1Department of Medicine, McMaster University, Hamilton, Ontario, Canada;
2Waterloo Regional Campus, McMaster University, Kitchener, Ontario, Canada;
3Division of Critical Care, Department of Medicine, Grand River Hospital, Kitchener, Ontario, Canada;
4Division of Respirology, St Mary’s General Hospital, Kitchener, Ontario, Canada
Tracheostomy is an essential procedure for patients requiring prolonged mechanical ventilation; however, it is controversial in patients with COVID-19-related acute respiratory distress syndrome (ARDS). This multicenter case series was undertaken to determine if tracheostomies can be performed safely in COVID-19 patients without transmission of infection to healthcare providers. Seven COVID-19-positive patients that underwent tracheostomy were included in the study. Descriptive analysis was undertaken with a focus on patient-important outcomes (mortality, duration of ventilation, and time to discharge from the intensive care unit) as well as healthcare provider workplace absences due to COVID-19. All patients (100%) were discharged from hospital alive. Furthermore, healthcare providers developed symptomatic SARS-CoV2 infection as a result of being involved in tracheostomy procedures for their patients. Tracheostomies are essential when providing critical care to patients with prolonged respiratory failure. This case series suggests that tracheostomy can be performed safely under conditions that protect healthcare workers in the COVID-19 era.
La trachéostomie est une intervention indispensable chez les patients nécessitant une ventilation mécanique prolongée; toutefois, elle est controversée chez les patients atteints du syndrome de détresse respiratoire aiguë (SDRA) lié à la COVID-19. Cette série de cas multicentrique a été entreprise pour savoir si les trachéostomies peuvent être réalisées en toute sécurité chez les patients atteints de la COVID-19 sans transmission de l’infection aux fournisseurs de soins. Sept patients positifs à la COVID-19 ayant subi une trachéostomie ont fait partie de cette étude. Une analyse descriptive a été réalisée en mettant l’accent sur les résultats importants pour les patients (mortalité, durée de la ventilation et temps écoulé avant la sortie de l’unité de soins intensifs), de même que sur les absences du travail des fournisseurs de soins à cause de la COVID-19. Tous les patients (100 %) ont obtenu leur congé de l’hôpital. En outre, des fournisseurs de soins ont contracté une infection symptomatique au SRAS-CoV-2 après avoir participé aux interventions de trachéostomie pratiquées sur leurs patients. La trachéostomie est indispensable lorsque des soins critiques sont prodigués aux patients présentant une insuffisance respiratoire prolongée. Cette série de cas laisse entendre que la trachéostomie peut être effectuée en toute sécurité dans des conditions qui protègent les travailleurs de la santé à l’ère de la pandémie de COVID-19.
Key words: COVID-19, SARS-CoV2, ARDS, tracheostomy
Corresponding Author: Jaymee Shell: email@example.com
Submitted: 7 January, 2021; Accepted: 25 February, 2021; Published: 15 December, 2021
All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).
The SARS-CoV2 pandemic has prompted deviations from usual care for hypoxic respiratory failure and Acute Respiratory Distress Syndrome (ARDS).1–4 Caution regarding tracheostomy insertion is a key example; in COVID-19-positive patients, this procedure is controversial. At least 12 medical societies1 have warned against this procedure in COVID-19 patients due to the potential risk of aerosolization of the virus and the risk of healthcare provider exposure.1–4 Published recommendations vary significantly regarding the timing, utility of confirming viral clearance, and the risk to healthcare workers.5–8
ARDS occurs in 8–20% of patients diagnosed with COVID-19; mortality among this subset of patients is as high as 45%9 and morbidity is significant.9–11 Tracheostomy is the current standard of care for patients requiring prolonged invasive ventilation secondary to ARDS in the intensive care unit (ICU).12,13 In the short term, tracheostomy decreases patients’ work of breathing,14 facilitates nursing care, and improves oral hygiene and patient comfort.12,13 Long-term benefits include shortened ventilator weaning times, lower incidence of ventilator-associated pneumonia,15–18 and decreased length of hospital stay.18–20
Upholding ARDS standards of care is crucial as critical care providers anticipate a second pandemic wave of COVID-19. The purpose of this case series, therefore, is to ascertain the outcomes of seven mechanically ventilated patients with COVID-19 who underwent tracheostomy as well as the incidence of symptomatic infections in the healthcare staff who performed the bedside procedure. We aimed to determine if performing tracheostomy resulted in outcomes similar to those reported in the literature prior to the COVID-19 pandemic, and if the procedure put healthcare workers at risk of viral transmission leading to illness.
