Timing of Tracheostomy for Patients With COVID-19 in the ICU—Setting Precedent in Unprecedented Times | Critical Care Medicine | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
[Skip to Content]
[Skip to Content Landing]
Views 13,986
Citations 0
Viewpoint
September 3, 2020

Timing of Tracheostomy for Patients With COVID-19 in the ICU—Setting Precedent in Unprecedented Times

Author Affiliations
  • 1Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, the Netherlands
  • 2Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
  • 3Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
  • 4Department of Otolaryngology–Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
  • 5Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, Ann Arbor
JAMA Otolaryngol Head Neck Surg. 2020;146(10):887-888. doi:10.1001/jamaoto.2020.2630

“Uncontrolled variation is the enemy of quality.”

W. Edwards Deming, Basic Statistical Tools for Improving Quality

Navigating the uncharted has been a pervasive theme during the coronavirus disease 2019 (COVID-19) pandemic, and lack of data to guide decisions has been the most evident regarding the timing of tracheostomy. Tracheostomy, an aerosol-generating procedure with risk of infectious transmission for health care workers,1 also has important implications for patient care and stewardship of critical resources.2,3 Emerging data concerning infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the course of patients with COVID-19, and clinical experience may alter practice, even preempting publication. For example, Chao et al4 originally recommended deferring tracheostomy beyond 21 days of intubation and recommended open surgical tracheostomy over percutaneous dilatational tracheostomy; however, updated practices at the authors’ institution reflect outcomes of tracheostomy performed at 10 to 14 days after intubation, with percutaneous technique performed regularly. Similarly, shortly after the New York Head and Neck Society advocated a 14-day standard,5 the New York University thoracic group published a series of 98 COVID-19 tracheostomy procedures, with surgical procedures at a mean (SD) of 10.6. (5) days of intubation,6 indicating that many patients underwent tracheostomy well before day 10 of intubation. When COVID-19 overwhelms capacity in intensive care units (ICUs), early timing of tracheostomy may accelerate ventilator weaning and free up critical equipment, staff, and units. Guidelines now recommend that timing of tracheostomy consider scarcity of ventilators and other ICU resources.3

Improving clinicians’ understanding of COVID-19 is a critical step in reducing uncontrolled variation and improving quality. Misconceptions regarding SARS-CoV-2 and COVID-19 (Table) likely contribute to arbitrary variation in timing of tracheostomy; therefore, dispelling misconceptions may encourage consistent standards. In patients with severe COVID-19, the pulmonary injury is extensive, and patients often require prolonged invasive ventilation. One misconception is that virtually all patients will either be extubated or succumb to disease in 2 to 3 weeks. Of note, the opposite misconception has also surfaced—that the course of ventilation is invariably so long that tracheostomy before 3 weeks is pointless. The data support a more nuanced interpretation. COVID-19–associated acute respiratory distress syndrome involves perturbed vasoregulation, often with preserved pulmonary compliance favoring the prone position. Its clinical features and management largely conform to existing parameters and care standards of classic acute respiratory distress syndrome.7 Tracheostomy should be avoided when prone positioning is necessary and is most appropriate for patients with evidence of recovery. Patients often have thick, viscous airway secretions that may require suctioning via tracheostomy; tenacious secretions may result in prompt reintubation after extubation.

Table.  Misconceptions That Predispose to Uncontrolled Variation in Tracheostomy Among Patients With COVID-19
Misconceptions That Predispose to Uncontrolled Variation in Tracheostomy Among Patients With COVID-19

The other major question is how early tracheostomy can be safely performed with appropriate personal protective equipment, including face shields with N95 or FFP3 masks or powered air-purifying respirators, along with fluid-repellent surgical gowns and gloves. Limited data are finally emerging on this pivotal question. No instances of health care worker transmission were reported in the New York University series,6 and, as of this writing 1 month later, there remain no cases of health care worker transmission despite a dramatic interval increase in number of tracheostomies performed (Robert Cerfolio, MD, written communication, May 22, 2020). The experience at University of Pennsylvania, which moved to the earlier standard of tracheostomy at 10 to 14 days, with 62 COVID-19 tracheostomies, is similarly without signs of transmission to health care workers. One critique of the 10-day standard is that during a COVID-19 surge, which can easily overwhelm ICU capacity, tracheostomy at 10 days’ intubation will only free up ICU capacity in patients requiring prolonged weaning.8 The 10-day threshold also precludes early rehabilitation in patients with preexisting frailty, muscle weakness, and copious secretions, all of which may prompt tracheostomy in patients without COVID-19. Clinicians in Brazil have observed that in patients with COVID-19 and severe comorbidities, earlier tracheostomy (day 4-5 of intubation) improves prognosis. In Brazil, approximately 15% of COVID-19 deaths are occurring in individuals younger than 50 years, a rate that is 10-fold higher than that observed in Italy or Spain (Fernando Dias, MD, Brazilian National Cancer Institute, written communication, May 22, 2020). More data are urgently needed.

