Tracheostomy in COVID-19: Who, When, How?
Tracheostomy in COVID-19: Many opportunities, limited evidence
By Andrew DeMaio, M.D. and David Feller-Kopman, M.D.
Let’s start with a case – one that unfortunately we have seen way too frequently over the past few months. A 61-year-old man with ESRD on hemodialysis and prior pulmonary embolism was admitted to the ICU for ARDS due to COVID-19. He was intubated and mechanically ventilated with an initial P/F ratio of 110. He required proning and neuromuscular blockade, although his gas exchange has improved over the past few days. He requires moderate ventilator support with FiO2 of 50% and PEEP 12 cmH2O. He is on a heparin infusion and no vasopressors. It is day 12 of mechanical ventilation and the intensivist consults your team regarding the risks and benefits of tracheostomy. What do you recommend?
Over the past several months, hospitals around the world have seen an unprecedented number of patients with respiratory failure due to COVID-19. Current studies suggest that 10-15% of patients hospitalized with COVID-19 require invasive mechanical ventilation (1-3), frequently for prolonged periods. In fact, a recent report from New York City noted that a significant proportion of patients required mechanical ventilation for more than 21 days (4). Before the pandemic, patients would generally be considered for tracheostomy after at least 10 days of mechanical ventilation (5), although COVID-19 introduces several complicating factors. Namely, could earlier tracheostomy free up resources at a time when ICU capacity is already stretched to the brink? Or should the risk of viral transmission delay tracheostomy until patients are presumably less infectious, and assume an increased risk of complications from prolonged trans-laryngeal intubation? Let’s take a quick look into each side of the story…
Several benefits of tracheostomy are well-established in critical care, including the ability to decrease sedation (6), improve secretion clearance and promote early mobility (7). Other potential advantages of tracheostomy are more controversial. For example, several studies suggest a decreased incidence of ventilator-associated pneumonia (8) and duration of mechanical ventilation (9) while others contradict these results. Additionally, one study even suggested a mortality benefit to early tracheostomy (10), although this was not replicated in the subsequent TracMan trial (11). Nevertheless, a fair amount of evidence highlights the potential advantages of tracheostomy. In addition to benefits in the general critically ill population, tracheostomy may incur incremental benefit in specialized populations, including those with traumatic brain injury and multi-system trauma due to their likelihood of requiring prolonged mechanical ventilation (12). Could patients with COVID-19 gain similar benefits due to a high incidence of prolonged respiratory failure, high sedation requirements and prolonged delirium / neuro-cognitive ramifications? Many institutions have recommended a conservative extubation strategy due to a high rate of re-intubation and the associated risk of viral spread. This may further stress a limited pool of intensive care resources, including mechanical ventilators and sedative drugs. In this setting, performance of tracheostomy in appropriate candidates has the potential to free up resources across a health system. This may or may not play a role in the decision based on local factors.
First and foremost, performance of tracheostomy puts healthcare workers at risk of SARS-CoV-2 infection because tracheostomy is an aerosol-generating procedure. In fact, a systematic review assessing infection among healthcare workers during the “original” SARS-CoV epidemic, tracheostomy increased the risk of viral transmission with an odds ratio of 4.2, second only in magnitude to endotracheal intubation (odds ratio 6.6) (13). Even if the procedure is performed proficiently with appropriate personal protective equipment (PPE) some risk remains, as contamination often occurs during doffing of PPE (14). Additionally, tracheostomy is only likely to benefit those who survive critical illness. It is difficult to predict which patients with COVID-19 associated respiratory failure will require prolonged (>14-21 days) mechanical ventilation. Thus, guidelines have recommended delaying tracheostomy until the patient is clinically improving (15). Finally, tracheostomy is associated with several potential complications (16). Most notably, bleeding related to the procedure can be magnified in a population with coagulopathy induced by COVID-19 (17). Additionally, many patients are receiving anticoagulation for various indications including venous thromboembolism (as in our patient) or extracorporeal membrane oxygenation (ECMO). Complications related to tracheostomy may be increased in these populations (18, 19).
Location and techniques
Tracheostomy can be performed using either open surgical (ST) or percutaneous dilational (PDT) techniques. Evidence to definitively support one type over the other is lacking, and prior to the pandemic showed a similar incidence of overall complications between ST and PDT (20). Further, several novel modifications to open (21) and percutaneous (22, 23) tracheostomy have been proposed to reduce viral aerosolization and improve safety. Local expertise should determine which approach is used. If resources allow, tracheostomy should be performed at the bedside in a negative-pressure room in the ICU. Alternatively, ST can be performed in an operative room (with attendant risk of exposure related to patient transport). Limiting the number of people in the room, and enhanced PPE (powered air-purifying respirators (PAPR)) are recommended, if available (24). PPE seems to work – several groups have reported their experience with COVID-19 tracheostomy without any reported transmission to healthcare workers (22, 25).
As this patient was expected to require continued mechanical ventilation, he underwent PDT in a negative-pressure intensive care room without complication. Anticoagulation was held peri-procedurally as his thromboembolic event was remote. Afterwards, his sedative requirement decreased and his encephalopathy gradually improved. He was transferred to an LTACH for ventilator liberation and rehabilitation.
