Timing Of Tracheostomy Research Articles

Timing of Tracheostomy for Prolonged Respiratory Wean in Critically Ill Coronavirus Disease 2019 Patients: A Machine Learning Approach.

To propose the optimal timing to consider tracheostomy insertion for weaning of mechanically ventilated patients recovering from coronavirus disease 2019 pneumonia. We investigated the relationship between duration of mechanical ventilation prior to tracheostomy insertion and in-hospital mortality. In addition, we present a machine learning approach to facilitate decision-making. Prospective cohort study. Guy's & St Thomas' Hospital, London, United Kingdom. Consecutive patients admitted with acute respiratory failure secondary to coronavirus disease 2019 requiring mechanical ventilation between March 3, 2020, and May 5, 2020. Baseline characteristics and temporal trends in markers of disease severity were prospectively recorded. Tracheostomy was performed for anticipated prolonged ventilatory wean when levels of respiratory support were favorable. Decision tree was constructed using C4.5 algorithm, and its classification performance has been evaluated by a leave-one-out cross-validation technique. One-hundred seventy-six patients required mechanical ventilation for acute respiratory failure, of which 87 patients (49.4%) underwent tracheostomy. We identified that optimal timing for tracheostomy insertion is between day 13 and day 17. Presence of fibrosis on CT scan (odds ratio, 13.26; 95% CI [3.61-48.91]; p ≤ 0.0001) and Pao2:Fio2 ratio (odds ratio, 0.98; 95% CI [0.95-0.99]; p = 0.008) were independently associated with tracheostomy insertion. Cox multiple regression analysis showed that chronic obstructive pulmonary disease (hazard ratio, 6.56; 95% CI [1.04-41.59]; p = 0.046), ischemic heart disease (hazard ratio, 4.62; 95% CI [1.19-17.87]; p = 0.027), positive end-expiratory pressure (hazard ratio, 1.26; 95% CI [1.02-1.57]; p = 0.034), Pao2:Fio2 ratio (hazard ratio, 0.98; 95% CI [0.97-0.99]; p = 0.003), and C-reactive protein (hazard ratio, 1.01; 95% CI [1-1.01]; p = 0.005) were independent late predictors of in-hospital mortality. We propose that the optimal window for consideration of tracheostomy for ventilatory weaning is between day 13 and 17. Late predictors of mortality may serve as adverse factors when considering tracheostomy, and our decision tree provides a degree of decision support for clinicians.

Experience of percutaneous tracheostomy in critically ill COVID-19 patients.

Background Coronavirus disease 2019 (COVID-19) is a highly contagious disease that causes respiratory failure. Tracheostomy is an essential procedure in critically ill COVID-19 patients; however, it is an aerosol-generating technique and thus carries the risk of infection transmission. We report our experience with percutaneous tracheostomy and its safety in a real medical setting.Methods During the COVID-19 outbreak, 13 critically ill patients were admitted to the intensive care unit (ICU) at Daegu Catholic University Medical Center between February 24 and April 30, 2020. Seven of these patients underwent percutaneous tracheostomy using Ciaglia Blue Rhino. The medical environment, percutaneous tracheostomy method, and COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) results were retrospectively reviewed. After treatment, the COVID-19 infection status of healthcare personnel was investigated by RT-PCR.Results The ICU contained negative pressure cohort areas and isolation rooms, and healthcare personnel wore a powered air-purifying respirator system. We performed seven cases of percutaneous tracheostomy in the same way as in patients without COVID-19. Five patients (71.4%) tested positive for COVID-19 by RT-PCR at the time of tracheostomy. The median cycle threshold value for the RNA-dependent RNA polymerase was 30.60 (interquartile range [IQR], 25.50–36.56) in the upper respiratory tract and 35.04 (IQR, 28.40–36.74) in the lower respiratory tract. All healthcare personnel tested negative for COVID-19 by RT-PCR.Conclusions Percutaneous tracheostomy was performed with conventional methods in the negative pressure cohort area. It was safe to perform percutaneous tracheostomy in an environment of COVID-19 infection.

Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation.

Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT-anaesthetics department led tracheostomy team. A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020. Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13-20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23-40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7-16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related. Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.

