needs of multiple individuals from one location by trained experts.

Tracheostomy Outcomes in Patients With COVID-19 at a New York City Hospital

Objective

Tracheostomies have been performed in patients with prolonged intubation due to COVID-19. Understanding outcomes in different populations is crucial to tackle future epidemics.

Study Design

Prospective cohort study.

Setting

Tertiary academic medical center in New York City.

Methods

A prospectively collected database of patients with COVID-19 undergoing open tracheostomy between March 2020 and April 2020 was reviewed. Primary endpoints were weaning from the ventilator and from sedation and time to decannulation.

Results

Sixty-six patients underwent tracheostomy. There were 42 males (64%) with an average age of 62 years (range, 23-91). Patients were intubated for a median time of 26 days prior to tracheostomy (interquartile range [IQR], 23-30). The median time to weaning from ventilatory support after tracheostomy was 18 days (IQR, 10-29). Of those sedated at the time of tracheostomy, the median time to discontinuation of sedation was 5 days (IQR, 3-9). Of patients who survived, 39 (69%) were decannulated. Of those decannulated before discharge (n = 39), the median time to decannulation was 36 days (IQR, 27-49) following tracheostomy. The median time from ventilator liberation to decannulation was 14 days (IQR, 8-22). Thirteen patients (20.0%) had minor bleeding requiring packing. Two patients (3%) had bleeding requiring neck exploration. The all-cause mortality rate was 10.6%. No patients died of procedural causes, and no surgeons acquired COVID-19.

Conclusion

Open tracheostomies were successfully and safely performed at our institution in the peak of the COVID-19 pandemic. The majority of patients were successfully weaned from the ventilator and sedation. Approximately 60% of patients were decannulated prior to hospital discharge.

ICU tracheotomies in patients with COVID-19: a lesson learned for future viral pandemic

INTRODUCTION

The coronavirus SARS-CoV-2 pandemic has resulted in a large number of patients requiring intubation and prolonged mechanical ventilation. The current knowledge on the tracheotomies regarding the time form intubation, method and ventilatory parameters optimal for their performance in the mechanically ventilated patients with COVID ARDS are scarce; thus, the aim of this study is to present new data regarding their safety, adverse events and timing.

MATERIALS AND METHODS

This retrospective observational study is based on the data of 66 critically ill COVID patients including demographic data, timing and technique of tracheotomy, ventilatory parameters in the time of procedure, as well as complication and survival rate.

RESULTS

A number of 66 patients with COVID-related pneumonia were included in the study, among whom 32 were tracheotomized-25 patients underwent an early tracheotomy and 7 patients had late tracheotomy. The median duration of mechanical ventilation before the tracheotomy in the early group was 8 days (IQR 6-10) compared to 11 days (IQR 11-12.5.) p < 0.001) in late group. Risk of death in tracheotomy patients was significantly growing with growing level of PEEP and FiO2 at the moment of decision on tracheotomy, OR = 1.91 CI₉₅ (1.23;3.57); p = 0.014 and OR = 1.18 CI₉₅(1.03;1.43); p = 0.048, respectively.

CONCLUSION

Early percutaneous tracheotomy is safe (both in terms of risk of viral transmission and complication rate) and feasible in COVID-19 patients. Stability of gas exchange, and ventilatory parameters are the main prognostic factors of the outcome.

Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis

BACKGROUND

A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated.

OBJECTIVES

To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients.

METHODS

Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021.

RESULTS

Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups.

CONCLUSIONS

Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.

Nine-month outcomes of tracheostomy in patients with COVID-19: A retrospective study

PURPOSE

The outcome of performing a tracheostomy in patients with coronavirus disease (COVID-19) seems promising based on the reported 30-day survival rate. However, long-term outcomes are still lacking. Therefore, our aim in this study was to evaluate the long-term outcomes of tracheostomy performed in critically ill COVID-19 patients.

METHODS

This was a retrospective analysis of 27 COVID-19 patients on whom tracheostomy was performed between February 28, 2020, and April 7, 2020, at Tongji Hospital (Wuhan, China). Patients' clinical characteristics, complications, and outcomes were analyzed.

