Evidence-Based Review

Early in the COVID-19 pandemic, small case series and retrospective reviews were published demonstrating the safety of tracheostomy in patients requiring >5–10 days of mechanical ventilation and anticipated to require prolonged ventilatory support. These publications yielded the dissemination of new techniques as noted above. The Summer of 2020 yielded studies sharing short-term outcomes of patients who had undergone tracheostomy for COVID-19 related illness. In a study by Murphy et al. [17], they shared their experience with percutaneous tracheostomy using intermittent apnea. In their patient population, roughly one-third of patients required an ICU level of care. The mortality rate for mechanically ventilated patients was 29%. They assessed 18 patients for percutaneous dilational tracheostomy and performed tracheostomy on 11. No personnel had infections related to the procedure. In the short follow-up (average of 20 days), 1 patient died from multiorgan failure, 2 were discharged from the hospital on mechanical ventilation, and the remaining 8 patients were liberated from the ventilator. A study from the University of Pennsylvania Health System published around the same time shared their experience with percutaneous and open surgical tracheostomy using techniques to mitigate aerosol exposures and demonstrated similarly successful implementation of new practices with no healthcare worker exposures [18].

Having documented safety, the question of impact on weaning and liberation from the ventilator and sedation requirements remained. This question was answered by Carmichael et al. [19], who performed a retrospective review of the outcomes of patients requiring mechanical ventilation for COVID-19 between March 1 and June 30, 2020. In their cohort, 206 patients required mechanical ventilation and 26 underwent tracheostomy tube placement at a mean of 25 ± 5 days after initial intubation. 81% of tracheostomy patients were liberated from the ventilator at a mean of 9 ± 6 days post-procedure, and 54% were decannulated prior to hospital discharge at a mean of 21 ± 10 days post-procedure. Sedation

and pain medication requirements decreased signi cantly in the week after the procedure with daily morning assessments using the Richmond Agitation and Sedation Scale (RASS) and the Critical Care Pain Observation Tool (CPOT) recorded, and patients considered to be adequately sedated with a RASS ≤1 and CPOT of 0.

Early in the pandemic, a COVID-19 diagnosis was a reason to categorically delay or avoid tracheostomy tube placement. This practice was challenged when faculty managing the initial surge in New York City published their data supporting early tracheostomy [20]. In their study, they de ned early tracheostomy as those procedures performed prior to day 10 of intubation and late as those occurring at day 10 or later. Timing of tracheostomy was signi cantly associated with length of stay with median length of stay of 40 days in those who underwent early tracheostomy and 49 days in those who underwent late tracheostomy. In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation. While safety was not an outcome of this study, 0/3 interventional pulmonologists performing percutaneous tracheostomies contracted COVID-19. The department of otolaryngology consisted of 35 faculty and 6 contracted COVID-19. Of these 6 cases, 5 were not involved in performing tracheostomies before they became ill.

Further support for early tracheostomy came via a propensity matched cohort study from Hernendez et al. which aimed to answer whether early tracheostomy could bene t overstrained intensive care units [21]. In their retrospective cohort study, which included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, they evaluated the outcomes of patients undergoing the procedure at three time intervals. The timing was <8 days, 8–10 days, and 11–14 days after intubation. Earlier tracheostomy was associated with more ventilator-free days at 28 days. ICU bed-free days at day 28 also favored earlier tracheostomy though there was no difference in hospital bed-free days between the groups. This study suggested that earlier trache-

ostomy has the potential to provide relief to overstained ICUs.

A small proportion of patients with COVID-­19 will exceed the support provided by mechanical ventilation and be considered for extracorporeal membrane oxygenation (ECMO). Performing a tracheostomy on ECMO carries similar risk of aerosol generation but also carries a higher bleeding risk given the use of systemic anticoagulation. To answer the question of safety, one of theve UK ECMO centers created a prospective tracheostomy database at the beginning of the COVID-19 surge [22]. They shared their experience with percutaneous tracheostomy placement in 38 patients mechanically ventilated in the ICU between March 27 and May 15, 2020. The average time of intubation before tracheostomy was 11.66 days. Complications were minimal with 2 patients requiring skin sutures for cessation of bleeding. No patient required the transfusion of blood products for tracheostomy-related bleeding. Given the hypercoagulable state of COVID-­19 patients, they safely performed the procedure without an anticoagulation hold in 15 patients.

More recently a systematic review and meta-­ analysis was conducted to determine the cumulative incidence of complications, mortality, time to decannulation, and ventilatory weaning in patients undergoing tracheostomy for COVID-19 [23]. Additional outcomes related to surgical versus percutaneous and outcomes relative to tracheostomy timing were analyzed. From 1016 unique studies, 39 articles reporting outcomes for a total of 3929 patients were included for meta-analysis. The cumulative incidence of complications was 14.24% with bleeding the predominant complication, accounting for 52% of those complications reported. There was no difference in incidence of mortality, decannulation, complications, and time to decannulation between percutaneous and surgical tracheostomy. In this meta-analysis, no difference was found in mortality between early and late tracheostomy and timing of tracheostomy did not predict time to decannulation. Given the small number of studies and subsequent sample size, linear regression

was used to con rm that time to tracheostomy did not signi cantly predict time to decannulation. Time from tracheostomy to weaning was only reported in 8 studies.