This retrospective multicenter seven-patient case series was performed at St. Mary’s General Hospital and Grand River Hospital in Kitchener, Ontario. Within the Region of Waterloo, there were 1441 confirmed COVID-19 cases between March 2020 and August 2020. Of these cases, 179 (14%) required hospitalization and 57 (4%) were admitted to the ICU. We examined the charts of all intubated patients that were treated for pneumonia or ARDS secondary to COVID-19 infection and underwent tracheostomy. We performed a retrospective chart review to identify features of patients who underwent tracheostomy, including baseline patient characteristics, investigations on admission to the ICU, ventilator settings on ICU admission and at time of tracheostomy, patient mortality, risk of healthcare worker exposure, and symptomatic infection rates among healthcare providers involved in the procedure. We present a descriptive analysis of this cohort of patients, including the severity of illness and underlying comorbidities, and report the outcomes following the procedure.
Unit managers of both ICUs were surveyed and it was confirmed that no employees (MD, RT, or nursing) missed work due to symptomatic COVID-19 infection post tracheostomy procedures. This study protocol was reviewed by the Tri-Cities Hospital Research Ethics Board and approved. This study follows the principles set out in the Declaration of Helsinki.
Patients included in this cases series were 18 years of age or older, had confirmed COVID-19 infection via polymerase chain reaction (PCR) testing either from nasopharyngeal swab or endotracheal aspirate, required more than 7 days of invasive mechanical ventilatory support, and had tracheostomy inserted for this reason. Patients who had a tracheostomy performed for respiratory failure unrelated to COVID-19 infection, or had a prior tracheostomy were excluded from this case series.
Primary patient outcomes assessed were duration of ventilation, time to ICU discharge, and mortality. COVID-19 illness in healthcare workers who participated in tracheostomy procedures were monitored for 14 days post-procedure. Furthermore, we provide a descriptive analysis of baseline patient characteristics (comorbidities, age, presenting fraction of inspired oxygen [FiO2], relevant imaging, and laboratory values), phenotype of patients at the time of tracheostomy (ventilator settings, disease stage, time on the ventilator), and complications and course following tracheostomy.
The data for this case series were analyzed descriptively and presented, when appropriate, with the mean and standard deviation calculated using Microsoft Excel.
Seven patients diagnosed with COVID-19-associated respiratory failure underwent tracheostomies. Patients ranged from ages 54 to 71 years and their major comorbidities are listed in Table 1. One patient had a single-system disease isolated to respiratory failure due to COVID-19. All other patients had multi-system organ failure with hepatic dysfunction being the most common. Markers of inflammation were elevated, with a median CRP of 196 mg/L and a D-dimer of 5.8 ug/L. All but one patient were intubated on the day of admission to the ICU, with the remaining patient intubated on day 2 of admission. The majority of patients were ventilated using volume control ventilation, with a mean peak end-expiratory pressure (PEEP) of 8 cmH20 and a mean FiO2 of 69%.
Table 1. Baseline patient characteristics at the time of admission for COVID-19-related illness
|2||71||F||Never||Hypertension, Coronary Artery Disease, Depression|
|4||67||M||Never||Congestive Heart Failure|
|6||71||M||Former||Diabetes, Congestive Heart Failure|
|7||67||M||Never||Hypertension, Diabetes, Congestive Heart Failure|
ID, identification; M, male; F, female.
Bedside tracheostomy was performed in six of seven patients; the seventh patient underwent tracheostomy in the operating room, at the request of the thoracic surgeon performing the procedure. At the time of tracheostomy, six of the seven patients were still COVID-19 positive by NPS or deep endotracheal aspirate; median time to tracheostomy from intubation was 21 days, with a minimum time of 13 days and a maximum of 53 days. The decision to proceed with tracheostomy in each case was based on the discretion of the intensivist. Ventilator settings for each patient at the time of ICU admission and at the time of tracheostomy are detailed in Table 2.
Table 2. Ventilator settings upon initial intubation and at the time of tracheostomy
|Patient ID||Ventilator Settings at ICU Admission||Ventilator Settings at Tracheostomy|
|Mode||Peak pressure (cm H20)||PEEP
|Mean (SD)||28 (3)||12 (3)||0.69 (0.26)||77 (9.4)||22 (3)||9 (1)||0.39 (0.10)||104 (32.4)|
ID, identification; ICU, intensive care unit; cm, centimeters; H2O, water; PEEP, positive end expiratory pressure; FiO2, fraction of inspired oxygen; PaO2, partial pressure of O2 (arterial); PCV, pressure control ventilation; VCV, volume control ventilation; PAV, pressure assist ventilation; PSV, pressure support ventilation; –, missing data.
