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1.
Head Neck ; 42(7): 1392-1396, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-1384168

ABSTRACT

The severe acute respiratory syndrome (SARS)-CoV-2 pandemic continues to produce a large number of patients with chronic respiratory failure and ventilator dependence. As such, surgeons will be called upon to perform tracheotomy for a subset of these chronically intubated patients. As seen during the SARS and the SARS-CoV-2 outbreaks, aerosol-generating procedures (AGP) have been associated with higher rates of infection of medical personnel and potential acceleration of viral dissemination throughout the medical center. Therefore, a thoughtful approach to tracheotomy (and other AGPs) is imperative and maintaining traditional management norms may be unsuitable or even potentially harmful. We sought to review the existing evidence informing best practices and then develop straightforward guidelines for tracheotomy during the SARS-CoV-2 pandemic. This communication is the product of those efforts and is based on national and international experience with the current SARS-CoV-2 pandemic and the SARS epidemic of 2002/2003.


Subject(s)
Clinical Decision-Making , Coronavirus Infections/epidemiology , Hospital Mortality/trends , Pandemics/statistics & numerical data , Pneumonia, Viral/epidemiology , Severe Acute Respiratory Syndrome/therapy , Tracheotomy/methods , COVID-19 , Coronavirus Infections/prevention & control , Critical Care/methods , Elective Surgical Procedures/methods , Elective Surgical Procedures/statistics & numerical data , Emergencies , Female , Follow-Up Studies , Humans , Intensive Care Units/statistics & numerical data , Internationality , Intubation, Intratracheal , Male , Occupational Health , Pandemics/prevention & control , Patient Safety , Pneumonia, Viral/prevention & control , Respiration, Artificial/methods , Risk Assessment , SARS Virus/pathogenicity , Survival Rate , Time Factors , Treatment Outcome , United States/epidemiology , Ventilator Weaning/methods
2.
Surgeon ; 19(5): e265-e269, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1003084

ABSTRACT

BACKGROUND: The current COVID-19 pandemic has placed enormous strain on healthcare systems worldwide. Understanding of COVID-19 is rapidly evolving. Pneumonia associated with COVID-19 may lead to respiratory failure requiring mechanical ventilation. The rise in patients requiring mechanical ventilation may lead to an increase in tracheostomies being performed in patients with COVID-19. Performing tracheostomy in patients with active SARS-CoV-2 infection poses a number of challenges. METHODS: These guidelines were written following multidisciplinary agreement between Otolaryngology, Head and Neck Surgery, Respiratory Medicine and the Department of Anaesthetics and Critical Care Medicine in the Royal College of Surgeons in Ireland. A literature review was performed and a guideline for elective tracheostomy insertion in patients with COVID-19 proposed. CONCLUSION: The decision to perform tracheostomy in patients with COVID-19 should be undertaken by senior members of the multidisciplinary team. Steps should be taken to minimise risks to healthcare workers.


Subject(s)
COVID-19/therapy , Critical Care , Respiration, Artificial , Tracheostomy , COVID-19/complications , Clinical Protocols , Elective Surgical Procedures , Humans , Infection Control , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Ireland , Patient Selection , Personal Protective Equipment
3.
JAMA Otolaryngol Head Neck Surg ; 147(3): 239-244, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-983878