Short-term Outcomes for Patients and Providers After Elective Tracheostomy in COVID-19–Positive Patients

BackgroundUrgent 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. MethodsThis 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. ResultsFrom 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. Conclusionsand 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.

US Practitioner Attitudes Toward Tracheostomy Timing, Benefits, Risks, and Techniques for Severe Stroke Patients: A National Survey and National Inpatient Sample Analysis.

US Practitioner Attitudes Toward Tracheostomy Timing, Benefits, Risks, and Techniques for Severe Stroke Patients: A National Survey and National Inpatient Sample Analysis.

Tracheostomy in Pediatric Intensive Care Unit: Experience from Eastern India.

ObjectiveTracheostomy is one of the most commonly used surgical intervention in sick children in the intensive care unit. The literature in the pediatric population is limited, therefore, we conducted this study to evaluate the indications, timing, complications, and outcomes of tracheostomy among the children at our center.MethodsThis retrospective study was conducted from January 2016 through December 2019. Data was collected from the patients’ records and analyzed.ResultsDuring this study period, 283 children were ventilated, of which 26 (9.1%) required tracheostomy. Among this 73% were boys. The median age of the children who underwent tracheostomy was 6.32 y. The most common indication for tracheostomy was prolonged mechanical ventilation [24 cases (92%)] followed by upper airway obstruction [2 cases (8%)]. The average time of tracheostomy was 11.65 d, range (1–21 d). Complications were seen in 14 patients (55%). The most common complications were accidental decannulation, occlusion, pneumothorax, and granulation tissue. Twenty one (80%) patients were successfully discharged, out of which 16 (61%) patients were discharged after decannulation and 5 (21%) were sent home with a tracheostomy tube in situ. Overall mortality in present study was 11.5%; none was directly related to tracheostomy.ConclusionsThe indication for tracheostomy has been changed from emergency to more elective one. Prolonged mechanical ventilation is the most common indication for tracheostomy. Although the timing of tracheostomy is not fixed, two weeks time is reasonable and it can be done safely at the bedside in pediatric intensive care.

Timing, Complications, and Safety of Tracheotomy in Critically Ill Patients With COVID-19

The current coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented needs for invasive ventilation, with 10% to 15% of intubated patients subsequently requiring tracheotomy. To assess the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19. This prospective cohort study assessed consecutive patients admitted to the intensive care unit (ICU) who had COVID-19 that required tracheotomy. Patients were recruited from March 16 to April 10, 2020, at a tertiary referral center. A surgical tracheotomy was performed for all patients following recommended criteria for use of personal protective equipment (PPE). The number of subthyroid operations, the tracheal entrance protocol, and use of PPE. Infections among the surgeons were monitored weekly by reverse-transcriptase polymerase chain reaction of nasopharyngeal swab samples. Short-term complications, weaning, and the association of timing of tracheotomy (early [≤10 days] vs late [>10 days]) with total required days of invasive ventilation were assessed. A total of 50 patients (mean [SD] age, 63.8 [9.2] years; 33 [66%] male) participated in the study. All tracheotomies were performed at the bedside. The median time from intubation to tracheotomy was 9 days (interquartile range, 2-24 days). A subthyroid approach was completed for 46 patients (92%), and the tracheal protocol was adequately achieved for 40 patients (80%). Adequate PPE was used, with no infection among surgeons identified 4 weeks after the last tracheotomy. Postoperative complications were rare, with minor bleeding (in 6 patients [12%]) being the most common complication. The successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group (adjusted hazard ratio, 2.55; 95% CI, 0.96-6.75), but the difference was not statistically significant. There was less time of invasive mechanical ventilatory support with early tracheotomy compared with late tracheotomy (mean [SD], 18 [5.4] vs 22.3 [5.7] days). The reduction of invasive ventilatory support was achieved at the expense of the pretracheotomy period. In this cohort study, with the use of a standardized protocol aimed at minimizing COVID-19 risks, bedside open tracheotomy was a safe procedure for patients and surgeons, with minimal complications. Timing of tracheotomy may be important in reducing time of invasive mechanical ventilation, with potential implications to intensive care unit availability during the COVID-19 pandemic.

