Percutaneous tracheostomy in patients with COVID-19 infection and acute respiratory failure

Abstract

Background: Tracheostomy is often performed in patients who need prolonged intubation. COVID -19 brought unforeseen challenges, thus altering previously established norms. In this study, the outcomes of the patients undergoing tracheostomy for respiratory failure due to COVID -19 were studied.

Methods: This is a single center retrospective observational cohort study of patients who underwent percutaneous tracheostomies between March 1, 2020, and September 30, 2021, due to respiratory failure secondary to COVID-19. Inclusion criteria included performance of percutaneous tracheostomies on patients with confirmed diagnosis of COVID-19. Exclusion criteria included patients undergoing surgical tracheostomies, extubation prior to the performance of a tracheotomy, and death prior to the performance of the tracheotomy.

Results: The study included 49 patients after reviewing the records of 101 patients who underwent tracheostomies during the study period. The average age of the population was 59 ± 11years; 33 patients (67%) were men. The median Sequential Organ Failure Assessment (SOFA) score on admission was 2.  The median duration of mechanical ventilation prior to tracheostomy was 18 days; the median positive end expiratory pressure was 10 cm H₂O and the median fraction of inspired oxygen (FiO₂) was 0.45. Two patients died during the procedure, one secondary to cardiac arrest and one secondary to bleeding. Eighteen patients (38%) died after the procedure during hospitalization; the median length of mechanical ventilation for all patients was 32.5 days.  Eleven patients (22%) were eventually decannulated. Twenty patients (40%) were discharged to rehabilitation, and nine patients (18%) were discharged home. Eighteen patients (36%) were alive at the end of 90 days. Twelve patients (26%) were lost to follow up after discharge from the hospital. At the time of the tracheostomy, 16 patients (32%) had moderate ARDS as per the Berlin definition, and 12 (24%) had severe ARDS.

Conclusion: Tracheostomy is an important therapeutic intervention in critically ill patients requiring mechanical ventilation.  The COVID-19 pandemic raised important concerns and uncertainties about the management of these patients and the safety of healthcare workers.  In this study, 29 patients (59%) undergoing tracheostomies recovered enough to be discharged to rehabilitation or to their homes.  The risks to patients and to healthcare workers seem reasonable, but the optimal timing is uncertain and is best tailored to each patient based on his/her clinical status and prognosis.

Keywords: COVID-19, tracheostomy, mechanical ventilation, acute respiratory failure