ABSTRACT

Importance: Decision-making in the timing of tracheostomy in patients with coronavirus disease 2019 (COVID-19) has centered on the intersection of long-standing debates on the benefits of early vs late tracheostomy, assumptions about timelines of infectivity of the novel coronavirus, and concern over risk to surgeons performing tracheostomy. Multiple consensus guidelines recommend avoiding or delaying tracheostomy, without evidence to indicate anticipated improvement in outcomes as a result. Objective: To assess outcomes from early tracheostomy in the airway management of patients with COVID-19 requiring mechanical ventilation. Design, Setting, and Participants: A retrospective medical record review was completed of 148 patients with reverse transcriptase-polymerase chain reaction-confirmed COVID-19 requiring mechanical ventilation at a single tertiary-care medical center in New York City from March 1 to May 7, 2020. Interventions: Open or percutaneous tracheostomy. Main Outcomes and Measures: The primary outcomes were time from symptom onset to (1) endotracheal intubation, (2) tracheostomy; time from endotracheal intubation to tracheostomy; time from tracheostomy to (1) tracheostomy tube downsizing, (2) decannulation; total time on mechanical ventilation; and total length of stay. Results: Participants included 148 patients, 120 men and 28 women, with an overall mean (SD) age of 58.1 (15.8) years. Mean (SD; median) time from symptom onset to intubation was 10.57 (6.58; 9) days; from symptom onset to tracheostomy, 22.76 (8.84; 21) days; and from endotracheal intubation to tracheostomy, 12.23 (6.82; 12) days. The mean (SD; median) time to discontinuation of mechanical ventilation was 33.49 (18.82; 27) days; from tracheostomy to first downsize, 23.02 (13.76; 19) days; and from tracheostomy to decannulation, 30.16 (16.00; 26) days. The mean (SD; median) length of stay for all patients was 51.29 (23.66; 45) days. Timing of tracheostomy was significantly associated with length of stay: median length of stay was 40 days in those who underwent early tracheostomy (within 10 days of endotracheal intubation) and 49 days in those who underwent late tracheostomy (median difference, -8; 95% CI, -15 to -1). In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation (hazard ratio, 0.84; 95% CI, 0.55 to 1.28). Conclusions and Relevance: This cohort study from the first 2 months of the pandemic in New York City provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19. Findings demonstrated noninferiority of early tracheostomy and challenges recommendations to categorically delay or avoid tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of the novel coronavirus, this approach may optimize outcomes from tracheostomy while keeping clinicians safe.


Subject(s)
COVID-19/therapy , Pneumonia, Viral/therapy , Respiration, Artificial , Tracheostomy , Female , Humans , Intubation, Intratracheal , Length of Stay/statistics & numerical data , Male , Middle Aged , Pneumonia, Viral/virology , Retrospective Studies , SARS-CoV-2 , Time Factors
4.
J Surg Res ; 260: 38-45, 2021 04.
Article in English | MEDLINE | ID: covidwho-974321

ABSTRACT

BACKGROUND: Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit. METHODS: This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications. RESULTS: From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. CONCLUSIONS: and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.


Subject(s)
Bronchoscopy/adverse effects , COVID-19/therapy , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Postoperative Complications/epidemiology , Respiration, Artificial/adverse effects , Tracheostomy/adverse effects , Adult , Aged , Airway Extubation/statistics & numerical data , Bronchoscopy/instrumentation , Bronchoscopy/methods , Bronchoscopy/standards , COVID-19/diagnosis , COVID-19/mortality , COVID-19/transmission , COVID-19 Nucleic Acid Testing/statistics & numerical data , Female , Follow-Up Studies , Hospital Mortality , Humans , Infectious Disease Transmission, Patient-to-Professional/statistics & numerical data , Intensive Care Units/standards , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Postoperative Complications/etiology , Respiration, Artificial/instrumentation , Respiration, Artificial/methods , Respiration, Artificial/statistics & numerical data , Retrospective Studies , SARS-CoV-2/isolation & purification , Severity of Illness Index , Time Factors , Tracheostomy/instrumentation , Tracheostomy/methods , Tracheostomy/standards , Treatment Outcome
5.
Ann Surg ; 2020 Nov 17.
Article in English | MEDLINE | ID: covidwho-936564

ABSTRACT

IMPORTANCE: Many ventilated COVID-19 patients require prolonged ventilation. We do not know if tracheostomy will improve their care. Given the paucity of data on this topic, the optimal surgical approach has yet to be elucidated. OBJECTIVE: To determine the optimal surgical strategy for performing tracheostomy in COVID-19 patients. DESIGN: Cohort study of 143 ventilator dependent COVID-19 patients undergoing tracheostomy at an academic medical center from April 15 to May 15, 2020, with follow up until June 1, 2020. SETTING: A New York City (NYC) academic quaternary referral center during its peak of COVID-19. PARTICIPANTS: Adult patients admitted to a NYC medical center with COVID-19 who required invasive mechanical ventilation for greater than 2 weeks who were unable to be extubated and determined to have reasonable chance of recovery and fit defined tracheostomy candidate criteria. EXPOSURE: Patients had either a percutaneous tracheostomy (PT) or open surgical tracheostomy (ST) performed by one of three surgical services. MAIN OUTCOME AND MEASURE: The primary aim of the study was to evaluate the safety and results of tracheostomy for both patients with COVID-19 and the surgeons performing the tracheostomy. Specifically, tracheostomy complications, inpatient mortality, disposition of patients, and transmission of COVID-19 to surgeons were measured. RESULTS: 143 patients underwent tracheostomy, 58 (41%) via a ST, and 85 (59%) via a PT. There were no significant differences in patient characteristics between the two groups, except that more patients who had a history of extracorporeal membrane oxygenation (ECMO) underwent PT (11% vs 2%, p=0.049). There were no statistical differences observed between the PT and ST groups with regard to bleeding complications (3.5% vs 10.3%, p=0.099), tracheostomy related complications (5.9% vs 8.6%, p=0.528), inpatient death (12% vs 5%, p=0.178), discharge from hospital (39% vs 36%,p=0.751) or surgeon illness (0% v 0%, p=1). CONCLUSION AND RELEVANCE: The rapid formation of a multi-disciplinary team allows for the efficient evaluation and performance of a large volume of tracheostomies in a resource-limited setting. Bedside tracheostomy in COVID-19 does not cause additional harm to patients if performed after 2 weeks from intubation. It also appears to be safe for proceduralists to perform in this timeframe. The manner of tracheostomy does not change outcomes significantly if it is performed safely and efficiently.

