Tracheotomy May Be Appropriate for Certain Ventilated Patients With COVID-19

By Will Boggs

May 18, 2020

NEW YORK (Reuters Health) — Tracheotomy might be reasonable for some patients with COVID-19 who have been ventilated for more than 21 days, according to guidelines from the University of Pennsylvania Health System.

"Some institutions have been recommending very early tracheostomy, and others have been avoiding tracheostomy altogether," Dr. Tiffany N. Chao of University of Pennsylvania, in Philadelphia, told Reuters Health by email. "Based on the available data, we believe there is a middle ground between the two camps."

An estimated 3% to 17% of patients hospitalized with COVID-19 require invasive mechanical ventilation. Current recommendations support early intubation, which decreases the risk of SARS-CoV-2 transmission through generation of aerosols compared with noninvasive positive pressure ventilation.

Dr. Chao and colleagues on the COVID-19 Tracheotomy Task Force highlight specific considerations regarding tracheotomy for patients with COVID-19 requiring ventilatory support in a report in Annals of Surgery.

While early tracheotomy (within seven days of intubation) is commonly recommended for critically ill ventilated patients without COVID-19, they say, it remains unclear that this would be beneficial for intubated patients with COVID-19, as their mortality is high and the median duration of intubation of non-survivors appears to be less than a week.

Based on the available evidence, the Task Force determined that tracheotomy might be considered in patients with durations of intubation greater than 21 days who are otherwise without significant comorbidities and would be expected to have a good prognosis if they survive.

Tracheotomy before 21 days should not be performed routinely in these patients solely for prolonged ventilator dependence, given the high risk of transmission and poor prognosis of patients requiring intubation and ventilation.

Tracheotomy for other indications, such as a known difficult airway, should be considered in COVID-19 patients on a case-by-case basis.

When tracheotomy is deemed necessary in these patients, an open surgical tracheotomy should be favored over a percutaneous dilational tracheotomy in order to minimize aerosol generation.

"Both percutaneous and open techniques are feasible and can be modified to minimize aerosolization for the safety of the surgical team, as long as appropriate personal protective equipment is worn," Dr. Chao said. "The technique with which the procedure team is most comfortable should be the one that is performed."

Where possible, these tracheotomies should be performed at bedside in a negative pressure room to minimize the risk of transmission during patient transport, and team members in the room should be kept to the minimal critical number, preferably with highly experienced personnel.

Airborne and droplet precautions should be followed, and each person in the room should properly don and doff personal protective equipment.

A multidisciplinary discussion of the patient's goals of care, overall prognosis, and expected benefits of tracheotomy should be a critical part of the decision-making process.

"Early tracheostomy must be considered very carefully along with the patient's expected prognosis, as data from some U.S. series suggests that the mortality of intubated patients is still quite high," Dr. Chao said. "On the other hand, there are patients who do warrant the procedure for a variety of reasons, which can be done in a way that is safe for the healthcare team, so it should not be avoided in patients with a reasonable indication and prognosis. The optimal timing should continue to be refined as more data is published."

Dr. Edward J. Damrose of Stanford University, in Palo Alto, California, who recently reviewed the management of head and neck cancer patients with tracheostomy or laryngectomy during the COVID-19 pandemic, told Reuters Health by email, "Tracheostomy is a high-risk procedure for the staff, but with careful planning can be done in a manner to reduce the risk of aerosolization and infection."

"Patient candidates will generally be those intubated greater than 21 days, longer than for standard indications, and deferred until patients test negative for COVID-19," said Dr. Damrose, who was not connected to the report. "It will remain to be seen if patients who survive COVID-19 have a greater incidence of postextubation laryngotracheal injury and how severe these injuries might be."

SOURCE: Annals of Surgery, online May 5, 2020.