Ventilated COVID-19 Patients Could Benefit from Tracheotomy

Tracheotomy might be reasonable for some patients with COVID-19 who have been ventilated for more than 21 days, according to a new guideline.

Issued by surgeons at the University of Pennsylvania (Penn; Philadelphia, USA) serving on the COVID-19 tracheotomy task force, the guideline highlights specific considerations regarding tracheotomy for patients with COVID-19 that are on ventilatory support. Based on available evidence, they recommend that tracheotomy might be considered in patients with durations of intubation greater than 21 days who are otherwise without significant comorbidities, and who would be expected to have a good prognosis if they survive.

Tracheotomy before 21 days should not be done routinely in these patients solely due to prolonged ventilator dependence, due to the high risk of transmission and poor prognosis of patients requiring intubation and ventilation. Tracheotomy for other indications, such as a known difficult airway, should be considered in COVID-19 patients on a case-by-case basis; when deemed necessary in these patients, an open surgical tracheotomy should be favored over a percutaneous dilational tracheotomy in order to minimize aerosol generation.

Where possible, these tracheotomies should be performed at bedside in a negative pressure room to minimize the risk of transmission during patient transport, and team members in the room should be kept to the minimal critical number, preferably with highly experienced personnel. Airborne and droplet precautions should be followed, and each person in the room should properly don and doff personal protective equipment (PPE). In addition, a multidisciplinary discussion of the patient's goals of care, overall prognosis, and the expected benefits of tracheotomy should be a critical part of the decision-making process. The guideline was published on May 19, 2020, in Annals of Surgery.

“Early tracheostomy must be considered very carefully along with the patient's expected prognosis, as data from some U.S. series suggests that the mortality of intubated patients is still quite high,” said lead author Tiffany Chao, MD. “On the other hand, there are patients who do warrant the procedure for a variety of reasons, which can be done in a way that is safe for the healthcare team, so it should not be avoided in patients with a reasonable indication and prognosis. The optimal timing should continue to be refined as more data is published.”

An estimated 3-17% of patients hospitalized with COVID-19 require invasive mechanical ventilation. While early tracheotomy (within seven days of intubation) is commonly recommended for critically ill ventilated patients without COVID-19, it remains unclear that this would be beneficial for intubated patients with COVID-19, as their mortality is high in any case, and the median duration of intubation of non-survivors appears to be less than a week.

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