RESULTS

All patients underwent successful bedside tracheostomy. Thirteen patients (48.1%) were successfully weaned off ventilation within 1 month. The survival rate at one, three, and nine months after tracheostomy were 63.0%, 37.0%, and 29.6%, respectively. At nine months after tracheostomy, 8/27 patients had survived, with five (62.5%) being discharged home while the remaining were dependent on nursing care.

CONCLUSION

The survival rate of COVID-19 patients who underwent tracheotomy decreased markedly from 1 to 3 months after tracheotomy, remaining stable between 3 and 9 months. Medical support is much needed for COVID-19 patients over the first 90 days after tracheotomy.

Extracorporeal membrane oxygenation for respiratory failure in phases of COVID-19 variants

Background

Adaptive mutations of the severe acute respiratory syndrome‐related coronavirus (SARS‐CoV‐2) virus have emerged throughout the coronavirus disease 2019 (COVID‐19) pandemic. The characterization of outcomes in patients requiring extracorporeal membrane oxygenation (ECMO) for severe respiratory distress from COVID‐19 during the peak prevalence of different variants is not well known.

Methods

There were 131 patients with laboratory‐confirmed SARS‐CoV‐2 infection supported by ECMO at two referral centers within a large healthcare system. Three predominant variant phase time windows (Pre‐Alpha, Alpha, and Delta) were determined by a change‐point analyzer based on random population sampling and viral genome sequencing. Patient demographics and outcomes were compared.

Results

The average age of patients was 46.9 ± 10.5 years and 70.2% (92/131) were male. Patients cannulated for ECMO during the Delta variant wave were younger compared to earlier Pre‐Alpha (39.3 ± 7.8 vs. 48.0 ± 11.1 years) and Alpha phases (39.3 ± 7.8 vs. 47.2 ± 7.7 years) (p < .01). The predominantly affected race in the Pre‐Alpha phase was Hispanic (52.2%; 47/90), while in Alpha (61.5%; 16/26) and Delta (40%; 6/15) variant waves, most patients were White (p < .01). Most patients received a tracheostomy (82.4%; 108/131) with a trend toward early intervention in later phases compared to Pre‐Alpha (p < .01). There was no significant difference between the duration of ECMO, mechanical support, intensive care unit (ICU) length of stay (LOS), or hospital LOS over the three variant phases. The in‐hospital mortality was overall 41.5% (54/131) and was also similar. Six‐month survival of patients who survived to discharge was 92.2% (71/77).

Conclusions

There was no significant difference in survival or time on ECMO support in patients during the peak prevalence of the three variants.

Characteristics, complications, and a comparison between early and late tracheostomy: A retrospective observational study on tracheostomy in patients with COVID‐19‐related acute respiratory distress syndrome

Background and Aims

As the coronavirus disease 2019 (COVID-19) pandemic spread worldwide in 2020, the number of patients requiring intensive care and invasive mechanical ventilation (IMV) has increased rapidly. During the pandemic, early recommendations suggested that tracheostomy should be postponed, as the potential benefits were not certain to exceed the risk of viral transmission to healthcare workers. The aim of this study was to assess the utility of tracheostomy in patients with COVID-19-related acute respiratory distress syndrome, in terms of patient and clinical characteristics, outcomes, and complications, by comparing between early and late tracheostomy.

Methods

A multicenter, retrospective observational study was conducted in Jönköping County, Sweden. Between 14 March 2020 and 13 March 2021, 117 patients were included. All patients ≥18 years of age with confirmed COVID-19, who underwent tracheostomy were divided into two groups based on the timing of the procedure (≤/>7 days). Outcomes including the time on IMV, intensive care unit (ICU) length of stay, and mortality 30 days after ICU admission, as well as complications due to tracheostomy were compared between the groups.

Results

Early tracheostomy (<7 days, n = 56) was associated with a shorter median duration of mechanical ventilation (7 [12], p = 0.001) as well as a shorter median ICU stay (8 [14], p = 0.001). The most frequent complication of tracheostomy was minor bleeding. With the exception of a higher rate of obesity in the group receiving late tracheostomy, the patient characteristics were similar between the groups.

