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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Timing of tracheostomy on COVID-19 patients and its impact: Our experiences at a tertiary care teaching hospital


 Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

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Date of Submission10-Jul-2021
Date of Decision15-Aug-2021
Date of Acceptance20-Aug-2021
Date of Web Publication29-Sep-2021
 

  Abstract 


Background: In the current coronavirus disease 2019 (COVID-19) pandemic, tracheostomy is an important surgical procedure on COVID-19 patients at the intensive care unit undergoing prolonged endotracheal intubation. The timing and outcome of tracheostomy in COVID-19 patients with ventilator are still controversial. Objective: The objective of this study was to evaluate the timing and outcome of tracheostomy in the airway management of patients with COVID-19 requiring mechanical ventilation. Materials and Methods: This is a retrospective study where 92 patients enrolled in this study and all were with positive reverse transcriptase–polymerase chain reaction which confirmed COVID-19 infection and requiring mechanical ventilation at a single tertiary care teaching hospital from May 2020 to June 2021. Results: Participants included 92 patients who underwent tracheostomy, 62 males and 30 females with a male-to-female ratio of 2.06:1. The age range of the participants was 18–68 years, with a mean age of 54.2 years. The mean time from onset of the symptoms to intubation was 9.46 days; the day of onset of intubation to day of tracheostomy was 18.34 days. Conclusion: The requirement of tracheostomy in COVID-19 is increasing. The tracheostomy should be performed in appropriate time with safe technique for benefit of the patients,particularly for avoiding transmission of infections to health-care workers.

Keywords: COVID-19 pandemic, mechanical ventilation, SARS-CoV-2, timing of tracheostomy


How to cite this URL:
Swain SK, Panda S. Timing of tracheostomy on COVID-19 patients and its impact: Our experiences at a tertiary care teaching hospital. Apollo Med [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.apollomedicine.org/preprintarticle.asp?id=327150





  Introduction Top


In the current coronavirus disease 2019 (COVID-19) pandemic, the hospitals and intensive care units (ICUs) are facing a surge of COVID-19 patients requiring urgent care or invasive mechanical ventilation. COVID-19 is a highly contagious infection of the respiratory tract caused by a novel virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] The health-care professionals are on the process to know the behavior of the SARS-CoV-2. Tracheostomy is a surgical procedure performed on severely ill COVID-19 patients where chance of transmission of this virus is very high.[2] Tracheostomy is one of the common surgical procedures performed on critical ill patients with prolonged ventilation.[3] Tracheostomy is an important procedure among COVID-19 patients those underwent prolonged endotracheal intubation. The optimum timing for performing tracheostomy remains controversial. There are several recommendations and guidelines on how to perform tracheostomy in COVID-19 patients, however, the timing to perform such procedure is variable. Tracheostomy usually reduces the stay at ICU in context to prolonged invasive mechanical ventilation.[4] Tracheostomy is also done to ease weaning from ventilator support, to enhance the airway and pulmonary toilet, and improve the patient comfort and long-term complication like laryngotracheal stenosis. However, there are not many studies for optimum timing to perform tracheostomy on COVID-19 patients at ICU and its impact. Here, the aim of this study is to evaluate the timing and its impact for performing tracheostomy on the COVID-19 patients at the ICU.


  Materials and Methods Top


This retrospective study was done at a COVID hospital ICU of a tertiary care teaching hospital. We evaluated the clinical data from COVID-19 patients who were admitted at the ICU and underwent tracheostomy. The study was done from May 2020 to June 2021. This study was done from May 2020 to June 2021 and was approved by the institutional ethical committee (IEC) with a reference number of IEC/IMS/ SOA/12/18.03.2020. All patients diagnosed with COVID-19 were confirmed by using reverse transcriptase–polymerase chain reaction. The demographic data of the enrolled patients were evaluated such as age and gender. The parameters of the patients during the hospital stay were documented such as time from onset of symptoms to endotracheal intubation, tracheostomy, and time from intubation to tracheostomy. The decannulation of the tracheostomy tube and any death after tracheostomy were assessed. The timing to perform tracheostomy was classified into early or late. The early tracheostomy is defined as procedure done prior to day 10 of intubation and late tracheostomy as procedure at day 10 or later. The exact definition of early and late tracheostomy has varied across meta-analysis; 10 days was selected for this study as point of demarcation as an average.[5] The inclusion criteria for enrolled patients were positive for COVID-19 patients. Patients with age <18 years and patients transferred from another hospital to our ICU with tracheostomy were excluded from this study.

