key: cord-0747543-nf0x2i4j authors: Hansson, Anna; Sunnergren, Ola; Hammarskjöld, Anneli; Alkemark, Catarina; Taxbro, Knut title: Characteristics, complications, and a comparison between early and late tracheostomy: A retrospective observational study on tracheostomy in patients with COVID‐19‐related acute respiratory distress syndrome date: 2022-04-22 journal: Health Sci Rep DOI: 10.1002/hsr2.595 sha: 72f34e7dc71ab97fd2ee54c04cd89e342da61da2 doc_id: 747543 cord_uid: nf0x2i4j BACKGROUND AND AIMS: As the coronavirus disease 2019 (COVID‐19) pandemic spread worldwide in 2020, the number of patients requiring intensive care and invasive mechanical ventilation (IMV) has increased rapidly. During the pandemic, early recommendations suggested that tracheostomy should be postponed, as the potential benefits were not certain to exceed the risk of viral transmission to healthcare workers. The aim of this study was to assess the utility of tracheostomy in patients with COVID‐19‐related acute respiratory distress syndrome, in terms of patient and clinical characteristics, outcomes, and complications, by comparing between early and late tracheostomy. METHODS: A multicenter, retrospective observational study was conducted in Jönköping County, Sweden. Between 14 March 2020 and 13 March 2021, 117 patients were included. All patients ≥18 years of age with confirmed COVID‐19, who underwent tracheostomy were divided into two groups based on the timing of the procedure (≤/>7 days). Outcomes including the time on IMV, intensive care unit (ICU) length of stay, and mortality 30 days after ICU admission, as well as complications due to tracheostomy were compared between the groups. RESULTS: Early tracheostomy (<7 days, n = 56) was associated with a shorter median duration of mechanical ventilation (7 [12], p = 0.001) as well as a shorter median ICU stay (8 [14], p = 0.001). The most frequent complication of tracheostomy was minor bleeding. With the exception of a higher rate of obesity in the group receiving late tracheostomy, the patient characteristics were similar between the groups. CONCLUSION: This study showed that early tracheostomy was safe and associated with a shorter time on IMV as well as a shorter ICU length of stay, implicating possible clinical benefits in critically ill COVID‐19 patients. However, it is necessary to verify these findings in a randomized controlled trial. In December 2019, an unknown form of pneumonia was reported in Wuhan, China. 1 Within the first weeks of 2020, the coronavirus disease 2019 (COVID-19) had spread worldwide, causing a pandemic. 2 In May 2021, the World Health Organization reported over 152 million cases and three million deaths globally due to In Sweden, the number of cases peaked in April 2020 and then again in December 2020, creating the characteristic "first and second wave." As the virus spread, the number of patients requiring admission to the intensive care unit (ICU) increased rapidly, leading to massive challenges for the healthcare system 4 in general and ICUs in particular. COVID-19 causes critical illness in 5% of cases 5, 6 and one of the most common and life-threatening complications of COVID-19 is acute respiratory distress syndrome (ARDS). 7 ARDS is characterized by hypoxemic respiratory failure, pulmonary epithelial injury in the alveoli, and a systemic inflammatory response. 8 Patients with ARDS due to COVID-19 generally require prolonged invasive mechanical ventilation (IMV) and are, therefore, often considered for tracheostomy. 4 The predominant indication for tracheostomy in patients with ARDS due to COVID-19 is to facilitate prolonged IMV and aid when difficult weaning is anticipated. 9 Tracheostomy is associated with a lower requirement for sedatives and improved patient comfort, as well as optimized clearance of airway secretions. It facilitates oral care and reduces the risk of ventilator-associated pneumonia and aspiration during weaning, while avoiding complications of long-term oral intubation, such as tracheal stenosis. 10, 11 In addition, tracheostomy tubes provide less need for breathing by bypassing the mouth and pharynx, thus creating less airway dead space. 4 As patients can be discharged to intermediate care facilities before decannulation, tracheostomy could potentially decrease the time in the ICU 12 liberating much needed resources. Tracheostomy can be performed using either open surgical or percutaneous techniques. Studies have not shown significant differences in outcomes between the methods used for tracheostomy in COVID-19 patients. 13 Performing tracheostomy has several advantages over oral intubation in critically ill patients requiring mechanical ventilation. 14 However, the optimal timing of the procedure has not been determined. Data on "early" vs. "late" tracheostomy regarding outcomes such as mortality and length of ICU and hospital stay are conflicting, and no consensus has yet been reached. 15 As the clinical trajectory of COVID-19 was unclear at the onset of the pandemic, the timing of tracheostomy was even more ambiguous in these patients. 16 As tracheostomy is an aerosol-generating procedure, 17 it is considered to be associated with a high risk of viral transmission to healthcare personnel, based on experience from the severe acute respiratory syndrome epidemic in 2003. 