key: cord-0705497-dn1474bp
authors: Arnold, J. M.; Gao, C. A.; Malsin, E.; Todd, K.; Argento, A. C.; Cuttica, M.; Coleman, J. M.; Wunderink, R. G.; Smith, S. B.; Investigators, NU COVID
title: Outcomes of Percutaneous Tracheostomy for Patients with SARS-CoV-2 Respiratory Failure
date: 2021-02-25
journal: medRxiv : the preprint server for health sciences
DOI: 10.1101/2021.02.23.21252231
sha: 9c99f86f27fa2fd8721fcc664ce0793f84b70809
doc_id: 705497
cord_uid: dn1474bp

Background: SARS-CoV-2 can cause severe respiratory failure leading to prolonged mechanical ventilation. Data are just emerging about the practice and outcomes of tracheostomy in these patients. We reviewed our experience with tracheostomies for SARS-CoV-2 at our tertiary care, urban teaching hospital. Methods: We reviewed the demographics, comorbidities, timing of mechanical ventilation, tracheostomy, and ICU and hospital lengths of stay (LOS) in SARS-CoV-2 patients who received tracheostomies. Early tracheostomy was considered <14 days of ventilation. Medians with interquartile ranges (IQR) were calculated and compared with Wilcoxon rank sum, Spearman correlation, Kruskal-Wallis, and regression modeling. Results: From March 2020 to January 2021, our center had 370 patients intubated for SARS-CoV-2, and 59 (16%) had percutaneous bedside tracheostomy. Median time from intubation to tracheostomy was 19 (IQR 17 - 24) days. Demographics and comorbidities were similar between early and late tracheostomy, but early tracheostomy was associated with shorter ICU LOS and a trend towards shorter ventilation. To date, 34 (58%) of patients have been decannulated, 17 (29%) before hospital discharge; median time to decannulation was 24 (IQR 19-38) days. Decannulated patients were younger (56 vs 69 years), and in regression analysis, pneumothorax was associated was associated with lower decannulation rates (OR 0.05, 95CI 0.01 - 0.37). No providers developed symptoms or tested positive for SARS-CoV-2. Conclusions: Tracheostomy is a safe and reasonable procedure for patients with prolonged SARS-CoV-2 respiratory failure. We feel that tracheostomy enhances care for SARS-CoV-2 since early tracheostomy appears associated with shorter duration of critical care, and decannulation rates appear high for survivors.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may cause acute, severe respiratory failure that can lead to prolonged mechanical ventilation.

At the onset of the pandemic there were questions regarding the safety and value of tracheostomy for SARS-CoV2 patients with prolonged respiratory failure. Tracheostomy has since been described and safely performed in these patients, and several societal guidelines support performing tracheostomy with proper personal protective equipment and precautions. [1] [2] [3] [4] [5] [6] Data are emerging about the practice and outcomes of tracheostomy for prolonged respiratory failure from SARS-CoV-2. Rates of decannulation and survival have varied in the literature. In the largest cohorts from Spain and England, median times to tracheostomy ranged from 12 to 16 days. 7, 8 The Spanish multicenter cohort found an overall mortality rate of 23%, and their decannulation rate for survivors weaned from ventilation was 81%. 7 Another study from England reported 85% survival at 30 days and a 99% overall decannulation rate for survivors. 9 Several smaller studies from earlier in the pandemic reported lower decannulation rates, ranging from 8% to 13%. 1, 3, 4 However, one of the largest systematic review and meta-analysis comprising over 3000 patients found an average decannulation rate of 34.9. 7 One potential explanation for differences is availability and willingness of long term acute care (LTAC) facilities to transfer SARS-CoV-2 infected patients.

We sought to review our practice at a large, US tertiary-care, urban teaching hospital that has had a high volume of patients with SARS-CoV-2 respiratory failure. Our All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 25, 2021. ; goals were to determine mortality and decannulation rates as well to assess patient characteristics associated with successful outcomes.

We reviewed patients with SARS-CoV-2 who had percutaneous bedside tracheostomy for prolonged respiratory failure in our single-center, tertiary-care, urban teaching hospital from March 2020 to January 2021. These tracheostomies were bedside percutaneous procedures performed by interventional pulmonologists wearing powered air purifying respirators, gowns, and gloves. The procedures followed our standard practices for percutaneous tracheostomy, although the oropharynx was packed with gauze to minimize aerosolization when the cuff on the endotracheal tube was deflated. Patient demographics and comorbidities, the timing of mechanical ventilation and tracheostomy, as well as ICU and hospital lengths-of-stay (LOS) were catalogued. Primary outcomes included overall mortality and decannulation rates, whereas the secondary outcome was time to weaning from mechanical ventilation. The timing of tracheostomy was at the discretion of the ICU attending and interventional pulmonologist who performed the procedures. Tracheostomy was considered early when performed within 14 days of initiation of mechanical ventilation. Like other centers, we experienced two waves of admissions: we considered the first wave those admitted from March to July 2020; whereas the second wave included those admitted after August 1, 2020.

Statistical analyses were performed with Stata 11.2 (College Station, TX). Not all continuous data were normally distributed, and so median values with interquartile ranges (IQR) were calculated. Non-parametric analyses included Wilcoxon rank sum and Spearman correlation testing. Kruskal-Wallis testing was used to compare data across All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252231 doi: medRxiv preprint multiple categories. Regression modeling was used to identify variables associated with outcomes. Statistical significance was established as p < 0.05.

From March 2020 to January 2021, 370 patients were intubated for SARS-CoV-2 respiratory failure, and percutaneous bedside tracheostomy was performed in 59 (15.9%) patients. Median age was 66 (IQR 61 -71) years, and 32% were female. Median body mass index was 27 (24 -33), and the median number of comorbidities was 2 (IQR 1 -3).

