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Kang K, Wang J, Du X, Li N, Jin S, Ji Y, Liu X, Chen P, Yue C, Wu J, Wang X, Tang Y, Lai Q, Lu B, Gao Y, Yu K. A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study. Front Surg 2022; 9:1018637. [PMID: 36386537 PMCID: PMC9649830 DOI: 10.3389/fsurg.2022.1018637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023] Open
Abstract
IMPORTANCE The number of infections and deaths caused by the global epidemic of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) invasion is steadily increasing daily. In the early stages of outbreak, approximately 15%-20% of patients with coronavirus disease 2019 (COVID-19) inevitably developed severe and critically ill forms of the disease, especially elderly patients and those with several or serious comorbidities. These more severe forms of disease mainly manifest as dyspnea, reduced blood oxygen saturation, severe pneumonia, acute respiratory distress syndrome (ARDS), thus requiring prolonged advanced respiratory support, including high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), and invasive mechanical ventilation (IMV). OBJECTIVE This study aimed to propose a safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19. DESIGN This is a single center quality improvement study. PARTICIPANTS Tracheotomy is a necessary and important step in airway management for COVID-19 patients with prolonged endotracheal intubation, IMV, failed extubation, and ventilator dependence. Standardized third-level protection measures and bulky personal protective equipment (PPE) may hugely impede the implementation of tracheotomy, especially when determining the optimal pre-surgical positioning for COVID-19 patients with ambiguous surface position, obesity, short neck or limited neck extension, due to vision impairment, reduced tactile sensation and motility associated with PPE. Consequently, the aim of this study was to propose a safer and more practical tracheotomy, namely percutaneous dilated tracheotomy (PDT) with delayed endotracheal intubation withdrawal under the guidance of bedside ultrasonography without the conventional use of flexible fiberoptic bronchoscopy (FFB), which can accurately determine the optimal pre-surgical positioning, as well as avoid intraoperative damage of the posterior tracheal wall and prevent the occurrence of tracheoesophageal fistula (TEF).
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Affiliation(s)
- Kai Kang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Junfeng Wang
- Department of Ultrasound, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xue Du
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Nana Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Songgen Jin
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuanyuan Ji
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinjia Liu
- Department of Ultrasound, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pengfei Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chuangshi Yue
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jihan Wu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xintong Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yujia Tang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qiqi Lai
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Baitao Lu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yang Gao
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Harbin Medical University, Harbin, China,Institute of Critical Care Medicine, The Sino Russian Medical Research Center of Harbin Medical University, Harbin, China,Correspondence: Yang Gao Kaijiang Yu
| | - Kaijiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China,Institute of Critical Care Medicine, The Sino Russian Medical Research Center of Harbin Medical University, Harbin, China,Key Laboratory of Hepatosplenic Surgery, Ministry of Education, Harbin, China,Key Laboratory of Cell Transplantation, National Health Commission, Harbin, China,Correspondence: Yang Gao Kaijiang Yu
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Sood RN, Palleiko BA, Alape-Moya D, Maxfield MW, Holdorf J, Uy KF. COVID-19 Tracheostomy: Experience in a University Hospital With Intermediate Follow-up. J Intensive Care Med 2021; 36:1507-1512. [PMID: 34713733 PMCID: PMC8600586 DOI: 10.1177/08850666211043436] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The benefits of percutaneous dilational tracheostomy (PDT) placement have been
well documented in patients requiring prolonged mechanical ventilation. However,
the data regarding the benefit of PDT in coronavirus-2019 (COVID-19) patients
are scarce. The objective of this study is to evaluate the outcomes of a cohort
of 37 patients who underwent tracheostomy as part of their COVID-19 care.
Retrospective data from a series for 37 patients undergoing tracheostomy was
collected using chart review. Primary outcomes included 30 and 60 day mortality,
weaning rate, and decannulation rate. Secondary outcomes collected included
admission demographics, comorbidities, and procedural information. Thirty-seven
(37) patients requiring prolonged mechanical ventilation due to COVID-19. Of
these 37 patients, 35 were alive 60 days post-PDT placement, 33 have been weaned
from mechanical ventilation and 18 have been decannulated. The low mortality and
high decannulation rates in this cohort in is a promising development in the
care of critically ill COVID-19 patients. Of note, all participating physicians
underwent routine polymerase chain reaction (PCR) testing for infection with the
severe acute respiratory syndrome coronavirus-2 virus and no physician
contracted COVID-19 as a result of their involvement. Overall, this case series
describes the modified PDT technique used by our team and discusses the
feasibility and potential benefit to PDT placement in COVID-19 patients
requiring long-term mechanical ventilation.
