Introduction
Coronavirus disease 2019 (COVID-19) has rapidly evolved into a pandemic since the first report emerged from China in December 20191. With the number of cases rising globally at an exponential rate and with over 10% of these requiring Intensive Care Unit (ICU) admission, demand for critical care increasingly threatens to exceed capacity even among the world’s most advanced economies2. At present, supportive treatment forms the basis of therapy, with trials currently ongoing to unearth the optimal medicinal treatment regimen and vaccine. Tracheotomy, through its ability to wean patients off ventilation, can shorten the ICU length of stay and in doing so increase ICU bed capacity; crucial for saving lives at a population level. 3,4 Median ICU stay for COVID-19 patients varies widely between countries ranging between 4 to over 20 days. 5
Tracheotomy constitutes an Aerosol Generating Procedure (AGP), thus potentially exposing the operating surgeon and Operating Room (OR) team to respiratory droplets from the SARS-CoV-2 infected patient6. With this added risk in mind it is vital that the potential benefits of a reduced ICU stay associated with performing a tracheotomy are balanced against the risks to healthcare professionals. Despite a number of authors having already published guidelines to minimize risks to healthcare personnel when performing tracheotomy in the COVID-19 positive patient7-11, there is currently a paucity of literature on patient selection criteria for this procedure and outcomes data for patients who have undergone tracheotomy in these circumstances. To address this, we present our data from the first 12 COVID-19 patients that underwent tracheotomy in our institution, and propose parameters to inform patient selection by identifying those patients who may be more likely to benefit from the procedure. Furthermore, we discuss potential predictive factors that may help clinicians identify at an early stage (48h post-operatively) those patients who are likely to have a positive outcome post-tracheotomy, which may facilitate decisions to step-down patient care and thus improve the availability of critical care resources to those patients that need it most.
Methods
This was a prospective study of all COVID-19 patients undergoing tracheotomy (n=12) in a Head & Neck Unit in the United Kingdom during a 4-week period (March-April 2020). Anesthesiological processes and surgical steps pre- and peri-tracheostomy insertion were standardised to minimise risk to staff and improve patient safety during this crucial part of the procedure (see Supplementary Material). Recordings of the patient’s Fraction of Inspired Oxygen (FiO2) and Peak End Expiratory Pressure (PEEP) were obtained for the 24 hours preceding the procedure, and subsequently collected on a daily basis until the patient was either decannulated and discharged from hospital, or died. Fluctuations in these values, which occurred due to patient intervention/movement were removed in order to facilitate calculation of representative averages for these values. The number of days that patients were kept under sedation and number of days taken for decannulation were also recorded.
Following our experience with our first 5 tracheotomies and in accordance with our local protocol (see Supplementary Material) and published literature 7–9,we instituted selection criteria for all subsequent tracheotomies as follows:
Correlation between data sets was determined using the ‘R’ statistical software (v3.6.1, © The R Foundation, Vienna, Austria). Data were ranked, and Spearman’s rank correlation coefficient was calculated to determine association between data sets.