Admittedly, this is a fairly straightforward case but it is useful to highlight the relevant decision points. While some may prefer to wait longer to allow for decreased viral loads, the timing seems appropriate and is consistent with practices prior to COVID-19. At the time of this post, several groups have released statements or guidelines related to tracheostomy in COVID-19 including an international expert panel (15), CHEST / AABIP / AIPPD (24), and American Academy of Otolaryngology and Head and Neck Surgery (26), among others. If you have a minute, please take a look through the formal recommendations to cover the points we may not have touched on here.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061-9. https://jamanetwork.com/journals/jama/fullarticle/2761044
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. 2020;323(20):2052-9. https://jamanetwork.com/journals/jama/fullarticle/2765184
Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, et al. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ. 2020;369:m1985. https://www.bmj.com/content/369/bmj.m1985.long
Argenziano MG, Bruce SL, Slater CL, Tiao JR, Baldwin MR, Barr RG, et al. Characterization and clinical course of 1000 patients with coronavirus disease 2019 in New York: retrospective case series. BMJ. 2020;369:m1996. https://www.bmj.com/content/369/bmj.m1996.long
Angus DC. When should a mechanically ventilated patient undergo tracheostomy? JAMA. 2013;309(20):2163-4. https://jamanetwork.com/journals/jama/article-abstract/1690679
Nieszkowska A, Combes A, Luyt CE, Ksibi H, Trouillet JL, Gibert C, et al. Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med. 2005;33(11):2527-33. https://journals.lww.com/ccmjournal/Abstract/2005/11000/Impact_of_tracheotomy_on_sedative_administration,.13.aspx
Clum SR, Rumbak MJ. Mobilizing the patient in the intensive care unit: the role of early tracheotomy. Crit Care Clin. 2007;23(1):71-9. https://www.criticalcare.theclinics.com/article/S0749-0704(06)00074-1/fulltext
Koch T, Hecker B, Hecker A, Brenck F, Preuss M, Schmelzer T, et al. Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study. Langenbecks Arch Surg. 2012;397(6):1001-8. https://link.springer.com/article/10.1007%2Fs00423-011-0873-9
Zheng Y, Sui F, Chen XK, Zhang GC, Wang XW, Zhao S, et al. Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation. Chin Med J (Engl). 2012;125(11):1925-30. https://journals.lww.com/cmj/fulltext/2012/06010/Early_versus_late_percutaneous_dilational.17.aspx
Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004;32(8):1689-94. https://journals.lww.com/ccmjournal/Abstract/2004/08000/A_prospective,_randomized,_study_comparing_early.9.aspx
Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan C. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-9. https://jamanetwork.com/journals/jama/fullarticle/1690674
Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. Respir Care. 2014;59(6):895-915; discussion 6-9. http://rc.rcjournal.com/content/59/6/895.short
Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0035797
Tomas ME, Kundrapu S, Thota P, Sunkesula VC, Cadnum JL, Mana TS, et al. Contamination of Health Care Personnel During Removal of Personal Protective Equipment. JAMA Intern Med. 2015;175(12):1904-10. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2457400
McGrath BA, Brenner MJ, Warrillow SJ, Pandian V, Arora A, Cameron TS, et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. Lancet Respir Med. 2020. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30230-7/fulltext
Spataro E, Durakovic N, Kallogjeri D, Nussenbaum B. Complications and 30-day hospital readmission rates of patients undergoing tracheostomy: A prospective analysis. Laryngoscope. 2017;127(12):2746-53. https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.26668
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-7. https://onlinelibrary.wiley.com/doi/full/10.1111/jth.14768
Dimopoulos S, Joyce H, Camporota L, Glover G, Ioannou N, Langrish CJ, et al. Safety of Percutaneous Dilatational Tracheostomy During Veno-Venous Extracorporeal Membrane Oxygenation Support in Adults With Severe Respiratory Failure. Crit Care Med. 2019;47(2):e81-e8. https://journals.lww.com/ccmjournal/Abstract/2019/02000/Safety_of_Percutaneous_Dilatational_Tracheostomy.30.aspx
Beiderlinden M, Eikermann M, Lehmann N, Adamzik M, Peters J. Risk factors associated with bleeding during and after percutaneous dilational tracheostomy. Anaesthesia. 2007;62(4):342-6. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2007.04979.x
Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007;117(3):447-54. https://onlinelibrary.wiley.com/doi/abs/10.1097/01.mlg.0000251585.31778.c9
Tanaka L, Alexandru M, Jbyeh S, Desbrosses C, Bouzit Z, Cheisson G, et al. A hybrid approach to tracheostomy in COVID-19 patients ensuring staff safety. Br J Surg. 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11705
Angel L, Kon ZN, Chang SH, Rafeq S, Shekar SP, Mitzman B, et al. Novel Percutaneous Tracheostomy for Critically Ill Patients with COVID-19. Ann Thorac Surg. 2020. https://www.annalsthoracicsurgery.org/article/S0003-4975(20)30603-2/fulltext
Al Yaghchi C, Ferguson C, Sandhu G. Percutaneous tracheostomy in patients with COVID-19: sealing the bronchoscope with an in-line suction sheath. Br J Anaesth. 2020. https://bjanaesthesia.org/article/S0007-0912(20)30284-1/fulltext
Lamb CR, Desai NR, Angel L, Chaddha U, Sachdeva A, Sethi S, et al. Use of Tracheostomy During the COVID-19 Pandemic: CHEST/AABIP/AIPPD: Expert Panel Report. Chest. 2020. https://journal.chestnet.org/article/S0012-3692(20)31639-1/abstract
Chao TN, Harbison SP, Braslow BM, Hutchinson CT, Rajasekaran K, Go BC, et al. Outcomes after Tracheostomy in COVID-19 Patients. Ann Surg. 2020. https://journals.lww.com/annalsofsurgery/Abstract/9000/Outcomes_after_Tracheostomy_in_COVID_19_Patients.94418.aspx
Parker NP, Schiff BA, Fritz MA, Rapoport SK, Schild S, Altman KW, et al. Tracheotomy Recommendations During the COVID-19 Pandemic. American Academy of Otorhinolaryngology – Head & Neck Surgery. 2020. https://www.entnet.org/content/tracheotomy-recommendations-during-covid-19-pandemic