key: cord-1007730-2pzj65f9
authors: McGrath, Brendan A.; Brenner, Michael J.; Warrillow, Stephen J.
title: Tracheostomy for COVID-19: business as usual?
date: 2020-09-03
journal: Br J Anaesth
DOI: 10.1016/j.bja.2020.08.048
sha: d27cd079b7d113e7f8079b30792bac752f80fe43
doc_id: 1007730
cord_uid: 2pzj65f9

nan

accelerate weaning from ventilation that frees up critical equipment, personnel, and beds, although this may or may not necessarily be in the interest of an individual patient. 14 These competing issues have been addressed by a number of guidelines developed by a variety of specialist societies and organisations. Given the limited data availalble early on during the pandemic, they are almost exclusively based on expert opinion. [15] [16] [17] It is notable how such guidance has evolved as our understanding of COVID-19 has developed, particularly as the predicted high risk of clinician infection from the tracheostomy procedure was did not manifest. For example, shortly after the New York Head and Neck Society advocated delaying tracheostomy to beyond 14 days of invasive ventilation, 18 the New York University thoracic group published a series of 98 COVID-19 tracheostomy procedures performed at a median of 10.6. (SD 5) days from intubation. 19 Notably, none of the staff involved in these procedures subsequently tested positive for SARS-CoV-2.

In this issue of the British Journal of Anaesthesia, the Queen Elizabeth Hospital (QEH) Birmingham COVID-19 airway team share their experiences of the first 100 COVID-19 patients to undergo tracheostomy. 20 They describe important modifications to their usual approach, reconfiguration of their service and a comprehensive educational program. The findings from this prospective observational cohort study suggest a significant survival advantage associated with tracheostomy, regardless of the severity of illness, and that early tracheostomy may significantly reduce duration of invasive ventilation and ICU length of stay. However, as with all things COVID, closer examination is required.

The QEH team reconfigured their tracheostomy service out of necessity to manage a surge in tracheostomy candidates. As with most institutions, their pandemic response reflects local resources and existing practices that will influence the approach to tracheostomy timing, technique, and aftercare, each being considered in turn below.

The first consideration for tracheostomy timing is to decide whether the procedure is indicated. Consensus opinion is that in order to positively influence the trajectory of patients suffering from COVID-19 associated pneumonitis, tracheostomy should occur only after there are signs of improvement, and after the patient demonstrates physiological reserve to J o u r n a l P r e -p r o o f tolerate the procedure. Performing tracheostomy risks potentially life-threatening derecruitment, as most tracheotomy techniques involve a pause in ventilation, usually accompanied by at least partial loss of PEEP. Additionally, a patient should be unlikely to require prone ventilation prior to proceeding with tracheotomy, due to heightened risk of dislodgement, displacement, occlusion or other device-related complications that may be less readily identified and managed in prone patients. Performing tracheostomy in those who are destined not to survive exposes staff to unnecessary aerosol-generating procedures during and after insertion, and does not benefit the patient.

The QEH team did not have explicit criteria for undertaking tracheostomy but used the clinical judgement of a small group of experienced multidisciplinary clinicians. The reported indications for tracheostomy included failed extubation (13%, including several multiple attempts), a failed sedation hold (52%) and anticipated prolonged respiratory wean (33%).

These indications were presumably influenced by the unit culture and the expectation that an early tracheostomy would be of benefit, resulting in a 61% tracheostomy rate amongst the 164 patients who were intubated due to COVID-19 during the 6-week reporting period. This contrasts strikingly with a 16.4% tracheostomy rate reported from 11,493 ICU patients during Spain's COVID-19 pandemic 21 and tracheostomy rates of 8-13% outside of the pandemic. 22 The QEH group report that tracheostomy timing was not influenced by SARS-CoV-2 test results, which have been used in an attempt to judge the clinical condition of the patient and the risks posed to healthcare staff, and (in some protocols) candidacy for tracheostomy. Viral load peaks around the time of symptom onset, and declines over the following 3-4 days in mild illness, but viral RNA can be detected for a prolonged period in the critically ill. 3, 23 However, detection of viral RNA by polymerase chain reaction (PCR) does not necessarily indicate that viable (and therefore infectious) virus is present. False negative results may also occur in around 30% of tests, due to poor sampling technique and the differences in anatomical sampling location and pre-test probablility also influences interpretation. 24 At the onset of the pandemic there were rightly concerns over the risks to staff from performing tracheostomy in patients still considered infectious. However, using upper respiratory tract viral PCR tests alone to determine infectivity and associated risks to staff is unreliable.