Summary and Recommendations

Tracheostomy guidelines during the COVID-19 pandemic vary by physician group and specialty, hospital system, and resource/staf ng allocation. Society-based guidelines published in academic journals must be balanced against institutional policies and unique staf ng or resource issues. The current literature suggests that with appropriate precautions, tracheostomy can be performed safely with the bene t of a bedside procedure minimizing transportation of COVID positive patients. The timing of the procedure should be guided by the patient’s clinical trajectory as well as institutional resources and policies related to the management of tracheostomy in patients who may have evidence of viral shedding. This summary is provided as a point-in-­ time current state of in November 2021 and is anticipated to change in coming weeks and months as the pandemic, vaccination status, and antibody testing evolves.

References

1.\ Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report. Chest. 1985;87(6):715–9.

2.\ Combes A, Luyt CE, Nieszkowska A, et al. Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med. 2007;35(3):802–7.

3.\ Cox CE, Carson SS, Holmes GM, et al. Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993-2002. Crit Care Med. 2004;32(11):2219–26.

4.\ Nieszkowska A, Combes A, Luyt CE, 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.

5.\ Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010;303(15):1483–9.

6.\Young D, Harrison DA, Cuthbertson BH, Rowan K. For the TracMan collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121–9.

7.\Wei WI, Tuen HH, Ng RWM, Lam LK. Safe tracheostomy for patients with severe acute respiratory syndrome. Laryngoscope. 2003;113:1777–9.

8.\Tay JK, Khoo ML, Loh WS. Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak. JAMA Otolaryngol Head Neck Surg. 2020;146(6):517–8.

9.\Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID19)­ outbreak in China: summary of a report of 72,314 cases from the Chinese center for disease control and prevention. JAMA. 2020;323(13):1239–42.

10.\Parker NP, Schiff BA, Fritz MA, Airway and Swallowing Committee of the American Academy of Otolaryngology-Head and Neck Surgery, et al. Tracheotomy recommendations during the COVID-19 pandemic. 2020. https://www.evhc.net/coronavirus/ covid-19/hm-intensivist-resources/tracheostomy- recommendations.pdf.

11.\Leung GM, Hedley AJ, Ho L-M, et al. The epidemiology of severe acute respiratory syndrome in the 2003 Hong Kong epidemic: an analysis of all 1755 patients. Ann Intern Med. 2004;141:662–73.

12.\Lamb CR, Desai NR, Angel L, et al. Use of tracheostomy during the COVID-19 pandemic: American college of chest physicians/American association for bronchology and interventional pulmonology/association of interventional pulmonology program directors expert panel report. Chest. 2020;158(4):1499–514.

13.\Hashimoto DA, Axtell AL, Auchincloss HG. Percutaneous tracheostomy. N Engl J Med. 2020;383:e112.

14.\Angel L, Kon ZN, Chang SH, et al. Novel percutaneous tracheostomy for critically ill patients with COVID-19. Ann Thorac Surg. 2020;110:1006–11.

15.\Takhar A, Walker A, Tricklebank S, et al. Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic. Eur Arch Otorhinolaryngol. 2020;277:2173–84.

16.\Raimonde AJ, Westhoven N, Winters R. Tracheostomy. In: StatPearls. Treasure Island, FL: StatPearls; 2021. https://www.ncbi.nlm.nih.gov/books/ NBK559124/. Accessed 31 Jul 2021.

17.\Murphy P, Holler E, Lindroth H, et al. Short-term outcomes for patients and providers after elective tracheostomy in COVID-19 positive patients. J Surg Res. 2021;260:38–45.

18.\Chao TN, Harbison SP, Braslow BM, et al. Outcomes after tracheostomy in COVID-19 patients. Ann Surg. 2020;272:e181–6.

19.\Carmichael H, Wright FL, McIntyre RC, et al. Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection. Trauma Surg Acute Care Open. 2021;6:e000591.

20.\Kwak PE, Connors JR, Benedict PA, et al. Early outcomes from early tracheostomy for patients with COVID-19. JAMA Otolaryngol Head Neck Surg. 2021;147(3):239–44.

21.\Hernandez G, Ramos FJ, Añon JM, et al. Early tracheostomy for managing ICU capacity during the COVID-19 outbreak: a propensity-matched cohort study. Chest. 2021;S0012-3692(21):01125–9.

22.\Valchanov K, Salaunkey K, Parmar J. Percutaneous dilatational tracheostomy in coronavirus disease 2019 extracorporeal membrane oxygenation patients: a case series. J Cardiothorac Vasc Anesth. 2021;35:348–50.

23.\Ferro A, Kotecha S, Auzinger G, et al. Systematic review and meta-analysis of tracheostomy outcomes in COVID-19 patients. Br J Oral Maxillofac Surg. 2021;59:1013. https://doi.org/10.1016/j. bjoms.2021.05.011.

24.\WHO. COVID-19 dashboard. Geneva: World Health Organization; 2020. https://covid19.who.int/.