As the number of patients infected by SARS-CoV-2 around the world is increasing, the demand for endotracheal intubation and invasive mechanical ventilatory support secondary to acute respiratory failure is increasing accordingly[9, 10], which will certainly lead to an increase in tracheostomy in the following days. Our study described the clinical characteristics and outcomes of COVID-19 patients who underwent tracheostomies, comprising 80 patients from 23 hospitals in Hubei Province, China. We found that tracheostomies were feasible to conduct by ICU physicians at bedside with few major complications, and compared with tracheostomies conducted after 14 days of intubation, tracheostomies within 14 days were associated with an increased mortality rate.
Most clinicians were concerned with the aerosol-generating risk while conducting tracheostomies in patients with COVID-19, so optimal management should be applied in the tracheostomy procedure to maintain the safety of operators. In our study, most procedures were performed by ICU physicians using percutaneous techniques at bedside, which avoided the unnecessary transport of ventilated patients and repeated connection and disconnection of ventilatory circuits during transfer. Regarding the type of tracheostomy performance, some argued against percutaneous tracheostomy performed in COVID-19 patients because it usually involves opening the ventilator circuit more frequently than surgical tracheostomy, and serial dilations during the procedure may put surgeons in face of the airway from the beginning. However, there is currently no evidence across the literature to advise which approach is less aerosol generating. In addition to standard personal protective equipment (PPE), PAPR is beneficial in preventing contracting. Another important aspect is paralytics, which reduce cough and facilitate the procedure.
Timing for elective tracheostomy performance is always controversial. Outside the context of the COVID-19 pandemic, Rumbak and colleagues reported that early tracheostomy was associated with a reduced mortality rate and incidence of pneumonia and shorter MV and ICU durations. However, Young and colleagues found that there was no difference in 30-day mortality and 1- and 2-year survival or length of ICU stay between early and late groups. During the pandemic of COVID-19, it remains unclear whether early tracheostomy performance is beneficial to critically ill COVID-19 patients. Some guidelines[16-18] suggested that tracheostomy should be delayed until at least 14 days from endotracheal intubation because viral load in the upper and lower airway may be high in the early course of the infection in COVID-19 patients.
Our study presented evidence that, compared with tracheostomies conducted after 14 days of intubation, tracheostomies within 14 days were associated with an increased mortality rate. Univariate analysis showed that patients who underwent early tracheostomies had higher SOFA scores and APACHE II scores, and more of these patients received ECMO. However, after adjusting SOFA and ECMO, the timing of tracheostomy was the only variable significantly associated with mortality. Further studies are needed to explore the relationship between the timing of tracheostomy and mortality.
This study has several limitations. First, the sample size of our study was relatively small, which might cause bias and limit the reliability or generalizability of our results. Second, some patients were still hospitalized at the end of this study, so some clinical outcomes, such as length of ICU stay and hospital stay, were unavailable at the time of analysis. Third, due to its retrospective design, the lack of randomization for patients who underwent early and late tracheostomy may increase the possibility of confounding in the subsequent comparison. In future research, rigorous prospective randomized trials with large samples are needed to make the research results more accurate.
In conclusion, in patients with severe SARS-CoV-2 pneumonia, tracheostomies were feasible to conduct by ICU physicians at bedside with few major complications. However, tracheostomies within 14 days of endotracheal intubation should be avoided.