Tracheostomy during intubation in COVID-19 patients: a survey on current clinical practice

Healthcare services experienced unexpected requests, lately. COVID-19 coronavirus pandemic changed the way of acting. Every operation became harder than before. Researchers in the UK conducted a survey on the current clinical practice of tracheostomy intervention during intubation in COVID-19 patients.

As all of us know, COVID-19 pandemic results in pneumonia and may rapidly progress to a severe acute respiratory syndrome. [3] Many patients conditions, such as coronavirus positive patients, intubation and mechanical ventilation are frequently required. Those patients who require prolonged ventilation, need a tracheostomy to get a benefit. [5] Benefits include weaning and pulmonary toilet in those requiring regular airway suction in the Intensive Care Unit. Tracheostomy in intubated patients has been usually undertaken between day 7 and 10 following intubation. However, ENT UK guidelines recognized the need for caution when performing a tracheostomy in COVID-19 patients. [8] Researchers from universities in the UK published the following survey to identify clinical practices.

Experience in COVID-19 patients intubation: what we have

Tracheostomy may be undertaken either via an open surgical approach or percutaneously, usually at the bedside.[7] However, little data show the optimal approach and subsequent outcome in COVID-19 positive ventilated patients. The territories in China which got hit the most by the pandemic developed a greater understanding of how to best manage COVID-19 positive patients. Their experience is of benefit to other institutions early in the pandemic cycle. Not only in terms of planning patient pathways and healthcare resources, but also predicting outcomes. The researchers’ team conducted an international survey to assess tracheostomy intervention during intubation in COVID-19 positive patients amongst ENT Surgeons.

 

ENT surgeons: tracheostomy during intubation in COVID-19 patients: methods and results

This survey is a Service Development Project obtained from the Research and Development Department of King’s College Hospital NHS Foundation Trust, London. Researchers launched an online questionnaire consisting of the following questions:

  1. In which country/region are you based?
  2. How many ventilated COVID-19 patients have you had at your hospital?
  3. What percentage of intubated patients have required a tracheostomy?
  4. On average on what day was the tracheostomy performed (eg, day 7 of intubation)?
  5. How long after tracheostomy was the patient weaned off the ventilator?
  6. What percentage of patients died despite tracheostomy?
  7. Were outcomes better with any specific tracheostomy technique (eg, percutaneous vs surgical)?

The questionnaire was disseminated on the March 27th, 2020 and data accepted until the April 15th, 2020. Patients and the public were not involved in the production of this survey or article.

The survey was completed by a total of 50 respondents from both the United Kingdom (n = 8) and International units (Figure 1.) The number of ventilated patients was 3403 with 68 patients per Hospital Unit/Trust (range 0-600). The percentage of intubated patients requiring tracheostomy was on average 9.65% (range 0%-100%) with a tracheostomy performed following intubation at a mean of 14.4 days (range 7-21).

This was drawn from 28 respondents from 2701 intubated and ventilated patients (Figure 2). Successfully, patients have weaned post tracheostomy on average after 7.4 days (range 1-16 days). Despite the tracheostomy on average 13.5% of patients died (drawn from 14 respondents from a population of 1687 intubated and ventilated patients). With regards to tracheostomy technique and outcome, 3 out of 50 respondents gave preference to a percutaneous tracheostomy. An open surgical approach was favored by 8 out of 50 respondents. Other respondents (20/50) stated neither preference, with a remaining 19/50 unable to contribute.

 

What did this survey on tracheostomy during intubation in COVID-19 patients take to?

Data from Wuhan suggests the median time from hospital admission to death was 5 days in the very first months of the pandemic, which means 11 days.[14] COVID-19 pandemic has resulted in unparalleled demand for critical care services and the need for intubation and mechanical ventilation.[1] Those who become critically require intubation and mechanical advanced ventilation because of the rapid progression of pneumonia. It turns into a severe acute respiratory distress syndrome leading to respiratory failure and death.[3,12,13]

Current guidelines published by the American Academy of Otorhinolaryngology-Head and Neck Surgery recommend that tracheostomy should not be performed prior to 14 days of intubation.[15] The results of this survey would suggest that approximately 1 out of every 10 intubated and ventilated COVID-19 patients require a tracheostomy. Other results would suggest that units are adopting a similar policy with few undertaking early tracheostomy routinely.

However, we should be aware of the potential risks of prolonged ventilation in those who may be weaned. These include late tracheal ulceration, stenosis and tracheo-esophageal fistula.[5] Acquired critical care illness is also likely to become more prevalent.[16]

More patients will require prolonged ventilation. This would cause the muscular atrophy which may prolong or prevent weaning.[17] Reports of glottic and supraglottic swelling and ulceration may also prohibit extubation and prolong the need for intubation, sedation and ventilation. This may be overcome by tracheostomy.