TRACHEOSTOMY TIMING AND OUTCOMES IN PATIENTS WITH COVID-19 PNEUMONIA

SESSION TITLE: Lessons from the ICU: What have We Learned about the Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Benefits of early tracheostomy (2-10 days after intubation) include decreased sedation, days on ventilator, ICU length of stay and long-term mortality. In addition, it helps improve patient’s comfort level, tracheal suctioning, oral hygiene and facilitates early mobility in comparison to delayed tracheostomy (7-14 days after intubation). With the recent COVID-19 pandemic, an unprecedented surge in patients requiring prolonged mechanical ventilation led to an increase in the need for tracheostomies. Tracheostomy is an aerosol-generating procedure that raises potential risk to the proceduralists. Therefore, international professional otolaryngology and surgical organizations published guidelines, which recommended delaying tracheostomy to after 21 intubation days in order to ensure viral clearance prior to the procedure. In the setting of these well-intended practice guidelines, intensivists are faced with a new dilemma; following the standard of care for tracheostomy planning vs. delaying the procedure without evidence to support the new recommended guidelines. METHODS: We utilized our previously established Institute for Critical Care Medicine Tracheostomy Team (ICCM-TT), with its multidisciplinary departments, which include Critical Care, General Surgery, Cardiac and Thoracic Surgery and Otolaryngology. In April 2020, throughout the nine ICUs dedicated to the management of COVID-19 patients, the ICCM-TT performed 111 tracheostomy procedures. Case selection involved a multidisciplinary team evaluation of patient’s clinical status and wishes after goals of care discussion. Median time from translaryngeal intubation to tracheostomy was 11 days. All cases were performed at bedside, using percutaneous dilatational technique with bronchoscopic guidance. Additionally, real-time ultrasound guidance was utilized in cases identified to have difficult anatomical landmarks. All of the 111 procedures were performed within 1 day of the tracheostomy request, unless medical instability deferred the procedure or revisiting goals of care was needed. RESULTS: Of the patients who received tracheostomy for COVID-19 prolonged respiratory failure: 35 (31.5 %) patients discharged home alive, 23 (20.7 %) weaned from mechanical ventilation (no ventilator support, downsized or decannulated) but remain hospitalized on non-ICU floors, 33 (29.7 %) expired and the remaining 20 (18 %) are either in the ICUs or undergoing active weaning in a designated weaning unit. Of note, none of the ICCM-TT proceduralists acquired COVID-19 infection, all have been tested negative for antibodies. This may be due to the thorough pre-procedural planning, adherence to ICCM-TT protocols and vigilance in maintaining infection control guidelines. CONCLUSIONS: Developing a dedicated tracheostomy team and following standard of care in timing of tracheostomy for COVID-19 patients avoided unnecessary delay of patient’s care without risk of viral transmission to the staff. This facilitated patient’s ventilator weaning and discharges, which improved ICU throughput. CLINICAL IMPLICATIONS: Our results support creating a dedicated tracheostomy team and following standard of care without the need to delay a necessary procedure for COVID-19 pneumonia patients. Furthermore, this deemed safe when infection control protocols were strictly followed. DISCLOSURES: No relevant relationships by Adel Bassily-Marcus, source=Web Response No relevant relationships by Ella Illuzzi, source=Web Response No relevant relationships by Roopa Kohli-Seth, source=Web Response No relevant relationships by Evan Leibner, source=Web Response No relevant relationships by Ahmed Mohammed, source=Web Response

Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis.

Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy. We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD). Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24-3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, -19.18 to -7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, -24.33 to -12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32-1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted. Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term outcomes of tracheostomy timing following acute SCI.

A Systematic Review on Tracheostomy in COVID-19 Patients: Current Guidelines and Safety Measures.

At this moment the world is fighting with COVID-19 pandemic. Because of increasing number of critical cases, the ICU admissions are also increasing and overwhelming the hospital. These group of patients often required Tracheostomy for proper management and ventilation. As Surgeons we often required to examine and perform procedures in head and neck patients and are in high risk of exposure to aerosol and droplet contamination. We did a literature search for research regarding tracheostomy and its post procedure care during the ongoing COVID-19 pandemic. In this review various international guidelines and sources were put together, and we aim to summarize in a systematic way the available recommendations: indications, timing, technique and safety measures for tracheostomy for COVID-19 patients, from all over the world.

