In bed hybrid tracheostomy procedure in COVID-19 patients. Technique and results

Background: COVID-19 pandemic, results in a great number of critically ill patients requiring long-lasting periods of invasive mechanical ventilatory support;tracheostomy is considered during their hospital stay, to free patients from ventilatory support and optimize the resources, we developed a safe in bed hybrid tracheostomy procedure to avoid the operating room and minimize SARS-CoV2 transmission due to aerosols exposure. Method(s): We developed this protocol using PDCA (Plan, Do, Check, Act) in order to perform a safe in bed hybrid tracheostomy: percutaneous tracheostomy + flexible bronchoscopy. We used the Ciaglia Blue Rhino technique and flexible bronchoscopy. We analyzed: Gender, age, body mass index, intubation days, ventilatory parameters, procedure time, apnea time, oxygen saturation, complications and patient clinical evolution. Statistical evaluation: Fisher test, U Mann-Whitney, T test, logistic regression and Kaplan-Meier curves. Result(s): From march 2020 to February 2021, 292 patients underwent hybrid tracheostomy;Tracheostomy was successfully completed in all patients: 211 men (72.2%);81 women (27.8%), age 58.5 years old, intubation days before tracheostomy 23 days (19 to 28 days), 133 patients (45.5%) deaths due to COVID19 complications. Procedure time 6 to 14 minutes (mean 9 minutes), apnea time 147 to 360 seconds (mean 240 seconds), O2 saturation 66%-96% (mean 87%), PaO2/fiO2 106-194 (mean 142), SOFA 4-6 (mean 5). No complications due to the trachesotomy. Conclusion(s): In bed hybrid tracheostomy procedure implementation with the PDCA cycles is safe, with good results, zero procedure complications and a good and rapid learning curve.

Spontaneous pneumomediastinum in COVID-19 patients. Case series

Spontaneous pneumomediastinum is defined as the presence of free air within the mediastinum without an apparent cause such as chest trauma. It is a benign, self-limiting condition that is conservatively treated. Clinical diagnosis is based on two symptoms: chest pain and dyspnea;and on a particular sign: subcutaneous emphysema. It has been reported in patients with influenza A (H1N1) and severe acute respiratory syndrome;however, it has been rarely observed in COVID-19 patients. In this work, we describe six male patients with COVID-19, aged between 27 and 82 years, who presented with spontaneous pneumomediastinum and subcutaneous emphysema;both conditions were completely resorbed with conservative management.