Percutaneous Tracheostomy in Respiratory Failure Due to COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can lead to hypoxemic respiratory failure resulting in prolonged mechanical ventilation. Typically, tracheostomy is considered in patients who remain ventilator dependent beyond 2 weeks. However, in the setting of this novel respiratory virus, the safety and benefits of tracheostomy are not well-defined. Our aim is to describe our experience with percutaneous tracheostomy in patients with COVID-19. MATERIALS AND METHODS: This is a single center retrospective descriptive study. We reviewed comorbidities and outcomes in patients with respiratory failure due to COVID-19 who underwent percutaneous tracheostomy at our institution from April 2020 to September 2020. In addition, we provide details of our attempt to minimize aerosolization by using a modified protocol with brief periods of planned apnea. RESULTS: A total of 24 patients underwent percutaneous tracheostomy during the study. The average body mass index was 33.0±10.0. At 30 days posttracheostomy 17 (71%) patients still had the tracheostomy tube and 14 (58%) remained ventilator dependent. There were 3 (13%) who died within 30 days. At the time of data analysis in November 2020, 9 (38%) patients had died and 7 (29%) had been decannulated. None of the providers who participated in the procedure experienced signs or symptoms of COVID-19 infection. CONCLUSION: Percutaneous tracheostomy in prolonged respiratory failure due to COVID-19 appears to be safe to perform at the bedside for both the patient and health care providers in the appropriate clinical context. Morbid obesity did not limit the ability to perform percutaneous tracheostomy in COVID-19 patients.

Central Venous Catheter Insertion in the Prone Position-A Last Resort in Critically Ill COVID-19 Patients.

BACKGROUND: In the setting of the COVID pandemic, many patients falling ill with acute respiratory distress syndrome eventually require prone positioning for gas exchange. Traditionally, central venous catheters are inserted with patient in the supine or Trendelenburg position. However, when a patient cannot tolerate supine position and the need for central venous access is urgent, catheter placement may be considered with the patient in the prone position. CASE SUMMARY: A 69-year-old male with rapidly declining respiratory status secondary to COVID pneumonia quickly developed acute respiratory distress syndrome, was rapidly intubated, and then placed in the prone position. Patient could not tolerate the supine position even briefly and required a central venous catheter insertion for continuous renal replacement therapy. We kept the patient in the prone position and successfully inserted a central venous catheter in such position with real-time ultrasound guidance and using micropuncture technique. CONCLUSION: In the setting of the COVID pandemic, many cases of acute respiratory distress syndrome require patients to be prone in order to improve gas exchange. In the most severe situations, these patients would not be able to tolerate rotating back to the supine position but would still require central venous catheter insertion urgently. We demonstrated feasibility of central venous catheter insertion in the prone position in these severely ill patients.