The Statistical Package for the Social Sciences (SPSS) Statistics for Windows, version 20, was used for all statistical analyses (IBM-SPSS Inc., Chicago, IL, USA).


  Results Top


In study period, there were 554 patients with confirmed SARS-CoV-2 infection admitted and intubated in ICU attached to the 800-bedded COVID hospital, among which surgical tracheostomy was performed in 92 patients (16.60%) [Table 1]. Ninety-two COVID-19 patients at the ICU underwent tracheostomy and all were enrolled in this study. The age range of the enrolled patients was 18–65 years, with a mean age of 44.4 years. There were 62 (67.39%) males and 32 (34.78%) females, with a male-to-female ratio of 2.06:1. The mean time from onset of the symptoms of the COVID-19 patients to day of intubation was 9.46 days. The day of onset of intubation to day of tracheostomy was 18.34 days. Thirty-five patients (38.04%) died after tracheostomy. The median time between tracheostomy and death was 4 days. No health-care workers from the team for tracheostomy procedure developed symptoms of COVID-19 infections. One health-care worker of tracheostomy team got infection from study patients and developed symptoms of COVID-19 infections. There were no complications occurred at the timing of performing tracheostomy on COVID-19 patients. Postoperative chest X-ray showed no clinical progression of the respiratory condition.
Table 1: Clinical parameters of patients with tracheostomy at intensive care unit

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  Discussion Top


COVID-19 is a highly infectious disease and is considered a global public health emergency.[6] The first case of COVID-19 infection was detected in Wuhan, Hubei Province, of China in late December 2019.[7] At present, hospitals are getting large number of COVID-19 patients with requirement of mechanical ventilation which is a sign of severe COVID-19 infection. In severe cases of COVID-19 infection, patients develop acute respiratory distress syndrome (ARDS) followed by need of mechanical ventilation. The increasing number of COVID-19 patients in the present pandemic will expect more endotracheal intubation and prolonged ventilation. Tracheostomy can be performed to avoid the complications of intubation and prolonged ventilation.[8] Tracheostomy is an effective and safe procedure performed on the ICU patients for prolonged tracheal intubation as in respiratory failure.[9] There is no definite guidelines for safety and usefulness of tracheostomy in COVID-19 patients and also no specific weaning protocol are defined.[10] The decisions for tracheostomy in COVID-19 patients should consider benefits of the patient and l infection of the SARS-CoV-2 in health care works in the current COVID-19 pandemic.[11] COVID-19 disease is a highly infectious disease caused by a novel virus called SARS-CoV-2 virus.[12] SARS-CoV-2 is found in high abundance at the upper and lower airway. This infection spreads from person to person through respiratory droplets or contact. Tracheostomy is usually an aerosol-generating procedure with a high risk of contamination by exposing the secretions from the airway to the health-care workers.[13] COVID-19 infection manifests its peak infectivity at 9–10 days following onset of symptoms and performing tracheostomy during this period would be risky for transmission of infections to health care workers.[14] However, the SARS-CoV-2 seems to present peak infectivity at, or even 2 days before to, onset of symptom and steadily decreasing its infectivity after that.[15] The severe manifestations of COVID-19 infection have higher viral loads which follow a similar trajectory, so the tracheostomy can be performed at a mean of 22 days from the day of symptom onset where the infectivity of the tracheal secretion is likely to be very minimal.[16]

