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

Educational Objective
To understand how to time tracheostomy for patients with COVID-19 in ICU
1 Credit CME

“Uncontrolled variation is the enemy of quality.”

W. Edwards Deming, Basic Statistical Tools for Improving Quality

Navigating the uncharted has been a pervasive theme during the coronavirus disease 2019 (COVID-19) pandemic, and lack of data to guide decisions has been the most evident regarding the timing of tracheostomy. Tracheostomy, an aerosol-generating procedure with risk of infectious transmission for health care workers,1 also has important implications for patient care and stewardship of critical resources.2,3 Emerging data concerning infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the course of patients with COVID-19, and clinical experience may alter practice, even preempting publication. For example, Chao et al4 originally recommended deferring tracheostomy beyond 21 days of intubation and recommended open surgical tracheostomy over percutaneous dilatational tracheostomy; however, updated practices at the authors’ institution reflect outcomes of tracheostomy performed at 10 to 14 days after intubation, with percutaneous technique performed regularly. Similarly, shortly after the New York Head and Neck Society advocated a 14-day standard,5 the New York University thoracic group published a series of 98 COVID-19 tracheostomy procedures, with surgical procedures at a mean (SD) of 10.6. (5) days of intubation,6 indicating that many patients underwent tracheostomy well before day 10 of intubation. When COVID-19 overwhelms capacity in intensive care units (ICUs), early timing of tracheostomy may accelerate ventilator weaning and free up critical equipment, staff, and units. Guidelines now recommend that timing of tracheostomy consider scarcity of ventilators and other ICU resources.3

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Article Information

Corresponding Author: Michael J. Brenner, MD, Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, 1500 E Medical Center Dr, 1903 Taubman Center SPC 5312, Ann Arbor, MI 48104 (mbren@med.umich.edu).

Published Online: September 3, 2020. doi:10.1001/jamaoto.2020.2630

Conflict of Interest Disclosures: Dr Brenner reported being president of the Global Tracheostomy Collaborative, a 501(c)(3) Quality Improvement Collaborative; he is not compensated. No other disclosures were reported.

References
1.
Tay  JK , Khoo  ML-C , Loh  WS .  Surgical considerations for tracheostomy during the COVID-19 pandemic.   JAMA Otolaryngol Head Neck Surg. 2020;146(6):517-518. doi:10.1001/jamaoto.2020.0764 PubMedGoogle ScholarCrossref
2.
McGrath  BA , Brenner  MJ , Warrillow  SJ ,  et al.  Tracheostomy in the COVID-19 era.   Lancet Respir Med. 2020;8(7):717-725. doi:10.1016/S2213-2600(20)30230-7PubMedGoogle ScholarCrossref
3.
Michetti  CP , Burlew  CC , Bulger  EM , Davis  KA , Spain  DA ; Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma.  Performing tracheostomy during the Covid-19 pandemic.   Trauma Surg Acute Care Open. 2020;5(1):e000482. doi:10.1136/tsaco-2020-000482 PubMedGoogle Scholar
4.
Chao  TN , Harbison  SP , Braslow  BM ,  et al.  Outcomes after tracheostomy in COVID-19 patients.   Ann Surg. Published online June 11, 2020. doi:10.1097/SLA.0000000000004166 PubMedGoogle Scholar
5.
Miles  BA , Schiff  B , Ganly  I ,  et al.  Tracheostomy during SARS-CoV-2 pandemic.   Head Neck. 2020;42(6):1282-1290. doi:10.1002/hed.26166 PubMedGoogle ScholarCrossref
6.
Angel  L , Kon  ZN , Chang  SH ,  et al.  Novel percutaneous tracheostomy for critically ill patients with COVID-19.   Ann Thorac Surg. Published online April 24, 2020. doi:10.1016/j.athoracsur.2020.04.010PubMedGoogle Scholar
7.
Rose  MR , Hiltz  KA , Stephens  RS , Hager  DN .  Novel viruses, old data, and basic principles.   Lancet Respir Med. 2020;8(7):661-663. doi:10.1016/S2213-2600(20)30236-8PubMedGoogle ScholarCrossref
8.
Phua  J , Weng  L , Ling  L ,  et al; Asian Critical Care Clinical Trials Group.  Intensive care management of coronavirus disease 2019 (COVID-19).   Lancet Respir Med. 2020;8(5):506-517. doi:10.1016/S2213-2600(20)30161-2 PubMedGoogle ScholarCrossref
9.
McGrath  BA , Wallace  W , Lynch  J ,  et al  Improving tracheostomy care in the United Kingdom.   Br J Anesthes. 2020;125(1):e119-e129. doi:10.1016/j.bja.2020.04.064PubMedGoogle ScholarCrossref
10.
Brenner  MJ , Pandian  V , Milliren  C ,  et al.  Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardization, education and patient partnership.   Br J Anesthes. 2020;125(1):e104-e118. doi:10.1016/j.bja.2020.04.054PubMedGoogle ScholarCrossref
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