Conclusion

This study showed that early tracheostomy was safe and associated with a shorter time on IMV as well as a shorter ICU length of stay, implicating possible clinical benefits in critically ill COVID-19 patients. However, it is necessary to verify these findings in a randomized controlled trial.

Extracorporeal membrane oxygenation for severe COVID-19-associated acute respiratory distress syndrome in Poland: a multicenter cohort study

Background

In Poland, the clinical characteristics and outcomes of patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) remain unknown. This study aimed to answer these unknowns by analyzing data collected from high-volume ECMO centers willing to participate in this project.

Methods

This retrospective, multicenter cohort study was completed between March 1, 2020, and May 31, 2021 (15 months). Data from all patients treated with ECMO for COVID-19 were analyzed. Pre-ECMO laboratory and treatment data were compared between non-survivors and survivors. Independent predictors for death in the intensive care unit (ICU) were identified.

Results

There were 171 patients admitted to participating centers requiring ECMO for refractory hypoxemia due to COVID-19 during the defined time period. A total of 158 patients (mean age: 46.3 ± 9.8 years) were analyzed, and 13 patients were still requiring ECMO at the end of the observation period. Most patients (88%) were treated after October 1, 2020, 77.8% were transferred to ECMO centers from another facility, and 31% were transferred on extracorporeal life support. The mean duration of ECMO therapy was 18.0 ± 13.5 days. The crude ICU mortality rate was 74.1%. In the group of 41 survivors, 37 patients were successfully weaned from ECMO support and four patients underwent a successful lung transplant. In-hospital death was independently associated with pre-ECMO lactate level (OR 2.10 per 1 mmol/L, p = 0.017) and BMI (OR 1.47 per 5 kg/m², p = 0.050).

Conclusions

The ICU mortality rate among patients requiring ECMO for COVID-19 in Poland was high. In-hospital death was independently associated with increased pre-ECMO lactate levels and BMI.

Percutaneous Tracheostomy in Respiratory Failure Due to COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) can lead to hypoxemic respiratory failure resulting in prolonged mechanical ventilation. Typically, tracheostomy is considered in patients who remain ventilator dependent beyond 2 weeks. However, in the setting of this novel respiratory virus, the safety and benefits of tracheostomy are not well-defined. Our aim is to describe our experience with percutaneous tracheostomy in patients with COVID-19.

MATERIALS AND METHODS

This is a single center retrospective descriptive study. We reviewed comorbidities and outcomes in patients with respiratory failure due to COVID-19 who underwent percutaneous tracheostomy at our institution from April 2020 to September 2020. In addition, we provide details of our attempt to minimize aerosolization by using a modified protocol with brief periods of planned apnea.

RESULTS

A total of 24 patients underwent percutaneous tracheostomy during the study. The average body mass index was 33.0±10.0. At 30 days posttracheostomy 17 (71%) patients still had the tracheostomy tube and 14 (58%) remained ventilator dependent. There were 3 (13%) who died within 30 days. At the time of data analysis in November 2020, 9 (38%) patients had died and 7 (29%) had been decannulated. None of the providers who participated in the procedure experienced signs or symptoms of COVID-19 infection.

CONCLUSION

Percutaneous tracheostomy in prolonged respiratory failure due to COVID-19 appears to be safe to perform at the bedside for both the patient and health care providers in the appropriate clinical context. Morbid obesity did not limit the ability to perform percutaneous tracheostomy in COVID-19 patients.

Pulmonary Procedures in the COVID-19 Era

Purpose of Review

The purpose of this review is to discuss the impact of the COVID-19 pandemic on pulmonary procedures, including new guidelines, restrictions, techniques, and overall effect on patient care.

Recent Findings

SARS-CoV-2 predominately impacts the pulmonary system and can result in a severe lower respiratory tract infection. Early guidelines based largely on data from the SARS epidemic recommended significant restrictions on procedure volume out of concern for healthcare worker safety. Newer data suggests relative safety in performing airway and pleural procedures as long as appropriate precautions are followed and new techniques are utilized. The introduction of effective vaccines and more reliable testing has led to a re-expansion of elective procedures.

Summary

Many guidelines and expert statements exist for the management and practice of pulmonary procedures during the COVID-19 pandemic. A flexible and individualized approach may be necessary as our understanding of COVID-19 continues to evolve.