18 Because of this, recommendations about being restrictive when performing tracheostomy in COVID-19 patients emerged at the onset of the pandemic. 19, 20 Experts in otolaryngology suggested that tracheostomy should be delayed when the patient is cleared of infection, unless an adequate airway cannot be maintained with oral intubation. 21 In June 2020, the American College of Chest physicians recommended that tracheostomy should be considered in COVID-19 patients, although evidence on the optimal timing of the procedure is still lacking. 22 In our hospitals, the strategy of COVID-19 tracheostomies This was a multicenter, retrospective observational study conducted at Ryhov County Hospital, Eksjö Hospital, and Värnamo Hospital, three nonacademic rural hospitals in Jönköping County in southern Sweden. The study included all adult patients (≥18 years old) who were Patients who underwent tracheostomy were categorized into two groups based on the timing of the procedure. Those who were on mechanical ventilation for ≤7 days before surgery were included in the "early" group and those who were on mechanical ventilation for >7 days were included in the "late" group. 23 Comorbidities were defined by International Classification of Diseases-10 codes in the medical records, that is, cardiovascular disease (I25 and/or I50), hypertension (I10), diabetes (E10/E11), asthma (J45), and chronic obstructive pulmonary disease (J44) in combination with active treatment. Immunosuppression was classified as systemic steroid treatment, radiation, or chemotherapy <6 months before hospital admission. 24 ARDS was defined using the criteria put forth by the Swedish Intensive Care Registry adopted from the Berlin definition. 24 Kidney function was defined using the "Kidney Disease: Improving Global Outcomes classification of chronic kidney disease" based on the glomerular filtration rate ml/min/1.73 m 2 . Complications associated with tracheostomy were defined as events that had a potential negative impact on the patients' clinical course and thus required intervention. All events occurring from the time of the procedure to the time of decannulation were included. The definitions of the complications are outlined in Table 1 . This study was approved by the Swedish Ethical Review Authority on August 26, 2020 (Dnr 2020-02758). Patient consent was waived due to the retrospective nature of the study. Table 2 . The baseline characteristics were similar between the early and late tracheostomy groups, with the exception that immunosuppressant treatment before ICU admission was more common in the late tracheostomy group (p = 0.026). In both the groups, the patients were predominantly men, with a median age of 66 years. Hypertension was the most frequent comorbidity (55%), followed by type 2 diabetes (28%). In total, 45% of the patients had a BMI of ≥30, with a significantly higher BMI (p = 0.025) among patients in the late tracheostomy group. Compared with those who received late tracheostomy, patients who received early tracheostomy had a shorter median ICU stay, with an absolute difference of 8 days (p = 0.002). Early tracheostomy was also associated with fewer days of IMV (p = 0.001) than those in late tracheostomy (Table 3) The BMI was significantly higher in patients who received late tracheostomy than in those who received early tracheostomy, with 53% of patients being obese (BMI ≥ 30) in the late group. As obesity is a risk factor for increased severity of COVID-19, 25 Comparison of all-cause mortality 30 days after initial ICU admission showed no advantages for early or late tracheostomy. These findings are similar to those of other studies, including the landmark TracMan trial. 28 Immunosuppression, n (%) 3 (6) 12 (20) 15 (13) Asthma, n (%) 6 (11) 8 (13) 14 (12) COPD, n (%) 6 (11) 5 (8) 11 (9) Other pulmonary disease, n (%) 7 (13) 9 (15) 16 (14) Cancer, n (%) Table 4) . The decision to perform tracheostomy was made at the discretion of the consultant intensive care physician at each hospital. As ICU beds rapidly filled up and the supply of sedatives declined, the threshold for performing early tracheostomy was low. This approach was retained Abbreviations: ARDS, acute respiratory distress syndrome; BMI, body mass index; COPD, chronic obstructive pulmonary disease; IQR, interquartile range; High-dose LMWH, ≥9000 units/day low molecular weight heparin; SAPS3, simplified acute physiology score 3; P/F ratio, the ratio between partial pressure (mmHg) of oxygen in arterial blood over the fraction of inspired oxygen. writing-original draft; writing-review and editing. We would like to express our gratitude to the staff of Jönköping County involved in caring for the COVID-19 patients. We would also like to acknowledge S. Wennerholm and R. Svensson for their meticulous work in collecting data. This study was supported by Futurum, the Academy for Healthcare, Jönköping County Council, Jönköping, Sweden. The authors declare no conflicts of interest. This study was approved by the Swedish Ethical Review Authority on August 26, 2020 (Dnr 2020-02758). Patient consent was waived due to the retrospective nature of the study. The corresponding author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. The data that support the findings of this study are available from the corresponding author upon reasonable request. 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