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis

Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes. We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes. An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P< .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P= .40). In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.

Timing of Tracheostomy for Patients With COVID-19 in the ICU—Setting Precedent in Unprecedented Times

Paul E. Kwak, MD, MM, MSc; Joseph R. Connors, BS; Peter A. Benedict, MD; Micah R. Timen, MD, MSc, CPA; Binhuan Wang, PhD; Yan Zhang, MPH; Stephanie Youlios, PA; Kimberly Sureau, NP; Michael J. Persky, MD; Samaan Rafeq, MD; Luis Angel, MD; Milan R. Amin, MD

Tracheotomy in a High-Volume Center During the COVID-19 Pandemic: Evaluating the Surgeon's Risk.

ObjectivePerforming tracheotomy in patients with COVID-19 carries a risk of transmission to the surgical team due to potential viral particle aerosolization. Few studies have reported transmission rates to tracheotomy surgeons. We describe our safety practices and the transmission rate to our surgical team after performing tracheotomy on patients with COVID-19 during the peak of the pandemic at a US epicenter.Study DesignRetrospective cohort study.SettingTertiary academic hospital.MethodsTracheotomy procedures for patients with COVID-19 that were performed April 15 to May 28, 2020, were reviewed, with a focus on the surgical providers involved. Methods of provider protection were recorded. Provider health status was the main outcome measure.ResultsThirty-six open tracheotomies were performed, amounting to 65 surgical provider exposures, and 30 (83.3%) procedures were performed at bedside. The mean time to tracheotomy from hospital admission for SARS-CoV-2 symptoms was 31 days, and the mean time to intubation was 24 days. Standard personal protective equipment, according to Centers for Disease Control and Prevention, was worn for each case. Powered air-purifying respirators were not used. None of the surgical providers involved in tracheotomy for patients with COVID-19 demonstrated positive antibody seroconversion or developed SARS-CoV-2–related symptoms to date.ConclusionTracheotomy for patients with COVID-19 can be done with minimal risk to the surgical providers when standard personal protective equipment is used (surgical gown, gloves, eye protection, hair cap, and N95 mask). Whether timing of tracheotomy following onset of symptoms affects the risk of transmission needs further study.

Controversies in Tracheostomy for Patients With COVID-19: The When, Where, and How

COVID-19 has impacted how we deliver care to patients, and much remains unknown regarding optimal management of respiratory failure in this patient population. There are significant controversies regarding tracheostomy in patients with COVID-19 related to timing, location of procedure, and technique. In this narrative review, we explore the recent literature, publicly available guidelines, protocols from different institutions, and clinical reports to provide critical insights on how to deliver the most benefit to our patients while safeguarding the health care force. Consensus can be reached that patients with COVID-19 should be managed in a negative-pressure environment with proper personal protective equipment, and that performing tracheostomy is a complex decision that should be made through multidisciplinary discussions considering patient prognosis, institutional resources, staff experience, and risks to essential health care workers. A broad range of practices exist because there is no conclusive guidance regarding the optimal timing or technique for tracheostomy.

Pediatric Tracheostomy at a Tertiary Healthcare Institution: A Retrospective Study Focused on Outcomes.

The aim of this study was to retrospectively evaluate all pediatric tracheotomies that had been performed at Sanliurfa Training and Research Hospital From September 2016 to July 2019. A retrospective study was performed on pediatric patients who had undergone tracheostomy during the three-year study period. Patient data were reviewed for the following variables: age, gender, age at the time of tracheostomy, primary indication for tracheostomy, length of stay in intensive care unit before and after tracheostomy, complications, mortality and cause of death. The primary indication for tracheostomy was categorized into 4 separate groups: congenital disease, traumatic injury, prolonged intubation and other causes. The study group consisted of 138 children. Seventy-one (51.4%) of the children were male, 67 (48.6%) were female and the mean age of tracheostomy was 13.30 (0.03–192.27) months, and 44.2% were younger than 1 year when tracheotomy was performed. The median age at the time of tracheostomy was highest in children who underwent tracheostomy for traumatic injury. The indication for tracheostomy was prolonged intubation in 73.2% of the children. Complications were observed in 13 (9%) children; bleeding (69.2%) was the most common. Complications were most frequent in children who underwent tracheostomy for prolonged intubation. The overall mortality ratewas 30.4% with cardiac arrest being the most common cause. At our center, the most common indication for tracheostomy in children was long-term intubation, possibly due to our center being a tertiary healthcare institute. Bleeding was the most common complication, while cardiac arrest was the most common cause of death.