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Affiliation(s)
- Rahul N Sood
- UMass Memorial Medical Center, Worcester, MA, USA
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Thomas Williams
- Academic Foundation Trainee, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| | - Brendan A McGrath
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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Rossetti M, Vitiello C, Campitelli V, Cuffaro R, Bianco C, Martucci G, Panarello G, Pappalardo F, Arcadipane A. Apneic Tracheostomy in COVID-19 Patients on Veno-Venous Extracorporeal Membrane Oxygenation. Membranes (Basel) 2021; 11:membranes11070502. [PMID: 34209380 PMCID: PMC8306463 DOI: 10.3390/membranes11070502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/19/2021] [Accepted: 06/23/2021] [Indexed: 01/08/2023]
Abstract
COVID-19 creates an impressive burden for intensive care units in terms of need for advanced respiratory care, with a huge number of acute respiratory distress syndromes (ARDS) requiring prolonged mechanical ventilation. In some cases, this proves to be insufficient, with a refractory respiratory failure calling for an extracorporeal approach (veno-venous ECMO). In this scenario, most of these patients need an early tracheostomy procedure to be carried out, which creates the risk of distribution of aerosol particles, possibly leading to personnel infection. The use of apneic tracheostomy has been proposed for COVID-19 patients, but in case of ECMO it may produce lung derecruitment, severe hypoxemia, and sudden worsening of respiratory mechanics. We developed an apneic tracheostomy technique and applied it in over 32 patients supported by veno-venous ECMO. We present data showing the safety and feasibility of this technique in terms of patient care and personnel protection. Gas exchange and pH did not show statistically significant changes after the tracheostomy, nor did respiratory mechanics data or the need for inspiratory pressure and FiO2. The use of apneic tracheostomy was a safe option for patient care during ECMO and reduced the possibility of virus spreading.
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Pauli N, Eeg‐Olofsson M, Bergquist H. Tracheotomy in COVID-19 patients: A retrospective study on complications and timing. Laryngoscope Investig Otolaryngol 2021; 6:446-452. [PMID: 34195366 PMCID: PMC8223451 DOI: 10.1002/lio2.560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/05/2021] [Accepted: 03/29/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The aim of this study was to analyze the timing of tracheotomy and the duration of mechanical ventilation and stay in the intensive care unit (ICU) in patients with COVID-19 infection. Furthermore, we aimed to investigate tracheotomy complications and mortality. METHODS Consecutive patients with COVID-19 infection admitted to the Department of Infectious Diseases in Gothenburg, Sweden were identified. Medical records were retrieved and retrospectively assessed. RESULTS One hundred eighty-eight patients with COVID-19 infection requiring hospital care were identified. Of these, 116 patients were critically ill and intubated, and 55 patients underwent tracheotomy. The mean time from endotracheal intubation to tracheotomy was 12 days (range 5-28 days). There was a correlation between the timing of tracheotomy and the duration of mechanical ventilation, where a shorter time between intubation and tracheotomy was correlated with a shorter duration of mechanical ventilation (r .58, P < .001), and a correlation was identified between the timing of tracheotomy and the duration of ICU stay (r .52, P < .001). Perioperative hypoxemia was registered in 9% of tracheotomies performed, whereas postoperative bleeding was observed in 27% of cases, the majority of which were minor. CONCLUSIONS This retrospective cohort study indicates that early tracheotomy is related to a reduced need for mechanical ventilation and a shorter duration of stay in the ICU in severe cases of COVID-19 disease. Complications during and after tracheotomy in this specific cohort included risk perioperative hypoxia and postoperative bleeding. Prospective randomized controlled trials would be of value to confirm these findings. LEVEL OF EVIDENCE 4, Case series.
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Affiliation(s)
- Nina Pauli
- Department of OtorhinolaryngologyInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
| | - Måns Eeg‐Olofsson
- Department of OtorhinolaryngologyInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
| | - Henrik Bergquist
- Department of OtorhinolaryngologyInstitute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
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West TE, Schultz MJ, Ahmed HY, Shrestha GS, Papali A. Pragmatic Recommendations for Tracheostomy, Discharge, and Rehabilitation Measures in Hospitalized Patients Recovering From Severe COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:110-119. [PMID: 33534772 PMCID: PMC7957235 DOI: 10.4269/ajtmh.20-1173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/04/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- T. Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Marcus J. Schultz
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Hanan Y. Ahmed
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gentle S. Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - for the COVID-LMIC Task Force and the Mahidol-Oxford Research Unit (MORU)
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
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