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Otolaryngology

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

Educational Objective
To understand the timing, complications, and safety of tracheotomy in critically ill patients with COVID-19

1 Credit CME

JAMA Otolaryngology–Head & Neck Surgery

Published Online: October 8, 2020

Original Investigation

Article Information and Disclosures

Francesc Xavier Avilés-Jurado, MD, PhD^1,2,3,4;

Daniel Prieto-Alhambra, MD, PhD⁵;

Nesly González-Sánchez, MD^1,6;

José de Ossó, MD¹;

Claudio Arancibia, MD¹;

María Jesús Rojas-Lechuga, MD¹;

Laura Ruiz-Sevilla, MD¹;

Joan Remacha, MD¹;

Irene Sánchez, MD¹;

Eduardo Lehrer-Coriat, MD^1,2,3;

Mauricio López-Chacón, MD^1,2,3;

Cristóbal Langdon, MD^1,2,3,7;

Josep María Guilemany, MD, PhD^1,2;

Francisco Larrosa, MD, PhD^1,2;

Isam Alobid, MD, PhD^1,2,3;

Manuel Bernal-Sprekelsen, MD, PhD^1,8;

Pedro Castro, MD, PhD^2,3,9;

Isabel Vilaseca, MD, PhD^1,2,3,4,7

Author Affiliations

¹Otorhinolaryngology Head Neck Surgery Department, Institut Clínic d'Especialitats Mèdiques i Quirúrgiques, Hospital Clínic, Barcelona, Spain
²Departament de Cirurgia i Especialitats Mèdico-Quirúrgiques, Universitat de Barcelona School of Medicine, Barcelona, Spain
³Institut d´Investigacions Biomèdiques August Pi i Sunyer, August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain
⁴Head Neck Clínic, Agència de Gestió d'Ajuts Universitaris i de Recerca, 2017-SGR-01581, Barcelona, Spain
⁵Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
⁶PhD Program, Universitat de Barcelona School of Medicine, Barcelona, Spain
⁷Centro de Investigación Biomédica en Red sobre Enfermedades Respiratorias, Bunyola, Spain
⁸Otorhinolaryngology Division, Department of Surgery, Universitat de Valencia, Valencia, Spain
⁹Medical Intensive Care Unit, Instituto Clínic de Medicina y Dermatología, Hospital Clínic, Barcelona, Spain

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Key Points

Question Is it safe to perform an early bedside surgical tracheotomy in patients with coronavirus disease 2019 (COVID-19)?

Findings In this cohort study of 50 patients with COVID-19 who underwent consecutive bedside tracheotomies following the recommended parameters for standard protective personal equipment, the successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group, and no infections among the surgeons were identified at the end of study.

Meaning With the use of a standardized protocol to minimize risk of spread of COVID-19, early bedside surgical tracheotomy may be a safe strategy for reducing time of mechanical ventilation, sparing intensive care unit beds during the COVID-19 pandemic.

Abstract

Importance 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.

Objective To assess the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19.

Design, Setting, and Participants 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.

Exposures A surgical tracheotomy was performed for all patients following recommended criteria for use of personal protective equipment (PPE).

Main Outcomes and Measures 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.

Results 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.

Conclusions and Relevance 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.

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Article Information

Corresponding Author: Isabel Vilaseca, MD, PhD, Otorhinolaryngology Head Neck Surgery Department, Institut Clínic d'Especialitats Mèdiques i Quirúrgiques. Hospital Clínic, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain (ivila@clinic.cat).

Published Online: October 8, 2020. doi:10.1001/jamaoto.2020.3641

Author Contributions: Drs Avilés-Jurado and Vilaseca contributed equally to this article. Drs Avilés-Jurado and Vilaseca had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Avilés-Jurado, Prieto-Alhambra, de Ossó, Lehrer, Alobid, Bernal-Sprekelsen, Castro, Vilaseca.

Acquisition, analysis, or interpretation of data: Avilés-Jurado, Prieto-Alhambra, González Sánchez, Arancibia, Rojas-Lechuga, Ruiz-Sevilla, Remacha, Sánchez, Lehrer, López-Chacón, Langdon, Guilemany, Larrosa, Alobid, Castro, Vilaseca.

Drafting of the manuscript: Avilés-Jurado, Prieto-Alhambra, Arancibia, Lehrer, Alobid, Vilaseca.

Critical revision of the manuscript for important intellectual content: Avilés-Jurado, Prieto-Alhambra, González Sánchez, de Ossó, Rojas-Lechuga, Ruiz-Sevilla, Remacha, Sánchez, López-Chacón, Langdon, Guilemany, Larrosa, Alobid, Bernal-Sprekelsen, Castro, Vilaseca.

Statistical analysis: Avilés-Jurado, Prieto-Alhambra, González Sánchez, Vilaseca.

Administrative, technical, or material support: Avilés-Jurado, de Ossó, Arancibia, Rojas-Lechuga, Ruiz-Sevilla, Remacha, Sánchez, Lehrer, López-Chacón, Larrosa.

Supervision: Avilés-Jurado, Prieto-Alhambra, Lehrer, Langdon, Alobid, Bernal-Sprekelsen, Castro.

Conflict of Interest Disclosures: Dr Prieto-Alhambra reported receiving grants and speaker honorarium from Amgen and UCB outside the submitted work. Dr Bernal-Sprekelsen reported receiving speaker honorarium from Olympus outside the submitted work. No other disclosures were reported.

Additional Contributions: The following COVID-19 Clinic Critical Care Group members from Hospital Clínic of Barcelona provided substantial collaboration to the work: Alex Almuedo, MD, PhD; Joan Ramon Alonso, MD, PhD; Rut Andrea MD, PhD; Fatima Aziz, MD; Joan Ramon Badia MD, PhD; Enric Barbeta, MD; Raquel Berger, MD; Xavier Borrat, MD, PhD; Ernest Bragulat, MD, PhD; Carmen Cañueto, RN; Inmaculada Carmona, RN; Manel Castellà, MD, PhD; Oriol De Diego, MD; Marta Farrero, MD, PhD; Javier Fernández, MD, PhD; Sara Fernández, MD; Carlos Ferrando, MD, PhD; Miguel Ferrer MD, PhD; Maria Forga, MD, PhD; Ignacio Grafiá, MD; Lídia Gómez, MD; Eduard Guasch, MD, PhD; María Hernández-Tejero, MD, PhD; Adriana Jacas, MD; Pere Leyes, MD, PhD; Teresa López, MD; Javier Marco, MD; Jose Antonio Martínez, MD, PhD; Graciela Martínez-Palli, MD, PhD; Ricard Mellado, MD, PhD; Jordi Mercadal, MD, PhD; Guillermo Muñoz, MD; José Muñoz, MD, PhD; Ricard Navarro, MD, PhD; Josep Maria Nicolás MD, PhD; José T Ortiz, MD, PhD; Esteban Poch, MD, PhD; Margalida Pujol, MD; Eduard Quintana, MD, PhD; Enric Reverter, MD, PhD; Irene Rovira, MD, PhD; Pablo Ruiz, MD; Xavier Sala-Blanch, MD PhD; Elena Sandoval, MD, PhD; Stefan Schneider, MD; Ferran Seguí, MD; Oriol Sibila, MD, PhD; Cristina Sierra, MD, PhD; Alex Soriano, MD, PhD; Dolors Soy, Pharm D, PhD; María Suárez, MD; Adrián Téllez, MD; David Toapanta MD; Antoni Torres MD, PhD; Xavier Urra MD, PhD; and Carles Zamora, MD. They were not compensated for their work.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.