When global experts were queried about early, usual, and late timing of tracheostomy in patients with and without COVID-19, there was far wider variation in timing for COVID-19–positive patients.2 This variation reflects the many unknowns. Prolonged viral shedding has been documented in patients recovering from COVID-19, but positive testing may be due to amplification of an inert virus that cannot grow in culture. This finding is reminiscent of how a rapid Streptococcus test may detect persistent antigen in a child long after recovery from streptococcal infection. Nonetheless, personal protective equipment precautions are prudent until duplicate negative results are confirmed. Data on infectivity amid immune response are not yet available for ventilated patients. Decisions on tracheostomy must be personalized; some patients may be awake but cannot yet be extubated (favoring tracheostomy), whereas other patients may have immediate, severe hypoxemia when lying supine or with any period of apnea (favoring deferral). The broadest engagement among existing guidelines involved a work group spanning approximately 10 specialties and geographies, combining otolaryngology, critical care, pulmonary, anesthesiology, virology, and infectious disease experts alongside medical ethicists and patient and family stakeholders. Using a modified Delphi method, this group evaluated COVID-19 clinical data and timeline of SARS-CoV-2 viral load and the emergence of an immune response, suggesting the 10- to 21-day window.2

Early on, the clinical and scientific communities were transfixed by the novelty of SARS-CoV-2, but there is increasing realization that critically ill patients with COVID-19 may be well served by long-standing, data-driven standards of intensive care. The virus’s virulence, infectivity, and affected populations will likely change over time, and guidance must adapt as data emerge and local circumstances evolve. Low- and middle-income countries bear a considerable COVID-19 disease burden, and protection of health care workers is of particular concern in settings where personal protective equipment is scarce and clinicians have little experience in tracheostomy care. Whenever possible, multidisciplinary and systematic approaches should be pursued. A 20-hospital quality improvement initiative in tracheostomy care found that multidisciplinary teams with patients, caregivers, and interdisciplinary teams reduced adverse events, mortality, days requiring ventilator assistance, ICU stay, and hospital length of stay.9 Ideally, prospective randomized trials investigating outcomes of early vs late tracheostomy in patients with COVID-19 receiving ventilation will be conducted to define best practices; however, such studies may be aspirational and may never occur, underscoring the importance of data registries and international data sharing.10

Back to top
Article Information

Corresponding Author: Michael J. Brenner, MD, Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, 1500 E Medical Center Dr, 1903 Taubman Center SPC 5312, Ann Arbor, MI 48104 (mbren@med.umich.edu).

Published Online: September 3, 2020. doi:10.1001/jamaoto.2020.2630

Conflict of Interest Disclosures: Dr Brenner reported being president of the Global Tracheostomy Collaborative, a 501(c)(3) Quality Improvement Collaborative; he is not compensated. No other disclosures were reported.

References
1.
Tay  JK, Khoo  ML-C, Loh  WS.  Surgical considerations for tracheostomy during the COVID-19 pandemic.   JAMA Otolaryngol Head Neck Surg. 2020;146(6):517-518. doi:10.1001/jamaoto.2020.0764 PubMedGoogle ScholarCrossref
2.
McGrath  BA, Brenner  MJ, Warrillow  SJ,  et al.  Tracheostomy in the COVID-19 era.   Lancet Respir Med. 2020;8(7):717-725. doi:10.1016/S2213-2600(20)30230-7PubMedGoogle ScholarCrossref
3.
Michetti  CP, Burlew  CC, Bulger  EM, Davis  KA, Spain  DA; Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma.  Performing tracheostomy during the Covid-19 pandemic.   Trauma Surg Acute Care Open. 2020;5(1):e000482. doi:10.1136/tsaco-2020-000482 PubMedGoogle Scholar
4.
Chao  TN, Harbison  SP, Braslow  BM,  et al.  Outcomes after tracheostomy in COVID-19 patients.   Ann Surg. Published online June 11, 2020. doi:10.1097/SLA.0000000000004166 PubMedGoogle Scholar
5.
Miles  BA, Schiff  B, Ganly  I,  et al.  Tracheostomy during SARS-CoV-2 pandemic.   Head Neck. 2020;42(6):1282-1290. doi:10.1002/hed.26166 PubMedGoogle ScholarCrossref
6.
Angel  L, Kon  ZN, Chang  SH,  et al.  Novel percutaneous tracheostomy for critically ill patients with COVID-19.   Ann Thorac Surg. Published online April 24, 2020. doi:10.1016/j.athoracsur.2020.04.010PubMedGoogle Scholar
7.
Rose  MR, Hiltz  KA, Stephens  RS, Hager  DN.  Novel viruses, old data, and basic principles.   Lancet Respir Med. 2020;8(7):661-663. doi:10.1016/S2213-2600(20)30236-8PubMedGoogle ScholarCrossref
8.
Phua  J, Weng  L, Ling  L,  et al; Asian Critical Care Clinical Trials Group.  Intensive care management of coronavirus disease 2019 (COVID-19).   Lancet Respir Med. 2020;8(5):506-517. doi:10.1016/S2213-2600(20)30161-2 PubMedGoogle ScholarCrossref
9.
McGrath  BA, Wallace  W, Lynch  J,  et al  Improving tracheostomy care in the United Kingdom.   Br J Anesthes. 2020;125(1):e119-e129. doi:10.1016/j.bja.2020.04.064PubMedGoogle ScholarCrossref
10.
Brenner  MJ, Pandian  V, Milliren  C,  et al.  Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardization, education and patient partnership.   Br J Anesthes. 2020;125(1):e104-e118. doi:10.1016/j.bja.2020.04.054PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×