Outcomes of COVID-19 positive and COVID-19 negative adult patients who underwent tracheostomy for prolonged intubation in a COVID-19 referral center during the pandemic

Objective@#To compare outcomes of COVID-19 positive and COVID-19 negative patients who underwent tracheostomy for prolonged intubation in terms of weaning duration, length of ICU and hospital stay, overall and 30-day mortality, and explore risk factors for particular outcomes (mortality, 30-day mortality and weaning duration post tracheostomy). @*Methods@#Design: Retrospective Cohort Study Setting: Tertiary National University Hospital Participants: Of 122 adult patients that underwent tracheotomy between March 30, 2020 and March 30, 2021; 76 adult patients underwent tracheostomy for prolonged intubation were analyzed.@*Results@#Open tracheotomy was performed on 122 adult patients. Seventy six (62.3%) due to prolonged intubation and 46 (37.7%) for airway prophylaxis. Among the former, the mean age was 58.46±16.81 and 54 (71.05%) patients were female, 22 (28.95%) tested COVID-19 positive and 54 (71.05%) tested negative. Mean APACHE II score was 16.62±6.78. Average days of intubation prior to tracheostomy was 29.14±17.66 days. No statistically significant difference in outcomes (weaning days, length of stay, days discharge from ICU and hospital, 30-day mortality, days to death) were noted between COVID19 positive and negative patients who underwent tracheostomy for prolonged intubation. Mortality rates post tracheostomy in this institution appear to be higher than existing literature. On multiple linear regression analysis, days of intubation prior to tracheostomy was associated with increased weaning time post-tracheostomy (OR: 0.35 CI:0.18-0.51 95% p = <.001). This implies that for every additional day of intubation prior to tracheostomy, weaning days increase by 0.35 of a day. @*Conclusion@#Outcomes of COVID-19 compared to non-COVID-19 patients undergoing tracheostomy for prolonged intubation do not seem to be significantly different which is consistent with existing literature.

Which dialysis method should be used for patients with COVID-19?

Key Findings@#• Very low-quality evidence from a single retrospective study suggests that continuous renal replacement therapy (CRRT) may reduce mortality among COVID-19 patients on invasive mechanical ventilation. Guidelines recommend CRRT for critically ill patients to minimize the risk of possible transmission, if this option is available. • Although uncommon, acute kidney injury (AKI) can occur in association with coronavirus disease 2019 (COVID-19) and is associated with increased in-hospital mortality. • There are currently no published or ongoing clinical trials directly comparing dialysis modalities for acute kidney injury in COVID-19 patients. • In reducing the risk of transmission during dialysis: currently, there are no studies comparing one dialysis modality to another. The method of dialysis is still primarily determined by the clinical picture of the patient, the expertise of the center, and the resources available. The American Society of Nephrology (ASN) recommends CRRT over intermittent hemodialysis (IHD) for critically ill patients with COVID-19 to minimize patient contact when it is available, and resources allow. Otherwise, intermittent hemodialysis may be done provided that, infection control measures are strictly followed. • Several international and local guidelines recommend strict adherence to infection prevention and control measures (e.g. hand hygiene, physical distancing, proper use of personal protective equipment (PPE), and cohorting of patients) who are undergoing dialysis.

Is high-flow nasal cannula oxygenation more effective than noninvasive ventilation or conventional oxygen therapy in treating acute hypoxemic respiratory failure in COVID-19 patients?

Key Findings@#Very low-quality evidence suggests lower mortality (based on five observational studies) but higher failure rate of respiratory support (based on two observational studies) in COVID-19 patients given high-flow nasal cannula (HFNC) oxygen compared with noninvasive ventilation (NIV) and conventional oxygenation therapy. Randomized controlled trials (RCT) are urgently needed in this area. • Respiratory failure accounts for about half of deaths in patients with COVID-19. • High-flow nasal cannula (HFNC) oxygen therapy reduces the need for escalating respiratory support and improves patient comfort compared with conventional oxygen therapy among those with acute respiratory failure. • Mortality was consistently lower in COVID-19 patients who received HFNC rather than NIV or conventional oxygen therapy (COT) across 5 very low-quality retrospective observational studies from China. • Several international guidelines recommend the use of HFNC oxygen therapy in COVID-19 patients who develop acute hypoxemic respiratory failure. However, local guidelines from the Philippine Society for Microbiology and Infectious Diseases (PSMID) and the Philippine College of Chest Physicians (PCCP) recommend against HFNC due to risks of transmission and paucity of direct evidence for efficacy. • Additional infection control precautions, i.e. wearing a surgical mask over the cannula, and locating in a negative pressure room, are recommended whenever using HFNC or NIV. • There are at least two ongoing trials due to be completed by the second quarter of 2021 comparing HFNC oxygenation with NIV or COT in COVID-19 patients.