The same team performed over 90% of the QEH tracheostomies, and none reported symptoms of coronavirus infection during the study period. Although this is reassuring, it J o u r n a l P r e -p r o o f should be noted that staff testing was not robust or comprehensive, and reporting was confined to the core tracheostomy team. If these data suggest that staff can be protected from coronavirus infection during tracheostomy by using appropriate mitigation strategies and personal protective equipment (PPE), when is it in the patient's best interests to perform a tracheostomy? The abundance of caution that characterised decisions for tracheotomy is giving way to a more traditional approached, where the overriding consideration is the quality of care delivered to the patient, with the caveat that the team should observe standard safety measures including use of PPE and surgical technique that minimises aerosols.

The QEH group have analysed their cohort and conclude that 30-day survival was significantly improved in patients receiving tracheostomy, and that early tracheostomy (within 14 days of intubation) was associated with significantly shortened ICU length of stay.

What remains unclear is the role of selection bias, as the study was not conducted in a randomised or blinded manner. Clinical judgement may of course have selected the improving patients destined to survive, some of whom may have undergone successful primary extubation had they not received a tracheostomy. Furthermore, if the authors hypothesized a benefit with tracheotomy, the result may have proved a self-fulfilling prophecy if life support efforts proved more purposeful in this group. While it would be premature to conclude from these data that tracheostomy materially alters survival and overall course of COVID-19, the improved pulmonary hygiene and earlier liberation from the ventilator may have significant salutary effects ranging from rehabilitation to mitigation of post-intensive care syndrome. Data on survivorship after critical care suggests that many patients with COVID-19 who require invasive mechanical ventilation will struggle with protracted physical and cognitive impairment. Such findings underscore the importance of collaboration between members of critical care multidisciplinary teams to optimise post-COVID-19 outcomes. 25 The group concluded that survival and length of stay were improved independently of severity of critical illness (judged by admission APACHE II scores). Other studies from large centres or hospital groups around the world are reporting that the times to tracheostomy for COVID-19 patients is rather less than that the 'optimum' delayed timeframe proposed by some early guidelines (>14 or >21 days), approaching windows recognisable outside of the pandemic. For example, a large Spanish observational study recently reported a median time to tracheostomy of 12 days amongst 1,890 patients. 21 It therefore seems that J o u r n a l P r e -p r o o f recommendations to delay tracheostomy in order to reduce infectivity have been superseded by clinical decision making, focusing on the physiological status of the patient.

Modifications to the insertion technique have been proposed by both surgical and intensive care groups for patients with COVID-19. Successful percutaneous, open surgical or hybrid approaches have been described, occurring in operating theatres or appropriate ICU locations.

Percutaneous tracheostomy has been the predominant technique in the critically ill for some time, with surgical approaches usually reserved for patients with more complex anatomy.

Percutaneous techniques involve more airway manipulation and risk leakage of exhaled gas and associated aerosols during ventilation, whilst endoscopic guidance makes aerosol generation more likely. 26 A controlled open surgical approach is thought to have less aerosol potential than a percutaneous approach, although this conclusion is based largely on experiences relating to SARS. [27] [28] [29] Subtle modifications to both techniques have been advocated during the current pandemic which include pausing ventilation at key points during the procedure and distal advancement of the tracheal tube.

Both techniques can be safely performed at the ICU bedside or in an operating theatre, with the latter providing a more controlled environment and better procedural conditions but requiring a patient transfer that risks the physiological stability of the patient and exposes multiple staff to potential infection. The QEH team provided a dedicated service able to perform percutaneous and surgical tracheostomy, with access to dedicated COVID operating theatres. The group describe that the choice of performing a surgical or percutaneous tracheostomy depended only on patient body habitus, adequate neck extension, and airway assessment. The reported 75% percutaneous tracheostomy rate is higher than most reports in the current coronavirus literature, and contrasts with a 42% percutaneous rate from other UK centres contributing to the COVIDtrach audit 30 and the 23% rate reported in a recent Spanish national report. 21 Expert opinion guiding technique for patients suffering from COVID-19 disease is influenced by a perception that the surgical approach is more controlled. There are also practical reasons why any given institution would adopt a particular strategy, not least the relative availability 

The provision of safe tracheostomy care can be challenging at the best of times and requires planning and multidisciplinary expertise. 31 To manage the increase in tracheostomy activity during the pandemic, the QEH team rapidly provided intensive training sessions to over 800 members of staff and supported this initial education with support from specialist staff. This comprehensive program allowed tracheostomised patients to be safely 'stepped down' to designated tracheostomy wards and although the authors did not collect comprehensive follow up data, no significant post-procedural complications were reported. This is an impressive achievement, particularly considering that many patients were cared for by staff previously untrained in tracheostomy care and managed in newly adapted locations.

