Earlier Tracheostomies No More Risky Than Later Ones, May Benefit COVID-19 Patients

By Linda Carroll

December 19, 2020

(Reuters Health) - In SARS-CoV-2 infected patients it may make sense to do tracheostomies earlier -seven to 14 days after the patient has started on a ventilator - rather than waiting another week, a new study suggests.

In a retrospective review of records for 148 patients with COVID-19 who were put on ventilators, researchers found that early tracheostomy led to a slightly shorter hospital stay, on average, according to the report published in JAMA Otolaryngology-Head & Neck Surgery.

Early in the pandemic, guidelines based on expert opinion suggested delaying tracheostomy to protect providers, said the study's lead author, Dr. Paul Kwak, an assistant professor in the department of otolaryngology-head and neck surgery at the NYU School of Medicine in New York City. "That was based on some data from the first SARS epidemic," Dr. Kwak said.

But data gathered this year suggested that SARS-CoV-2 peaked in infectiousness earlier, Dr. Kwak said. "Our concern was that waiting comes at a cost to the patient," he added. "Waiting two to three weeks really does predispose patients to airway narrowing and vocal cord paralysis."

For that reason, Dr. Kwak and colleagues started doing tracheostomies in the 7- to 14-day range. "We saw no increase in infections in surgeons or providers and this demonstrated the long-term outcomes of these patients indeed were comparable to the late group, with some measures in which the early patients did better."

The researchers don't know yet whether the earlier tracheostomies will result in fewer patients ending up with airway narrowing and/or vocal cord paralysis, but they plan to explore that in a future study, Dr. Kwak said.

To take a closer look at the impact of tracheostomy timing, Dr. Kwak and his colleagues examined medical records from 148 patients, average age 58.1, who had been placed on ventilators. Of these, 52 patients received tracheostomy early.

Overall, the mean time from symptom onset to intubation was 10.57 days, from symptom onset to tracheostomy, 22.76 days, and from endotracheal intubation to tracheostomy 12.23 days. For the early tracheostomy group, the mean time to tracheostomy was 17.38 days from symptom onset and 5.8 days from intubation. For the late tracheostomy group, the mean time to tracheotomy was 25.69 days from symptom onset and 15.83 days from intubation.

At the completion of the study, 108 patients (73%) had discontinued ventilation, 94 had been decannulated and 107 had been discharged. Ten were still on a ventilator and 30 had died.

The mean time for discontinuing ventilation from intubation was 26.5 days for the early group and 31 days for the late group.

The new study is an example of how consensus statements and data can differ, said Dr. Eric Wang, an associate professor of otolaryngology, ophthalmology and neurological surgery at the University of Pittsburgh School of Medicine.

Early on, no one knew when it would be best to do tracheostomies on these patients, Dr. Wang said. It's unfortunate that there weren't swabs from the patients to give information on what their viral load was, he added.

"The original driving force was to try to preserve the healthcare workforce," Dr. Wang said. "This is one of the first studies to try to find the answer."

These days, fewer patients are being put on ventilators as doctors have learned more methods for keeping them healthy without ventilator use, Dr. Wang said. Nevertheless, some patients still need to be put on ventilators and this data may help change practice, especially since the study is peer reviewed and published in a leading journal, he added.

SOURCE: https://bit.ly/38kjfh8 JAMA Otolaryngology-Head & Neck Surgery, online December 17, 2020.