Effect of Patient Demographics and Tracheostomy Timing and Technique on Patient Survival.

The ideal timing and technique of tracheostomy vary among patients and may impact outcomes. We aim to examine the association between tracheostomy timing, placement technique, and patient demographics on survival. Retrospective cohort study. A retrospective review was performed for all patients who underwent tracheostomy in 2016 and 2017 at one urban academic tertiary-care hospital. Kaplan-Meier curves were created based on combinations of tracheostomy timing and technique (early percutaneous, early non-percutaneous, late percutaneous, and late non-percutaneous). Cox proportional hazard models were used to determine multivariable effects of timing, technique, and other demographic factors. Primary outcome measures were tracheostomy-related mortality and overall survival. Secondary outcomes were in-hospital, 30-day, and 90-day mortality. Our study included 523 patients. There were six tracheostomy-related deaths, with hemorrhage and tracheoesophageal fistula being the most common causes. Tracheostomy timing and technique combinations were not associated with differences in all-cause mortality or survival following discharge. Cox proportional hazard models showed that Charlson Comorbidity Index (CCI) and unknown partner status were associated with a decrease in survival (P < .01 and P=.05, respectively). Additionally, patient age, gender, race, CCI, and body mass index were not independently associated with changes in survival. Late and non-percutaneous tracheostomies were associated with more tracheostomy-related deaths, but timing and technique were not associated with differences in patient survival. Multiple regression analysis showed that increased patient comorbidities, measured via CCI, and unknown partner status were independently associated with decreased survival. Proceduralists should discuss timing, technique, and patient social factors together with the medical care team when constructing plans for postdischarge management. 4 Laryngoscope, 131:1468-1473, 2021.

Tracheostomy from Insertion to de cannulation

Tracheostomy is a common surgical procedure, and is increasingly performed in the intensive care unit (ICU) as opposed to the operating room. Procedural knowledge is essential and is therefore outlined in this review. We also review several high-quality studies comparing percutaneous dilational tracheostomy and open surgical tracheostomy. The percutaneous method has a comparable, if not superior, safety profile and lower cost compared with the open surgical approach; therefore the percutaneous method is increasingly chosen. Standard and specialized varieties of tracheostomy tubes are available and the appropriate type is determined by patient anatomy and the indication for the tracheostomy. Fibre optic endoscopic evaluation of swallowing should be considered in assessment of bulbar function and tracheostomy weaning. A patient with a tracheostomy who develops respiratoryDistress during the ward weaning process should be investigated for upper airway pathology. Studies comparing early versus late tracheostomy suggest morbidity benefits that include less nosocomial pneumonia, shorter mechanical ventilation and shorter stay in the ICU. However, we discuss the questions that remain regarding the optimal timing of tracheostomy. We outline the potential acute and chronic complications of tracheostomy and their management, and we review the different tracheostomy tubes, their indications and when to remove them.

Outcome of 1890 tracheostomies for critical COVID-19 patients: a national cohort study in Spain.