As per hospital policy for aerosol-generating medical procedures (AGMPs), each tracheostomy was performed in a negative pressure isolation room. All healthcare staff performing or assisting in the procedure followed hospital policy regarding personal protective equipment (PPE), wearing an N-95 mask, face shield, hair covering (bouffant or surgical cap), and impermeable gown and gloves. The use of “double-gloving” was left to the discretion of the thoracic surgeon performing the tracheostomy. Bedside percutaneous tracheostomies were facilitated using the serial dilational technique, with an experienced ICU physician performing bronchoscopy for anatomical identification and landmarking. Assisting staff were limited to only essential individuals: two respiratory therapists and two critical care nurses. Details regarding six of the seven procedures are found in Table 3. One procedure note was not available for viewing in the hospital EMR.
Table 3. Detailed description of tracheostomy timing and technique
|Patient ID||Time to tracheostomy (Days)*||Covid status at the time of trach||Procedure||Bronchoscopy used (Y/N)||Difficult anatomy (Y/N)|
|2||14||NPS negative||Surgical OR||Y||Y|
|6||22||NPS negative||Bedside percutaneous||Y||N|
|Mean (SD)||21 (6)|
ID, identification; Y, yes; N, no; OR, operating room; –, missing procedure note.
*Time to tracheostomy from intubation.
There were no immediate complications requiring resuscitation of the patient. Only one patient had bleeding from the tracheostomy site after the procedure, which resolved spontaneously and did not require transfusion.
Patients’ mean time on the ventilator was 30 days in total. Outcomes related to mechanical ventilation are listed in Table 4 and Figure 1. Following tracheostomy, the mean duration of tracheostomy mask trials was 8 days and the mean time to decannulation was 19 days. The mean total length of stay in the ICU was 36 days and the mortality rate was zero. Reported complications (as presented in Table 5) were a consequence of the underlying disease process and/or critical illness, and not necessarily reflective of the tracheostomy procedure. The most prevalent complications were delirium (86%) and critical illness polyneuropathy (86%), which were the most frequently cited reasons for prolonged mechanical ventilation. Four patients developed secondary ventilator-associated pneumonia, requiring antibiotic treatment.
Figure 1. Mean time to major milestone events for patients who received tracheostomy for COVID-19 illness. Bars represent standard deviation
Table 4. Patient outcomes related to the length of time requirement for mechanical ventilation and the length of ICU admission
|Patient ID||Time on the ventilator (Days)*||Time trach mask trialling (Days)||Time to decannulation (Days)**||Time to ICU discharge (Days)***|
|Mean (SD)||32 (15)||8 (5)||24 (17)||40 (14)|
ID, identification; Trach, tracheostomy; ICU, intensive care unit.
*Time on ventilator from intubation.
**Time to decannulation from tracheostomy.
***Time to ICU discharge from ICU admission.
Table 5. Medical complications of critically ill COVID-19 patients
|Patient ID||VAP||AKI||Liver failure||Delirium||CIPN||Ischemic limb||Death|
ID, identification; VAP, ventilator-associated pneumonia; AKI, acute kidney injury; CIPN, critical illness polyneuropathy.
Within the intensive care departments, no healthcare providers who participated in the tracheostomy procedure developed symptomatic COVID-19 infections in the 2 weeks after the procedure All procedure notes mentioned that airborne precautions were maintained by those involved, including the procedure being performed in a negative pressure room, in keeping with Infection Prevention and Control recommendations for AGMPs.3
This seven-patient case series demonstrates that performing tracheostomies in COVID-19-positive patients did not result in symptomatic COVID-19 infections in healthcare workers at two community hospitals, when appropriate airborne precautions were used.
Debate regarding the safety of this procedure arises from the potential of aerosolization and risk of provider exposure, weighed against the known benefits of tracheostomy in patients with ARDS. Guidelines on this topic have evolved since the beginning of the pandemic, with conflicting recommendations.1–4,22–25 For example, the Canadian Society of Otolaryngologists recommended against the use of tracheostomies in COVID-19-positive patients,4 while the American College of Chest Physicians (ACCP) recommended consideration of tracheostomy in patients requiring prolonged invasive mechanical ventilation.3 The ACCP stipulated that tracheostomy should only be performed with appropriate PPE, and suggested waiting for at least 21 days to perform the procedure to minimize the viral load in the event of aerosolization.3 The ACCP did not recommend routine use of PCR to “confirm” viral clearance.3 A systematic review of otolaryngology practice guidelines on this subject determined that the procedure should be performed if patients were expected to require prolonged invasive mechanical ventilation, cautioning that healthcare staff, ICU physicians, and surgeons in the room at the time of procedure were at the highest risk of exposure.4,23 Others recommended consideration of tracheostomy after at least 10 days of ventilation in patients showing clinical signs of improvement, stipulating use of techniques that minimized blood loss and avoiding diathermy.1–4 With minimal consensus regarding the safety and optimal timing of tracheostomy, the decision to perform the procedure still largely falls within the decision-making capacity of the healthcare team and individual institutional policies.