Staff education has been shown to be fundamental in improving the safety of care and it is possible to provide safe and high-quality care in a variety of settings. 32, 33 Key principles of tracheostomy care during the pandemic include a focus on essential care and avoidance of unnecessary interventions (especially those that generate aerosols), early recognition of deterioration, and timely responses to emergencies. 16 A recent UK study showed that the quality and safety of tracheostomy care can be significantly improved by application of a comprehensive educational program and careful consideration of all aspects of the patient journey. 33 The pandemic has focused attention and resulted in the rapid roll-out of NHS England's Safer Tracheostomy Care National Patient Safety Improvement Program. 15 It remains to be seen whether higher standards of tracheostomy care will be maintained. Quality Improvement programs such as those advocated by the Global Tracheostomy Collaborative (www.globaltrach.org) should be encouraged, as evidence continues to emerge describing a positive impact on the safety and quality of tracheostomy care. 32, 34 Conclusions J o u r n a l P r e -p r o o f COVID-19 has produced a shock to the system. Tracheostomy management has previously largely been based on opinion, but now is now increasingly guided by evidence. Global efforts to share data and strategies that benefit patients and protect staff should be applauded and encouraged, as should reporting of local experiences in different contexts. Emerging data suggest that tracheostomy appears safe for patients and for staff who follow appropriate precautions, and tracheostomy clearly has a role to play in the management of patients who require prolonged invasive ventilation. There are more questions to address around the direct laryngeal effects of the virus, 35 optimal timing of tracheostomy and optimal strategies for post-procedural care that protect staff whilst encouraging laryngeal rehabilitation. In the end, it seems the more we learn, the more is seems that best practice aligns with business as usual;

just with better PPE.

J o u r n a l P r e -p r o o f

Wrote, edited approved the final version: all authors.

BAM is National Clinical Advisor for Tracheostomy for NHS England, Chair of the National Tracheostomy Safety Project, and serves on the Executive Committee of the Global Tracheostomy Collaborative. MJB is the President of the Global Tracheostomy Collaborative. SJW is immediate past president of the Australian and New Zealand Intensive Care Society.

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

Clinical Characteristics of 138 Hospitalized Patients With

Novel Coronavirus-Infected Pneumonia in Wuhan, China

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore

ICNARC report on COVID-19 in critical care 31

Tracheostomy tube occlusion protocol predicts significant tracheal obstruction to air flow in patients requiring prolonged mechanical ventilation

Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: The tracman randomized trial

Timing of tracheostomy in critically ill patients: a meta-analysis

Early versus late tracheostomy for critically ill patients

Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis

Performing tracheostomy during the Covid-19 pandemic: guidance and recommendations from the Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma

Multidisciplinary Guidance for Safe Tracheostomy Care During the COVID-19 Pandemic: The NHS National Patient Safety Improvement Programme (NatPatSIP)

Tracheostomy in the COVID-19 Era: Global and Multidisciplinary Guidance

COVID-19 Pandemic: What Every Otolaryngologist-Head and Neck Surgeon Needs to Know for Safe Airway Management

Tracheostomy during SARS-CoV-2 pandemic: Recommendations from the New York Head and Neck Society

Novel Percutaneous Tracheostomy for Critically Ill Patients with COVID-19

Tracheostomy in COVID-19 -safety and 30-day outcomes of the first 100 cases from a single tertiary UK hospital: a prospective observational cohort study

Outcome of 1890 tracheostomies for critical COVID-19 patients: a national cohort study in Spain

Trends in Tracheostomy for Mechanically Ventilated Patients in the United States

SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients

Interpreting Diagnostic Tests for SARS-CoV-2

Survivorship after COVID-19 ICU stay

Surgical tracheostomies in Covid-19 patients: Important considerations and the "5Ts" of safety

Elective and emergency surgery in patients with severe acute respiratory syndrome (SARS). Canadian journal of surgery

Infection control measures for operative procedures in severe acute respiratory syndrome-related patients

Surgical Considerations for Tracheostomy During the COVID-19 Pandemic: Lessons Learned From the Severe Acute Respiratory Syndrome Outbreak

COVIDTrach; the outcomes of mechanically ventilated COVID-19 patients undergoing tracheostomy in the UK: Interim Report 22nd

Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency

Global Tracheostomy Collaborative: Improving Patient Safety through teamwork, standardisation, and data

Improving Tracheostomy Care in the United Kingdom: results of a guided quality improvement program in 20 diverse hospitals

Multidisciplinary Tracheostomy Care: How Collaboratives Drive Quality Improvement

Laryngeal oedema associated with COVID-19 complicating airway management