Long‐term upper aerodigestive sequelae as a result of infection with COVID ‐19

Objectives

Respiratory, voice, and swallowing difficulties after severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) may result secondary to upper airway disease from prolonged intubation or mechanisms related to the virus itself. We examined a cohort who presented with new laryngeal complaints following documented SARS‐CoV‐2 infection. We characterized their voice, airway, and/or swallowing symptoms and reviewed the clinical course of their complaints to understand how the natural history of these symptoms relates to COVID‐19 infections.

Methods

Retrospective review of patients who presented to our department with upper aerodigestive complaints as sequelae of prior infection with, and management of, SARS‐CoV‐2.

Results

Eighty‐one patients met the inclusion criteria. Median age was 54.23 years (±17.36). Most common presenting symptoms were dysphonia (n = 58, 71.6%), dysphagia/odynophagia (n = 16, 19.75%), and sore throat (n = 9, 11.11%). Thirty‐one patients (38.27%) presented after intubation. Mean length of intubation was 16.85 days (range 1–35). Eighteen patients underwent tracheostomy and were decannulated after an average of 70.69 days (range 23–160). Patients with history of intubation were significantly more likely than nonintubated patients to be diagnosed with a granuloma (8 vs. 0, respectively, p < .01). Fifty patients (61.73%) were treated for SARS‐CoV‐2 without requiring intubation and were significantly more likely to be diagnosed with muscle tension dysphonia (19 vs. 1, p < .01) and laryngopharyngeal reflux (18 vs. 1, p < .01).

Conclusion

In patients with persistent dyspnea, dysphonia, or dysphagia after recovering from SARS‐CoV‐2, early otolaryngology consultation should be considered. Accurate diagnosis and prompt management of these common underlying etiologies may improve long‐term patient outcomes.

Level of evidence

4

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%.

Tracheostomy in Mechanically Ventilated Patients With SARS-CoV-2-ARDS: Focus on Tracheomalacia

BACKGROUND

The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. The aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence.

METHODS

This retrospective, single-center study was performed in an Italian teaching hospital. All adult subjects admitted to the ICU between February 24, 2020, and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, whereas information regarding airway management was collected daily.

RESULTS

A total of 151 subjects were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 40%. A tracheostomy was performed in 73 (48%), open surgical technique in 54 (74%), and percutaneous Ciaglia technique in 19 (26%). Subjects who had a tracheostomy performed had, compared to the other subjects, a longer duration of mechanical ventilation and longer ICU and hospital stay. Tracheomalacia was diagnosed in 8 (5%). The factors associated with tracheomalacia were female sex, obesity, and tracheostomy.

CONCLUSIONS

In our population, approximately 50% of subjects with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized subjects had a longer ICU and hospital stay. In our population, 5% were diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature, and the underlying mechanisms are not fully understood.

Tracheostomy Outcomes in COVID-19 Patients in a Low Resource Setting

OBJECTIVES

COVID-19 predominately affects safety net hospitals. Tracheostomies improve outcomes and decrease length of stay for COVID-19 patients. Our objectives are to determine if (1) COVID-19 tracheostomies have similar complication and mortality rates as non-COVID-19 tracheostomies and (2) to determine the effectiveness of our tracheostomy protocol at a safety net hospital.

METHODS

Patients who underwent tracheostomy at Los Angeles County Hospital between August 2009 and August 2020 were included. Demographics, SARS-CoV-2 status, body mass index (BMI), Charlson Co-morbidity Index (CCI), length of intubation, complication rates, decannulation rates, and 30-day all-cause mortality versus tracheostomy related mortality rates were all collected.

RESULTS

Thirty-eight patients with COVID-19 and 130 non-COVID-19 patients underwent tracheostomies. Both groups were predominately male with similar BMI and CCI, though the COVID-19 patients were more likely to be Hispanic and intubated for a longer time (P = .034 and P < .0001, respectively). Both groups also had similar, low intraoperative complications at 2% to 3% and comparable long-term post-operative complications. However, COVID-19 patients had more perioperative complications within 7 days of surgery (P < .01). Specifically, they were more likely to have perioperative bleeding at their tracheostomy sites (P = .03) and long-term post-operative mucus plugging (P < .01). However, both groups had similar 30-day mortality rates. There were no incidences of COVID-19 transmission to healthcare workers.