BackgroundThe question of an optimal strategy and outcomes in COVID-19 tracheostomy has not been answered yet. The critical focus in our case study is to evaluate the outcomes of tracheostomy on intubated COVID-19 patients.MethodsA multicentric prospective observational study of 1890 COVID-19 patients undergoing tracheostomy across 120 hospitals was conducted over 7 weeks in Spain (March 28 to May 15, 2020). Data were collected with an innovative approach: instant messaging via WhatsApp. Outcome measurements: complications, achieved weaning and decannulation and survival.ResultsWe performed 1,461 surgical (81.3%) and 429 percutaneous tracheostomies. Median timing of tracheostomy was 12 days (4–42 days) since orotracheal intubation. A close follow-up of 1616/1890 (85.5%) patients at the cut-off time of 1-month follow-up showed that in 842 (52.1%) patients, weaning was achieved, while 391 (24.2%) were still under mechanical ventilation and 383 (23.7%) patients had died from COVID-19. Decannulation among those in whom weaning was successful (n = 842) was achieved in 683 (81%) patients.ConclusionTo the best of our knowledge, this is the largest cohort of COVID-19 patients undergoing tracheostomy. The critical focus is the unprecedented amount of tracheostomies: 1890 in 7 weeks. Weaning could be achieved in over half of the patients with follow-up. Almost one out of four tracheotomized patients died from COVID-19.

Tracheostomy for Coronavirus Disease 2019 Patients: Maintaining the Standard of Care.

Objectives:To respond to the new recommendations for delaying tracheostomy for coronavirus disease 2019 patients to day 21 post-intubation to ensure viral clearance.Design:Prospective observational cohort from April 1, 2020, to April 30, 2020, with 60 days follow-up.Setting:Academic medical center with nine adult ICUs dedicated to caring for coronavirus disease 2019 patients requiring mechanical ventilation.Patients:Mechanically ventilated patients with coronavirus disease 2019 pneumonia requiring tracheostomy for prolonged ventilatory support.Interventions:Adherence to the standard of care for timing of tracheostomy as deemed necessary by the intensivist without delay and utilizing the existing tracheostomy team in performing the needed procedures within 1 day of the request.Measurements and Main Results:One hundred eleven patients with coronavirus disease 2019 received tracheostomy in the month of April 2020. Median time to tracheostomy was 11 days. All procedures were performed percutaneously at bedside under bronchoscopic guidance. Sixty-three percent of patients who received tracheostomy either weaned or discharged alive within 60 days of the procedure. Performing tracheostomy on these patients without delay did not lead to coronavirus disease 2019 viral transmission to the tracheostomy team as evident by lack of symptoms and negative antibody testing.Conclusions:Adherence to standard of care in timing of tracheostomy is safe. Recommending delaying the procedure may lead to harmful consequences from prolonging mechanical ventilation and sedation without apparent benefit.

Time to tracheostomy impacts overall outcomes in patients with cervical spinal cord injury.

The morbidity associated with cervical spine injury increases in the setting of concomitant cervical spinal cord injury (CSCI). A significant proportion of these patients require placement of a tracheostomy. However, it remains unclear if timing to tracheostomy following traumatic CSCI can impact outcomes. The aim of our study was to characterize outcomes associated with tracheostomy timing following traumatic CSCI. We performed a 5-year (2010-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age, ≥18 years) trauma patients who had traumatic CSCI and received tracheostomy. Patients were subdivided into two groups: early tracheostomy (ET) (≤4 days from initial intubation) and late tracheostomy (LT) (>4 days). Outcome measures included respiratory complications, ventilator-free days, intensive care unit-free days and hospital length of stay, and mortality. Multivariate logistic regression analysis was performed. A total of 5,980 patients were included in the study, of which 1,010 (17%) patients received ET, while 4,970 (83%) patients received LT. Mean age was 46 years, and 73% were men. In terms of CSCI location, 48% of the patients had high CSCI (C1-C4), while 52% had low CSCI (C5-C7). Patients in the ET group had lower rates of respiratory complications (30% vs. 46%, p = 0.01), higher ventilator-free days (13 days vs. 9 days; p = 0.02), intensive care unit-free days (11 days vs. 8 days; p = 0.01), and a shorter hospital length of stay (22 days vs. 29 days; p = 0.01) compared with those in the LT group. On regression analysis, ET was associated with lower rates of respiratory complications in patients with high CSCI (odds ratio, 0.55 [0.41-0.81]) and low CSCI (odds ratio, 0.93 [0.72-0.95]). However, no association was found between time to tracheostomy and in-hospital mortality. Early tracheostomy regardless of CSCI level may lead to improved outcomes. Quality improvement efforts should focus on defining the optimal time to tracheostomy and considering ET as a component of SCI management bundle. Therapeutic, level IV.