Low Risk of SARS-CoV-2 Transmission During Tracheostomy

By Marilynn Larkin

June 03, 2021

NEW YORK (Reuters Health) - With appropriate personal protective equipment (PPE), healthcare professionals (HCPs) are at low risk of contracting SARS-CoV-2 while performing tracheostomy, a new systematic review and meta-analysis suggests.

"By demonstrating the relative safety of tracheostomy for HCPs using appropriate PPE, particularly after 20 days since disease onset, COVID-19 patients admitted to the ICU (intensive-care unit) can now potentially undergo tracheostomy earlier in their disease course," Drs. Doron Sommer and Philip Staibano of McMaster University in Hamilton, Canada, told Reuters Health in a joint email.

"This is in an effort to hopefully shorten ICU stay and reduce upper airway prolonged intubation complications," they said. "However, future studies are needed to further address the impact of earlier tracheostomy on COVID-19 patient outcomes and transmission risk."

"This is a change from earlier in the pandemic when many centers required a negative RT-PCR in order to proceed with nonurgent aerosol-generating medical procedures such as tracheostomy," they added.

"Some centers/jurisdictions still are requiring this," they noted, "but evidence like this study will hopefully help the evolution, as RT-PCR remains positive for many weeks in ICU patients, likely due to non-viable viral fragments and non-replicating virus."

As reported in JAMA Otolaryngology-Head and Neck Surgery, 69 studies were included in the team's qualitative synthesis, of which 14 (20%) were included in the meta-analysis.

A total of 4,669 patients (mean age, 61; 74% men) were involved in the 69 studies. Twenty-eight studies (41%) investigated either surgical tracheostomy or percutaneous dilatational tracheostomy.

Overall, three of 58 studies (5%) identified a small subset of HCPs who developed tracheostomy-associated COVID-19; however, the studies did not consistently report the number of HCPs involved in tracheostomy.

Among patients, early tracheostomy was associated with faster ICU discharge (mean difference, 6.17 days), but no change in intermittent mandatory ventilation weaning (mean difference, −2.99 days) or decannulation (mean difference, −3.12 days).

Further, there was no association between mortality or perioperative complications and type of tracheostomy.

In addition, a risk-of-bias evaluation demonstrated notable bias in the confounder and patient selection domains because of a lack of randomization and cohort matching. There was also heterogeneity in study reporting.

Drs. Sommer and Staibano noted that their team is in the process of updating recommendations from the Canadian Society of Otolaryngology Head and Neck Surgery taskforce on the performance of tracheotomy during the COVID-19 pandemic to reflect the new evidence, in addition to other guidance.

Dr. Matthew Exline, a critical care and pulmonary-disease specialist at The Ohio State University Wexner Medical Center in Columbus, commented in a phone interview, "Overall, this study conformed to what I've seen clinically. Tracheostomy does tend to get patients out of the ICU sooner, but it doesn't seem to improve their overall time on the ventilator or survival."

"This is probably because we tend to only offer tracheostomy to patients who are clinically improving," he said, "and once we do the tracheostomy, many, many, many medical centers will then look to move the patient out of the ICU to a rehab facility."

"I always tell patients the tracheostomy is just a means to deliver the ventilation," he said. "It is not a cure in and of itself."

"The authors also found that tracheostomies can be done safely with adequate PPE," he said. "Something we've seen, as well as every other study that looked at this, is that some healthcare providers did get COVID. But because a lot of people got COVID, their risk was more related to the community they lived in than the procedure they happened to be part of."

"In the ICU, we should treat COVID patients like we treat any other patients," he said. "We have the equipment to keep us safe. We have the vaccine to keep us safe. And we now have learned that COVID patients are much more like every other ICU patient than they are distinct with a different risk."

"So," he concluded, "decisions should be based on what the patient needs clinically, not on their COVID status at that moment."

SOURCE: https://bit.ly/34BUpaS JAMA Otolaryngology-Head and Neck Surgery, online May 27, 2021.