CONCLUSIONS

COVID-19 tracheostomies are safe for patients and healthcare workers. Careful attention should be paid to suctioning to prevent mucus plugging.

LEVEL OF EVIDENCE

3.

Treatment of acute respiratory distress syndrome from COVID-19 with extracorporeal membrane oxygenation in obstetrical patients

BACKGROUND

Extracorporeal membrane oxygenation therapy has been used as a rescue therapy for patients with severe acute respiratory distress syndrome from COVID-19 who have failed conventional ventilatory strategies. Little is known about the outcome of pregnant and postpartum patients on extracorporeal membrane oxygenation therapy.

OBJECTIVE

To describe the medical and surgical outcomes of pregnant and postpartum patients who were placed on extracorporeal membrane oxygenation therapy for severe acute respiratory distress syndrome from COVID-19.

STUDY DESIGN

A case series reviewing pregnant or postpartum patients with laboratory-confirmed COVID-19 who were placed on extracorporeal membrane oxygenation therapy was conducted within the Baylor Scott & White Healthcare system. The demographics and the medical and surgical outcomes were collected and reviewed.

RESULTS

Between March 2020 and October 2021, 5 pregnant and 5 postpartum women were supported with venovenous extracorporeal membrane oxygenation therapy. The median age was 30 years (interquartile range, 26–33.5) and the median body mass index was 36.6 kg/m² (interquartile range, 29.5–42.0). There was a median of 4.5 days (interquartile range, 1.5–6.8) from admission to any hospital to intubation and 9 days (interquartile range, 7–13) to extracorporeal membrane oxygenation therapy cannulation. One patient had an ischemic stroke, 1 patient had a presumed hemorrhagic stroke, and 9 patients developed bleeding while on extracorporeal membrane oxygenation therapy. Of the 5 pregnant women, 2 patients had intrauterine fetal demise and 3 underwent delivery for maternal hemodynamic instability. The 5 postpartum women were initiated on extracorporeal membrane oxygenation therapy a median of 10 days (interquartile range, 3–11) after delivery. The median length of time on extracorporeal membrane oxygenation therapy was 22 days (interquartile range, 11–31). At the time of the study, there were 2 inpatient mortalities, 6 patients survived to discharge from the extracorporeal membrane oxygenation therapy hospital, and 2 patients were still admitted.

CONCLUSION

There is limited information regarding the use of extracorporeal membrane oxygenation therapy for COVID-19 acute respiratory distress syndrome in obstetrical patients. This case series describes the use of extracorporeal membrane oxygenation therapy and survival in pregnant and postpartum patients with COVID-19.

Timing of tracheostomy in mechanically ventilated COVID-19 patients

According to the World Health Organization as of September 16, 2021, there have been over 226 million documented cases of coronavirus disease 2019 (COVID-19), which has resulted in more than 4.6 million deaths and approximately 14% develop a more severe disease that requires respiratory assistance such as intubation. Early tracheostomy is recommended for patients that are expected to be on prolonged mechanical ventilation; however, supporting data has not yet been provided for early tracheostomies in COVID-19 patients. The aim of this study was to explore established guidelines for performing tracheostomies in patients diagnosed with COVID-19. Factors considered were patient outcomes such as mortality, ventilator-associated pneumonia, intensive care unit length of stay, complications associated with procedures, and risks to healthcare providers that performed tracheostomies. Various observational studies, meta-analyses, and systematic reviews were collected through a PubMed Database search. Additional sources were found through Google. The search was refined to publications in English and between the years of 2003 and 2021. The keywords used were “Coronavirus” and/or “guidelines'' and/or “tracheostomy” and/or “intensive care”. Twenty-three studies were retained. Due to the complex presentation of the respiratory virus COVID-19, previously established guidelines for tracheostomies had to be reevaluated to determine if these guidelines were still applicable to these critically ill ventilated patients. More specifically, medical guidelines state benefits to early tracheostomies in critically ill ventilated non-COVID-19 patients. However, after having conducted this review, the assumptions about the benefits of early tracheostomies in critically ill ventilated patients may not be appropriate for COVID-19 patients.