In the early tracheostomy, the hospital stay is shorter than those with late tracheostomy.[17] There are vast ranges of the symptoms in COVID-19 patients, which is the hallmark of this disease, unclear neat categorization of the COVID-19 patients into early and late tracheostomy groups which undermines the significance of that distinction. This analysis makes a more multifaceted decision about timing of tracheostomy in COVID-19 patients. The timing of the tracheostomy should be decided by the clinician on the data basis of disease severity, viral load, and therapies which may alter the clinical course of the COVID-19 patients. Early tracheostomy would be associated with a better outcome for a certain selected patient. There has been any evidence that delayed tracheostomy improves the outcome; on the contrary, data indicate that delayed tracheostomy is often associated with higher incidence of long-term airway stenosis.[18],[19] In this study, we performed bedside surgical tracheostomy in all enrolled patients. Bedside tracheostomy avoids unnecessary transport of the patients to operating room and frequent connections and disconnection of the ventilator during the transfer of the patients.[20] The bedside tracheostomy should be well planned with optimum time from tracheal intubation with limited transfer of the surgical instruments with proper positioning of the patient.

A study on non-COVID-19 critically ill patients showed that early tracheostomy (within 10 days on intubation) is associated with longer ventilation-free days, lesser ICU stay, lesser duration of sedation, lower mortality rates whereas another study for timing of the tracheostomy does not support the favorable the clinical outcome.[21],[22] The clinical experiences from COVID-19 pandemic suggest that prolonged intubation should not be alone an indication for performing tracheostomy in COVID-19 patients, as there is a risk for health-care personnel and patients likely show any marginal benefits in this pandemic. Rather tracheostomy should be done only in a specific condition such as airway obstruction where successful extubation is challenged or in a certain condition where tracheostomy placement has a positive impact on patients' potential for successful weaning of the ventilation support.[3] Hence, it requires careful consideration when the health-care resources like ventilators are in limited supply in the current COVID-19 pandemic. As per current recommendations, clinicians should believe the situations and assessment by multidisciplinary fashion like consensus among the specialists for clinical benefits after tracheostomy as weighed against the risk of this surgical procedure on COVID-19 patients.[23] In this study, the mean time from onset of the symptoms of the COVID-19 patients to day of intubation was 9.46 days. The day of onset of intubation to day of tracheostomy was 18.34 days.

To protect the health-care workers from COVID-19 infections, a strict and an appropriate infection control protocol is required for any aerosol-generating procedures such as tracheostomy, bronchoscopy, and intubation.[24] If tracheostomy is performed in early period of COVID-19 infection, it is usually essential to establish an experienced team for reducing the occupational infection in health-care professionals. It is necessary to use enhanced personal protective equipment by health-care professionals before performing the tracheostomy. One study showed that the survival of the COVID-19 patients requiring mechanical ventilation is very poor (<20%) which suggests against the early tracheostomy.[25] However, if the tracheostomy is performed from 2 weeks to 3 weeks, there is sufficient decline in viral load.[25]

The mortality benefit of tracheostomy in severely ill patients in ICU has not been demonstrated.[26] In this study, 38.04% of the patients died after tracheostomy. To reduce aerosolization during the surgical tracheostomy, the role of timing to perform the procedure plays an important role. The optimum timing to perform tracheostomy on COVID-19 patients in ICU is an important criterion for safety of the health-care professionals and other patients.


  Conclusion Top


Health-care workers are facing the greatest challenges in the current COVID-19 pandemic. COVID-19 patients with ARDS and respiratory failure require mechanical ventilation and prolonged mechanical ventilation is a common indication for tracheostomy. This study proposed optimum timing for tracheostomy in COVID-19 patients of 2–3 weeks after endotracheal intubation from our experiences at a tertiary care teaching hospital. A multidisciplinary team with experienced health-care professionals is needed to perform a safe tracheostomy in COVID-19 patients to reduce the risk of SARS-CoV-2 infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Santosh Kumar Swain,
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_71_21




 
 
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