key: cord-1002512-ahgvjpck authors: Brenner, Michael J.; Feller-Kopman, David; De Cardenas, Jose title: POINT: Tracheostomy in patients with COVID-19. Should we do it before 14 days? Yes. date: 2021-02-27 journal: Chest DOI: 10.1016/j.chest.2021.01.074 sha: 6093aff457ee2c4b1a1c69f4c9ccf24adc6599fb doc_id: 1002512 cord_uid: ahgvjpck nan Early in the COVID-19 pandemic, fears of viral transmission to healthcare workers prompted institutions around the world to reassess timing and technique for performing tracheostomy. There was great hesitance to perform tracheostomy during the first wave of the pandemic, evident in a study spanning 26 countries, in which of over 90% of protocols and practices involved deferral beyond 14 days. 1 Fortunately, we have learned a lot over the last nine months. A growing body of evidence documents the safety and benefit of tracheostomy in COVID-19 patients, provided appropriate precautions are taken. [2] [3] [4] [5] [6] Early tracheostomy accelerates weaning from the ventilator and may have a critical role in freeing up ventilators, ICU beds, and staff during surges. 4 This consideration is important, as resource scarcity may limit access to life-saving interventions for other patients. 7 We argue that tracheostomy before 14 days has a role in a select group of patients with COVID-19 respiratory failure requiring prolonged mechanical ventilation. Sizing Up the Enemy: What makes COVID-19 different? Early reports described COVID-19 ARDS ("CARDS") as a unique entity. 8 COVID-19 patients purportedly had unusually high lung compliance and poorer oxygenation; yet, comparison of COVID-19 ARDS data to that of earlier ARDS trials reveals only minimal differences. 9 Favourable response to prone ventilation mirrors historical ARDS data. 10 Pulmonary microthrombosis and alveolar damage in COVID-19 has also attracted interestfindings also documented in ARDS over three decades ago 9 ; thus, if a distinct CARDS phenotype exists, it is yet to be proven. Misconceptions about COVID-19 have likely been an impediment to maximizing benefit from tracheostomy. For example, the early misconception that patients with COVID-19 would declare themselves swiftly -by recovering or succumbing to disease within 2-3 weeks -made tracheostomy seem pointless. As with all ARDS patients, the course is variable, and quite difficult to predict. ARDS is not a single disease, but rather a syndrome 11 The foremost consideration regarding tracheostomy is not timing, but whether the procedure is indicated. Critically ill patients requiring invasive ventilation have up to 50% mortality. 12 Tracheostomy should occur only after there are signs of improvement, as performing the procedure in patients with grim prognosis offers no benefit and exposes staff to unnecessary aerosol-generating procedures. 4 Delaying tracheostomy may reduce the risk to healthcare workers as the viral load of SARS-CoV-2 may be lower, but that reduction in risk must be weighed against prolonged intubation. 13 Additionally, there have not been any reports of increased risk to healthcare workers associated with tracheostomy as long as adequate personal protective equipment is utilized. Importantly, the patient must demonstrate physiological reserve to tolerate the procedure. Most tracheotomy techniques in the COVID-19 era involve a pause in ventilation with loss of PEEP, risking de-recruitment. Furthermore, tracheostomy should not be performed in a patient requiring prone ventilation, because of the heightened risk of accidental decannulation, displacement, occlusion, or other device-related complications that are less readily identified and managed in prone position. 13 Therefore, we suggest that established principles regarding indications and candidacy should take precedence over considerations of timing (Figure 1) . Numerous randomized trials attest to benefits of early tracheostomy in appropriately selected patients. Tracheostomy reduces the cumulative sedation dose 14 and allows for earlier participation in physical therapy and rehabilitation; this improvement in early mobility lessens the risk of critical illness myopathy and venous thromboembolism. Early tracheostomy is also associated with earlier walking, talking and eating. 15 Earlier extubation lowers the risk of airway complications arising from prolonged translaryngeal intubation, such as focal tracheomalacia, and tracheal stenosis (Figure 2) . Predicted high rates of infection in healthcare workers performing tracheostomy have not been reported. Colleagues at New York University reported 98 COVID-19 tracheostomy procedures at a median 10.6 days from intubation with no team members testing positive for J o u r n a l P r e -p r o o f SARS-CoV-2, 2 as did subsequent reports. 3, 5 Reluctance to perform tracheostomy is gradually being replaced by an approach where the primary considerations are patient-centered outcomes along with proper safety measures with PPE and modified techniques to minimize aerosol generation. Enhanced PPE, standardized donning/doffing protocols, and modified tracheostomy techniques may all minimize risk; however, other factors may also contribute to lower than expected transmission with tracheostomy. SARS-CoV-2 infectivity peaks 3-4 days after infection, whereas a tracheostomy after 10 days of intubation may be 2 weeks out from initial infection, once infectivity has diminished. 4 COVID-19 test results from patients often detect inert viral RNA, which can be amplified by PCR, long after virus is nonviable in culture and hence noninfectious. 16 Last, SARS-CoV-2 viral loads are highest in upper respiratory tract mucosa, particularly the nasopharynx, 17 whereas viral loads for SARS-CoV, the virus responsible for SARS outbreaks, were highest in the lower respiratory tract. 16 Going beyond the procedure: Post-tracheostomy care in COVID-19 patients Another challenge in caring for patients with COVID-19 is disposition after tracheostomy. The tracheostoma creates an open source of aerosolization and necessitates, suctioning, change of tracheostomy tubes or inner cannulas, and other routine care. A multidisciplinary tracheostomy team consisting of interventional pulmonologists, otolaryngologists, nursing, speech language pathology, and respiratory therapy ensures attentive care. 13 Patients on trach collar may be candidates for downsizing, capping, and decannulation. 18 COVID-19-specific management and decannulation protocols are critical aspects of postoperative care. It should be noted that long-term assisted care units and sub-acute rehabilitation facilities may be limited in their ability to accept patients after an ICU stay with COVID-19. COVID-19 survivorship may be associated with Post-Intensive Care Unit Syndrome (PICS), which encompasses physical, cognitive, and mental health impairments that may persist for months or years beyond hospital discharge. 19 Prolonged translaryngeal endotracheal tube intubation and sedation predisposes to laryngotracheal injury, dysphagia, dysphonia, laryngotracheal stenosis, and diaphragmatic dysfunction. 20 Minimizing the duration of sedation, translaryngeal intubation and ICU stay with appropriate timing of tracheostomy may expedite recovery and decrease severity of PICS (Figure 3) . Last, humanistic considerations are integral to decision making in the ICU. Clinicians taking care patients with COVID-19 are all-too-familiar with how tubes, lines, and other ICU paraphernalia can render edematous faces unrecognizable. There is no more humanizing thing than to restore a face to sick patients; the emotional toll is ponderous for patients, families, and the healthcare team. The Zulu tribe greeting, "Sawubona" means "I see you" but also communicates, "You are important to me and I value you." When we embrace this conceptmake the other person visible, then we accept them and grant them dignity. A virtue of the COVID-19 pandemic has been opening of our eyes to how much we have to learn, and a vice has been closing our eyes to what is known, from decades of data. Tracheostomy is a safe procedure that plays a vital role in management of COVID-19 patients with severe ARDS. Once prone positioning is no longer required, candidacy for tracheostomy may be assessed by a multidisciplinary team, preferably on a timeline similar to other ICU patients requiring prolonged mechanical ventilation. We should treat every patient, COVID-19 positive or not, as an individual, with an eye towards honoring safety, humanity, and dignity. 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