6.
Ear Nose Throat J ; 100(2_suppl): 113S-115S, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-655415

ABSTRACT

Acute airway obstruction caused by invasive laryngeal cancer can make surgeons reluctant to perform a high-risk tracheostomy, which is life-saving for such patients. In the setting of the current COVID19 pandemic, we present a case of severe transglottic stenosis due to stage IV laryngeal carcinoma, in which gaseous exchange was facilitated by venovenous (VV) extracorporeal membrane oxygenation prior to emergent tracheostomy. The VV technique can ensure adequate oxygenation and CO2 removal. Venovenous extracorporeal membrane oxygenation provided sufficient time for surgical planning and preparation. It reduced the formation of aerosol, lowered the risk associated with life-saving tracheostomy, and protected the patient from ischemia.


Subject(s)
Airway Obstruction/surgery , Extracorporeal Membrane Oxygenation/methods , Laryngeal Neoplasms/diagnosis , Perioperative Care/methods , Squamous Cell Carcinoma of Head and Neck/diagnosis , Tracheostomy/methods , Acute Disease , Aged , Airway Obstruction/etiology , COVID-19 , Emergencies , Humans , Laryngeal Neoplasms/complications , Laryngeal Neoplasms/pathology , Laryngoscopy , Male , Neoplasm Staging , SARS-CoV-2 , Squamous Cell Carcinoma of Head and Neck/complications , Squamous Cell Carcinoma of Head and Neck/pathology , Tomography, X-Ray Computed
7.
Am J Otolaryngol ; 41(5): 102578, 2020.
Article in English | MEDLINE | ID: covidwho-457086

ABSTRACT

PURPOSE: COVID-19 has become a pandemic with significant consequences worldwide. About 3.2% of patients with COVID-19 will require intubation and invasive ventilation. Moreover, there will be an increase in the number of critically ill patients, hospitalized and intubated due to unrelated acute pathology, who will present underlying asymptomatic or mild forms of COVID-19. Tracheostomy is one of the procedures associated with an increased production of aerosols and higher risk of transmission of the virus to the health personnel. The aim of this paper is to describe indications and recommended technique of tracheostomy in COVID-19 patients, emphasizing the safety of the patient but also the medical team involved. MATERIALS AND METHODS: A multidisciplinary group made up of surgeons with privileges to perform tracheostomies, intensive care physicians, infectious diseases specialists and intensive pulmonologists was created to update previous knowledge on performing a tracheostomy in critically ill adult patients (>18 years) amidst the SARS-CoV-2 pandemic in a high-volume referral center. Published evidence was collected using a systematic search and review of published studies. RESULTS: A guideline comprising indications, surgical technique, ventilator settings, personal protective equipment and timing of tracheostomy in COVID-19 patients was developed. CONCLUSIONS: A safe approach to performing percutaneous dilational bedside tracheostomy with bronchoscopic guidance is feasible in COVID-19 patients of appropriate security measures are taken and a strict protocol is followed. Instruction of all the health care personnel involves is key to ensure their safety and the patient's favorable recovery.


Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Critical Care , Infection Control/organization & administration , Pneumonia, Viral/epidemiology , Tracheostomy , COVID-19 , Clinical Protocols , Coronavirus Infections/prevention & control , Coronavirus Infections/transmission , Humans , Pandemics/prevention & control , Patient Selection , Pneumonia, Viral/prevention & control , Pneumonia, Viral/transmission , SARS-CoV-2
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