Indications and Recommendations for Tracheostomy in Trauma Population With COVID-19 Infection: A Review of the Literature

This review explores the current body of evidence pertaining to tracheostomy placement in COVID-19 seropositive patients and summarizes the research by tracheostomy indications, timing, and procedure. Literature review was performed in accordance with the 2020 PRISMA guidelines and includes 12 papers discussing protocols for adult patients seropositive for COVID-19. The studies demonstrated high mortality rates after tracheostomy, especially in geriatric patients, and suggested a multifactorial determination of whether to perform a tracheostomy. There was inconclusive data regarding wait time between testing seropositive, tracheostomy, and weaning off of ventilation. COVID-19 generally reaches highest infectivity between days 9 and 10; furthermore, high early mortality rates seen in COVID-19 may confound mortality implicated by tracheostomy placement. Due to the aerosol-generating nature of tracheostomy placement, management and maintenance, techniques, equipment, and personnel should be carefully considered and altered for COVID-19 patients. With surgical tracheostomy, literature suggested decreased usage of electrocautery; with percutaneous tracheostomy, single-use bronchoscope should be used. The nonemergent exchange of tracheostomy should be done only after the patient tested negative for COVID-19. Placement of tracheostomy should only be considered in COVID-19 patients who are no longer transmissible, with rigorous attention to safety precautions. Understanding procedures for airway maintenance in a respiratory disease like COVID-19 is imperative, especially due to current shortages in ventilators and PPE. However, because of a lack of available data and its likelihood of change as more data emerges, we lack complete guidelines for tracheostomy placement in COVID-19 seropositive patients, and those existing will likely evolve with the disease.

Systematic review and meta-analysis of tracheostomy outcomes in COVID-19 patients

A systematic review and meta-analysis of the entire COVID-19 Tracheostomy cohort was conducted to determine the cumulative incidence of complications, mortality, time to decannulation and ventilatory weaning. Outcomes of surgical versus percutaneous and outcomes relative to tracheostomy timing were also analysed. Studies reporting outcome data on patients with COVID-19 undergoing tracheostomy were identified and screened by 2 independent reviewers. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Outcome data were analysed using a random-effects model. From 1016 unique studies, 39 articles reporting outcomes for a total of 3929 patients were included for meta-analysis. Weighted mean follow-up time was 42.03±26 days post-tracheostomy. Meta-analysis showed that 61.2% of patients were weaned from mechanical ventilation [95%CI 52.6%-69.5%], 44.2% of patients were decannulated [95%CI 33.96%-54.67%], and cumulative mortality was found to be 19.23% [95%CI 15.2%-23.6%] across the entire tracheostomy cohort. The cumulative incidence of complications was 14.24% [95%CI 9.6%-19.6%], with bleeding accounting for 52% of all complications. No difference was found in incidence of mortality (RR1.96; p=0.34), decannulation (RR1.35, p=0.27), complications (RR0.75, p=0.09) and time to decannulation (SMD 0.46, p=0.68) between percutaneous and surgical tracheostomy. Moreover, no difference was found in mortality (RR1.57, p=0.43) between early and late tracheostomy, and timing of tracheostomy did not predict time to decannulation. Ten confirmed nosocomial staff infections were reported from 1398 tracheostomies. This study provides an overview of outcomes of tracheostomy in COVID-19 patients, and contributes to our understanding of tracheostomy decisions in this patient cohort.

Sedation and Analgesia in Patients Undergoing Tracheostomy in COVID-19, a Multi-Center Registry

INTRODUCTION

Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS.

STUDY DESIGN AND METHODS

A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected.

RESULTS

128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012).

INTERPRETATION

This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.

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.

Practice of tracheostomy in patients with acute respiratory failure related to COVID-19 - Insights from the PRoVENT-COVID study

Objective

Invasively ventilated patients with acute respiratory failure related to coronavirus disease 2019 (COVID–19) potentially benefit from tracheostomy. The aim of this study was to determine the practice of tracheostomy during the first wave of the pandemic in 2020 in the Netherlands, to ascertain whether timing of tracheostomy had an association with outcome, and to identify factors that had an association with timing.

