Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report.

American Academy of Otolaryngology Head and Neck Surgery 2000 Annual Meeting

Importance Decision-making in the timing of tracheostomy in patients with coronavirus disease 2019 (COVID-19) has centered on the intersection of long-standing debates on the benefits of early vs late tracheostomy, assumptions about timelines of infectivity of the novel coronavirus, and concern over risk to surgeons performing tracheostomy. Multiple consensus guidelines recommend avoiding or delaying tracheostomy, without evidence to indicate anticipated improvement in outcomes as a result. Objective To assess outcomes from early tracheostomy in the airway management of patients with COVID-19 requiring mechanical ventilation. Design, Setting, and Participants A retrospective medical record review was completed of 148 patients with reverse transcriptase–polymerase chain reaction–confirmed COVID-19 requiring mechanical ventilation at a single tertiary-care medical center in New York City from March 1 to May 7, 2020. Interventions Open or percutaneous tracheostomy. Main Outcomes and Measures The primary outcomes were time from symptom onset to (1) endotracheal intubation, (2) tracheostomy; time from endotracheal intubation to tracheostomy; time from tracheostomy to (1) tracheostomy tube downsizing, (2) decannulation; total time on mechanical ventilation; and total length of stay. Results Participants included 148 patients, 120 men and 28 women, with an overall mean (SD) age of 58.1 (15.8) years. Mean (SD; median) time from symptom onset to intubation was 10.57 (6.58; 9) days; from symptom onset to tracheostomy, 22.76 (8.84; 21) days; and from endotracheal intubation to tracheostomy, 12.23 (6.82; 12) days. The mean (SD; median) time to discontinuation of mechanical ventilation was 33.49 (18.82; 27) days; from tracheostomy to first downsize, 23.02 (13.76; 19) days; and from tracheostomy to decannulation, 30.16 (16.00; 26) days. The mean (SD; median) length of stay for all patients was 51.29 (23.66; 45) days. Timing of tracheostomy was significantly associated with length of stay: median length of stay was 40 days in those who underwent early tracheostomy (within 10 days of endotracheal intubation) and 49 days in those who underwent late tracheostomy (median difference, −8; 95% CI, −15 to −1). In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation (hazard ratio, 0.84; 95% CI, 0.55 to 1.28). Conclusions and Relevance This cohort study from the first 2 months of the pandemic in New York City provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19. Findings demonstrated noninferiority of early tracheostomy and challenges recommendations to categorically delay or avoid tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of the novel coronavirus, this approach may optimize outcomes from tracheostomy while keeping clinicians safe.

/pdf/early-outcomes-from-early-tracheostomy-for-patients-with-49efya8guz.pdf

Early Outcomes From Early Tracheostomy for Patients With COVID-19.

Background The role of tracheostomy in coronavirus disease 2019 (COVID-19) is unclear, with several consensus guidelines advising against this practice. We developed both a dedicated airway team and coordinated education programme to facilitate ward management of tracheostomised COVID-19 patients. Here, we report outcomes in the first 100 COVID-19 patients who underwent tracheostomy at our institution. Methods This was a prospective observational cohort study of patients confirmed to have COVID-19 who required mechanical ventilation at Queen Elizabeth Hospital, Birmingham, UK. The primary outcome measure was 30-day survival, accounting for severe organ dysfunction (Acute Physiology and Chronic Health [APACHE]-II score>17). Secondary outcomes included duration of ventilation, ICU stay, and healthcare workers directly involved in tracheostomy care acquiring COVID-19. Results A total of 164 patients with COVID-19 were admitted to the ICU between March 9, 2020 and April 21, 2020. A total of 100 patients (mean [standard deviation] age: 55 [12] yr; 29% female) underwent tracheostomy; 64 (age: 57 [14] yr; 25% female) did not undergo tracheostomy. Despite similar APACHE-II scores, 30-day survival was higher in 85/100 (85%) patients after tracheostomy, compared with 27/64 (42%) non-tracheostomised patients {relative risk: 3.9 (95% confidence intervals [CI]: 2.3–6.4); P Conclusion Independent of the severity of critical illness from COVID-19, 30-day survival was higher and ICU stay shorter in patients receiving tracheostomy. Early tracheostomy appears to be safe in COVID-19.

Safety and 30-day outcomes of tracheostomy for COVID-19: a prospective observational cohort study

ObjectiveIn the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literat...

https://journals.sagepub.com/doi/pdf/10.1177/0194599820961990

Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review.

BACKGROUND: The COVID-19 pandemic has resulted in the implementation of rapidly changing protocols and guidelines related to the indications and perioperative precautions and protocols for tracheostomy. The purpose of this study was to evaluate current guidelines for tracheostomy during the COVID-19 pandemic to provide a framework for health systems to prepare as the science evolves over the upcoming months and years. METHODS: Literature review was performed. Articles reporting clinical practice guidelines for tracheostomy in the context of COVID-19 were included. RESULTS: A total of 13 tracheotomy guidelines were identified. Two were available via PubMed, five in society or organization websites, and six identified via health system websites or other sources. Five were from Otolaryngology-Head and Neck Surgery specialties, six from Anesthesiology and one from Pulmonary/Critical Care. All (100%) studies recommended postponing elective OR cases in COVID-19 positive patients, while seven recommended reducing team members to only essential staff and three recommended forming a designated tracheostomy team. Recommendations with supporting references are summarized in the article. CONCLUSIONS: Tracheostomy guidelines during the COVID-19 pandemic vary by physician groups and specialty, hospital systems, and supply-chain/resource availability. This summary is provided as a point-in-time current state of the guidelines for tracheotomy management in April 2020 and is expected to change in coming weeks and months as the COVID-19 pandemic, virus testing and antibody testing evolves.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/hed.26192

Tracheostomy protocols during COVID-19 pandemic.

Paradoxical Vocal Fold Movement: A Retrospective Analysis.

Objective:To evaluate the success of sole medical therapy (MT) versus surgical therapy (ST) in patients with both clinically and radiographically confirmed peritonsillar abscess (PTA). To also dete...

Peritonsillar Abscess Size as a Predictor of Medical Therapy Success.

Vestibular dysfunction in cochlear implant candidates: Prevalence and outcomes

The muscles of the pharynx play an integral role in many vital processes such as breathing, swallowing, and speaking. Coordination of the pharyngeal musculature with the laryngeal and tongue muscles is essential to the efficiency of these essential human functions. Broadly categorized by their orientation (circular versus longitudinal), these muscles allow the pharynx to change its size and shape to achieve with the required function. Understanding the embryology, structure, blood supply, lymphatics, innervation, and function of each of the paired pharyngeal muscles is critical for diagnosis and treatment of pathologic conditions.

Cameron Heyd

Papers

Tracheostomy protocols during COVID-19 pandemic.

Paradoxical Vocal Fold Movement: A Retrospective Analysis.

Peritonsillar Abscess Size as a Predictor of Medical Therapy Success.

Vestibular dysfunction in cochlear implant candidates: Prevalence and outcomes

Anatomy, Head and Neck, Pharynx Muscles