Timing, Complications, And Safety Of Tracheotomy In Critically Ill Patients With Covid-19

This cohort study assesses the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19.Question Is it safe to perform an early bedside surgical tracheotomy in patients with coronavirus disease 2019 (COVID-19)? Findings In this cohort study of 50 patients with COVID-19 who underwent consecutive bedside tracheotomies following the recommended parameters for standard protective personal equipment, the successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group, and no infections among the surgeons were identified at the end of study. Meaning With the use of a standardized protocol to minimize risk of spread of COVID-19, early bedside surgical tracheotomy may be a safe strategy for reducing time of mechanical ventilation, sparing intensive care unit beds during the COVID-19 pandemic.Importance The current coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented needs for invasive ventilation, with 10% to 15% of intubated patients subsequently requiring tracheotomy. Objective To assess the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19. Design, Setting, and Participants This prospective cohort study assessed consecutive patients admitted to the intensive care unit (ICU) who had COVID-19 that required tracheotomy. Patients were recruited from March 16 to April 10, 2020, at a tertiary referral center. Exposures A surgical tracheotomy was performed for all patients following recommended criteria for use of personal protective equipment (PPE). Main Outcomes and Measures The number of subthyroid operations, the tracheal entrance protocol, and use of PPE. Infections among the surgeons were monitored weekly by reverse-transcriptase polymerase chain reaction of nasopharyngeal swab samples. Short-term complications, weaning, and the association of timing of tracheotomy (early [<= 10 days] vs late [>10 days]) with total required days of invasive ventilation were assessed. Results A total of 50 patients (mean [SD] age, 63.8 [9.2] years; 33 [66%] male) participated in the study. All tracheotomies were performed at the bedside. The median time from intubation to tracheotomy was 9 days (interquartile range, 2-24 days). A subthyroid approach was completed for 46 patients (92%), and the tracheal protocol was adequately achieved for 40 patients (80%). Adequate PPE was used, with no infection among surgeons identified 4 weeks after the last tracheotomy. Postoperative complications were rare, with minor bleeding (in 6 patients [12%]) being the most common complication. The successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group (adjusted hazard ratio, 2.55; 95% CI, 0.96-6.75), but the difference was not statistically significant. There was less time of invasive mechanical ventilatory support with early tracheotomy compared with late tracheotomy (mean [SD], 18 [5.4] vs 22.3 [5.7] days). The reduction of invasive ventilatory support was achieved at the expense of the pretracheotomy period. Conclusions and Relevance In this cohort study, with the use of a standardized protocol aimed at minimizing COVID-19 risks, bedside open tracheotomy was a safe procedure for patients and surgeons, with minimal complications. Timing of tracheotomy may be important in reducing time of invasive mechanical ventilation, with potential implications to intensive care unit availability during the COVID-19 pandemic.