At the two participating institutions in this case series, decisions to advance to tracheostomy were made according to patient needs and the desire to provide optimal care in the setting of prolonged mechanical ventilation. There are multiple benefits of tracheostomy in patients with traditional ARDS, including a mortality benefit at 1 year18–20 and earlier liberation from mechanical ventilation. It is not yet known if these benefits occur with tracheostomy in the treatment of ARDS related to COVID-19.
The aerosolization risk to providers is an ongoing concern. Great care was taken to reduce the risk of exposure to healthcare workers. All seven tracheostomies were performed after 13 days, in keeping with guidelines recommending consideration of tracheostomy after at least 10 days of mechanical ventilation.3,5 Of note, six of the seven patients in this case series had prolonged positive NPS, and were positive at the time of the procedure. Healthcare workers in this study adhered to appropriate enhanced PPE protocols, including the use of an N-95 mask, face shield, and fluid-resistant gown and gloves. Although asymptomatic transmission cannot be excluded, there were no symptomatic COVID-19 cases among healthcare providers involved in these tracheostomy procedures.
While the optimal timing of tracheostomy in mechanically ventilated ICU patients with COVID-19-related ARDS remains controversial, multiple physicians have advocated for delayed tracheostomies in COVID-19 patients due to unproven mortality benefit and the high mortality rate in COVID-19 once a patient is intubated.5–8 The unknown period of infectivity was a significant barrier to providing the standard of care in terms of tracheostomy procedures, and this pandemic has reinforced the need for tremendous advocacy for optimal patient care while balancing concerns of minimizing healthcare worker exposure in the face of many unknowns, particularly early on in the pandemic. This further highlights the quickly changing landscape when applying evidence-based medicine to a rapidly evolving pandemic.
The type of tracheostomy procedure used should be dictated by the expertise of the performing surgeon,26 and in our center the percutaneous technique was generally preferred. Previous studies conducted during the SARS-CoV1 outbreak reported that surgical tracheostomies were preferred over bedside percutaneous techniques, due to the lower risk of aerosolization during the procedure. The percutaneous technique requires reopening of the ventilator circuit several times during the procedure.27,28 However, there are currently no studies comparing the rates of healthcare provider infection with surgical versus percutaneous tracheostomy procedures. In addition, we adhered to previously published recommendations, including minimizing the personnel in the room to six people or less, pre-oxygenating the patient prior to starting the procedure to maximize safe apneic time, using paralytic drugs to reduce coughing and potential transmission to healthcare staff.27,28
There were no symptomatic COVID-19 infections in ICU staff as a result of the tracheostomies performed in these two centers. In 2002, tracheostomies were performed in SARS-CoV1- positive patients. There were reports in Canada of healthcare workers contracting the virus as a result of AGMPs; however, many of these patients had not yet been diagnosed and full enhanced infection control procedures were still being ascertained at that time.21,23,24,29 In Singapore, however, there were no documented healthcare worker infections associated with the tracheostomies performed in SARS-Cov1 patients.27
Our results are consistent with that of Chao et al., who performed tracheostomies in 53 patients diagnosed with COVID-19 in five hospitals within the University of Pennsylvania Health System using standard PPE and airborne precautions without any reported infections in healthcare workers. Our mortality rate was 0%, compared to 11.6% in this paper, but our case series did not include patients on extracorporeal membrane oxygenation (ECMO), which may have contributed to the low mortality rate, as these patients typically have a greater severity of illness.30 The complications observed in our cohort were comparable to those previously cited for COVID-19-positive critically ill patients.31
Limitations of this study include the small sample size. A larger cohort of patients would provide more robust conclusions regarding outcomes following tracheostomy and may further inform optimal timing of the procedure. Furthermore, all surgeons at our participating institutions used the same serial dilational tracheostomy technique, so further studies are required to determine if there is an increased risk of viral transmission using other tracheostomy techniques. Furthermore, there could have been omissions in reporting to ICU unit managers; however, this analysis was completed within 1 month of all procedures making this less likely. There were no screening COVID-19 swabs performed on HCPs involved in the procedures, as our institutional policy does not recommend them in the absence of symptoms. It is unknown if any healthcare workers developed asymptomatic cases of COVID-19 post-procedure.
In this case series, with the use of appropriate PPE and negative pressure environments, seven tracheostomies were performed in patients actively infected with the novel coronavirus, SARS-CoV2, with no resultant symptomatic infections in the healthcare workers involved in the procedure.
More data are needed to inform appropriate timing of tracheostomy, ARDS-related outcomes specific to COVID-19-infected patients, and to determine if asymptomatic infection occurs in healthcare workers post tracheostomy procedure.
The authors report no conflict of interest
All authors contributed equally to this work.
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