Methods

Secondary analysis of the ‘PRactice of VENTilation in COVID–19’ (PRoVENT–COVID) study, a multicenter observational study, conducted from March 1, 2020 through June 1, 2020 in 22 Dutch intensive care units (ICU) in the Netherlands. The primary endpoint was the proportion of patients receiving tracheostomy; secondary endpoints were timing of tracheostomy, duration of ventilation, length of stay in ICU and hospital, mortality, and factors associated with timing.

Results

Of 1023 patients, 189 patients (18.5%) received a tracheostomy at median 21 [17 to 28] days from start of ventilation. Timing was similar before and after online publication of an amendment to the Dutch national guidelines on tracheostomy focusing on COVID–19 patients (21 [17–28] vs. 21 [17–26] days). Tracheostomy performed ≤ 21 days was independently associated with shorter duration of ventilation (median 26 [21 to 32] vs. 40 [34 to 47] days) and higher mortality in ICU (22.1% vs. 10.2%), hospital (26.1% vs. 11.9%) and at day 90 (27.6% vs. 14.6%). There were no patient demographics or ventilation characteristics that had an association with timing of tracheostomy.

Conclusions

Tracheostomy was performed late in COVID–19 patients during the first wave of the pandemic in the Netherlands and timing of tracheostomy possibly had an association with outcome. However, prospective studies are needed to further explore these associations. It remains unknown which factors influenced timing of tracheostomy in COVID–19 patients.

Association Between Caseload Surge and COVID-19 Survival in 558 U.S. Hospitals, March to August 2020

BACKGROUND

Several U.S. hospitals had surges in COVID-19 caseload, but their effect on COVID-19 survival rates remains unclear, especially independent of temporal changes in survival.

OBJECTIVE

To determine the association between hospitals' severity-weighted COVID-19 caseload and COVID-19 mortality risk and identify effect modifiers of this relationship.

DESIGN

Retrospective cohort study. (ClinicalTrials.gov: NCT04688372).

SETTING

558 U.S. hospitals in the Premier Healthcare Database.

PARTICIPANTS

Adult COVID-19-coded inpatients admitted from March to August 2020 with discharge dispositions by October 2020.

MEASUREMENTS

Each hospital-month was stratified by percentile rank on a surge index (a severity-weighted measure of COVID-19 caseload relative to pre-COVID-19 bed capacity). The effect of surge index on risk-adjusted odds ratio (aOR) of in-hospital mortality or discharge to hospice was calculated using hierarchical modeling; interaction by surge attributes was assessed.

RESULTS

Of 144 116 inpatients with COVID-19 at 558 U.S. hospitals, 78 144 (54.2%) were admitted to hospitals in the top surge index decile. Overall, 25 344 (17.6%) died; crude COVID-19 mortality decreased over time across all surge index strata. However, compared with nonsurging (<50th surge index percentile) hospital-months, aORs in the 50th to 75th, 75th to 90th, 90th to 95th, 95th to 99th, and greater than 99th percentiles were 1.11 (95% CI, 1.01 to 1.23), 1.24 (CI, 1.12 to 1.38), 1.42 (CI, 1.27 to 1.60), 1.59 (CI, 1.41 to 1.80), and 2.00 (CI, 1.69 to 2.38), respectively. The surge index was associated with mortality across ward, intensive care unit, and intubated patients. The surge-mortality relationship was stronger in June to August than in March to May (slope difference, 0.10 [CI, 0.033 to 0.16]) despite greater corticosteroid use and more judicious intubation during later and higher-surging months. Nearly 1 in 4 COVID-19 deaths (5868 [CI, 3584 to 8171]; 23.2%) was potentially attributable to hospitals strained by surging caseload.

LIMITATION

Residual confounding.

CONCLUSION

Despite improvements in COVID-19 survival between March and August 2020, surges in hospital COVID-19 caseload remained detrimental to survival and potentially eroded benefits gained from emerging treatments. Bolstering preventive measures and supporting surging hospitals will save many lives.

PRIMARY FUNDING SOURCE

Intramural Research Program of the National Institutes of Health Clinical Center, the National Institute of Allergy and Infectious Diseases, and the National Cancer Institute.