The most common comorbidities were hypertension (61%), diabetes (54%), and obesity (41%). Twenty-six patients (44%) were treated with steroids, and 21 (36%) with remdesivir, either under the emergency use authorization or following FDA approval. An additional 5 (8%) patients participated in a double blind remdesivir versus placebo trial.

Median time from intubation to tracheostomy was 19 (IQR 17 -24) days. Median PEEP was 10 (IQR 6 -10), and FiO2 was 40% (40% -50%) on the day of tracheostomy.

The most common tracheostomy placed was a Shiley 6 distal XLT (n=36, 61%). No procedural complications related to tracheostomy placement occurred. The most common overall hospital complications were pneumonia (83%), and the majority of pneumonia cases (37/49) occurred before tracheostomy placement. Venous thromboembolism (56%), acute renal failure requiring dialysis (44%), and pneumothorax (24%) were the other common hospital complications.

Median length of follow-up has been 42 (IQR 16 -125) days, and 81% have 30day follow-up data available. Decannulation occurred in 34 patients (83% of survivors and 58% of all patients), with 17 patients (50%) being decannulated prior to hospital discharge.

Median time to decannulation was 24 (IQR 19 -38) days. Median ICU LOS was 37 (IQR All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. No providers involved in the placement of tracheostomies developed symptoms or tested positive for SARS-CoV-2.

There were 45 patients who had tracheostomy in the first wave and 14 in the second.

In the second wave, 3 of the 14 patients remained admitted at the time of this study.

Baseline demographics (i.e., age, gender, comorbidities) and times from intubation to tracheostomy were similar between the two waves. There was significantly higher utilization of steroids (92.9% vs. 28.9%, p<0.001) and remdesivir (85.7% vs. 20.0%, p<0.001) in the second wave. Rates of renal failure and pneumonia were similar, but there were trends toward higher rates of pneumothorax (42.9% vs. 17.8%, p=0.056) and venous thromboemboli (78.6% vs. 48.9%, p=0.053) in the second wave. Mortality, hospital LOS, ICU LOS, duration of mechanical ventilation, and time to weaning from mechanical All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 25, 2021. ; ventilation were similar between the two waves. Decannulation by hospital discharge was higher in the first wave (37.8% vs 0%, p=0.016).

We found that tracheostomy for SARS-CoV-2 patients was a safe and reasonable practice for prolonged respiratory failure. As described in similar studies, we found no incidents of operators contracting SARS-CoV-2 infection during tracheostomy. 2, 5, 6, [8] [9] [10] The ideal time from intubation to tracheostomy for SARS-CoV-2 has been debated, as it has been for other critical illnesses. There had been initial concerns that tracheostomy should be delayed until after active SARS-CoV-2 viral replication, whereas others proposed early tracheostomy to facilitate weaning and preserve resources during pandemic. 11 Our practice has been to maintain traditional standards for tracheostomy selection with regard to timing, oxygenation, and hemodynamic stability. Although we do not have data regarding sedation dosing before and after tracheostomy, we suspect that tracheostomy facilitates lightening sedation and weaning SARS-CoV-2 patients as in other causes of prolonged respiratory failure. 7 Our median times to tracheostomy (19 days) and times to weaning (17 days) are similar to other reports in the literature. [2] [3] [4] 12, 13 Mata-Castro et al. (2021) found that a longer time from intubation to tracheostomy was related to a longer time from tracheostomy to weaning. 13 Two other studies found that early tracheostomy was associated with shorter overall duration of mechanical ventilation and ICU LOS. 2, 6 We did not find an association between the time to tracheostomy and the outcomes of weaning, decannulation, or mortality, although there was shorter ICU LOS after early tracheostomy. All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 25, 2021. ;

Differences between the initial surge in the spring of 2020 and a second wave later in the fall have been described. Subgroup analyses between our two waves found trends towards more pneumothorax and venous thromboemboli in the second wave, and undoubtedly more patients received steroids in the second wave because of the RECOVERY trial. 14 Studies have demonstrated overall relatively good survival rates for patients with SARS-CoV-2 who had tracheostomy, with mortality ranging from 7% to 23%. 1, 3, 5 Many studies have been affected by duration of follow-up and available outcome data, and the largest study from Spain reports one of the higher mortality rates of 23%. 7 Complete 30day follow-up data were available for 81% of our patients, and this subgroup had a 33% 30-day mortality rate. This elevation in mortality found in our study may be attributed to the high number of external hospital transfers (n=9, 15%) for escalation of care. Survival amongst tracheostomy patients has been described as higher than those who did not receive tracheostomy, 9 although selection bias is to be considered for which patients are stable enough to have tracheostomy.

Long-term outcomes of lung function are unknown for patients who survive SARS-CoV-2 respiratory failure. Short-term decannulation rates for non-SARS-CoV-2 ARDS are not well published, but already multiple studies, including ours, have demonstrated high rates of decannulation within only a few months after ARDS from SARS-CoV-2.

More than 80% of our surviving patients have been decannulated, although long-term lung function is yet unknown. We have used our data to counsel families when deciding upon tracheostomy, as we feel that tracheostomy is a safe and appropriate procedure that can facilitate weaning from mechanical ventilation. All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table 1 : Baseline characteristics of patients with SARS-CoV-2 who had tracheostomy.

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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table 3 : Hospital complications of patients with SARS-CoV-2 who had tracheostomy.

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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 25, 2021. ; https://doi.org/10.1101/2021.02.23.21252231 doi: medRxiv preprint

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Acknowledgements: The authors thank the many individuals (nurses, respiratory