However, this survey failed to establish any clear benefit regards tracheostomy technique. Comments by respondents explained that intervention was taken on a case by case basis and dependent on local surgical experience. Limitations include the number of respondents with COVID-19 positive patients concentrated in specific units. The authors express their immense gratefulness to those who have taken the time to respond to this survey to support the decision making of colleagues throughout the world.

 

AUTHORS

Ayman D’Souza: Christ Church, University of Oxford, Oxford, UK

Ricard Simo FRCS (ORL-HNS): Department of Otorhinolaryngology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

Alwyn D’Souza FRCS (ORL-HNS): Department of Otorhinolaryngology, University Hospital Lewisham, London, UK

Francis Vaz FRCS (ORL-HNS): Department of Head and Neck Surgery, University College Hospital, London, UK  | Institute of Medical Sciences, Medway Campus, Canterbury Christ Church University, Kent, UK

Andrew Prior FRCS (ORL-HNS): Department of Otorhinolaryngology, Princess Royal University Hospital, Kent, UK

Rahul Kanegaonkar FRCS (ORL-HNS): Institute of Medical Sciences, Medway Campus, Canterbury Christ Church University, Kent, UK

 

REFERENCES

  1. Willan J, King AJ, Jeffery K, Bienz N. Challenges for NHS hospitals during covid-19 epidemic. BMJ. 2020;368:m1117. https:// doi.org/10.1136/bmj.m1117.
  2. https://www.who.int/docs/default-source/coronaviruse/situationreports/20200414-sitrep-85-covid-19.pdf?sfvrsn=7b8629bb_4). Accessed April 14, 2020.
  3. Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan. China JAMA Int Med. 2020;e200994. https://doi.org/10.1001/jamainternmed. 2020.0994.
  4. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323 (13):1239–1242. https://doi.org/10.1001/jama.2020.2648
  5. Dempster J. Tracheostomy (Chapter 35). In: Musheer Hussain S, ed. Logan Turner’s Diseases of the Nose, Throat and Ear Head and Neck Surgery. 11th ed. Boca Raton, FL: CRC Press; 2015.
  6. Freeman BD, Borecki IB, Coopersmith CM, Buchman TG. Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med. 2005;33(11):2513-2520.
  7. Lipton G, Stewart M, McDermid R, et al. Multispecialty tracheostomy experience. Ann R Coll Surg Engl. 2020;1:1-5.
  8. Takhar A, Walker A, Tricklebank S. Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic. Eur Arch Otorhinolaryngol. 2020. http://dx.doi.org/ 10.1007/s00405-020-05993-x.
  9. Murthy S, Gomersall CD, Fowler RA. Care for Critically ill patients with COVID-19. JAMA. 2020;323(15):1499–1500. https://doi.org/10.1001/jama.2020.3633.
  10. https://www.entuk.org/tracheostomy-guidance-during-covid19-pandemic. Accessed April 14, 2020.
  11. https://www.who.int/docs/default-source/coronaviruse/ situation-reports/20200415-sitrep-86-covid-19.pdf?sfvrsn= c615ea20_6. Accessed April 14, 2020.
  12. Guan W-J, Ni Z, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. New Eng J Med. 2020;382:1708– 1720. https://doi.org/10.1056/NEJMoa2002032.
  13. Chen J, Qi T, Liu L, et al. Clinical progression of patients with in Shanghai, China. J Infect. 2020;80(5):E1–E6. https://doi.org/ 10.1016/j.jinf.2020.03.004.
  14. Leung C. Clinical features of deaths in the novel coronavirus epidemic in China. Reviews in Medical Virology. 2020;323(15): 1499–1500. https://doi.org/10.1002/rmv.2103.
  15. AAO-HNS Position Statement. Tracheostomy Recommendations During COVID-19 Pandemic https://www.ent.org/content/ tracheostomy-recommendations-during-covid-19-pandemic
  16. Vassilakopoulos T. Respiratory muscle wasting in the ICU: is it time to protect the diaphragm? Thorax. 2016;71(5):397-398. https://doi.org/10.1136/thoraxjnl-2016-208354.
  17. Bolton CF. Neuromuscular manifestations of critical illness. Muscle Nerve. 2005;32(2):140-163.

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SOURCE

ResearchGate

University of Oxford 

Guy’s and St Thomas’ NHS Foundation Trust

University Hospital Lewisham

University College Hospital

Princess Royal University Hospital

MedCampus Canterbury Christ ChurchUniversity

 

 

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