Short term outcomes for patients and providers following elective tracheostomy in COVID-19 positive patients

Murphy, Patrick; Holler, Emma; Lindroth, Heidi; Laughlin, Michelle; Simons, Clark J.; Streib, Erik W.; Boustani, Malaz; Ortiz, Damaris

IMPORTANCE: Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. OBJECTIVE: 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 ICU. We hypothesize that the usual indications for tracheostomy including prolonged mechanical ventilation, high sedative requirements, and copious secretions apply to patients with COVID-19 and thus this diagnosis should modify tracheostomy technique but not change clinical indications. DESIGN: Observational case series SETTING: Single center medical intensive care unit at a Level-1 Trauma center PARTICIPANTS: Patients diagnosed with COVID-19 who were assessed for tracheostomy MAIN OUTCOMES AND MEASURES: 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, 2,030 patients were admitted to the hospital with COVID-19, 615 required ICU care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. 18 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 prior to tracheostomy was 15 days (IQR 13-24). The median PEEP at time of tracheostomy was 10.8. The median PaO2/FiO2 ratio on the day of tracheostomy was 142.8 (IQR 104.5-224.4). Two patients had bleeding complications. At 1 week follow-up 8 patients still required ventilator support (73%). At the most recent follow-up 8 patients (73%) have been liberated from the ventilator, 1 patient (9%) died as a result of respiratory/multi-organ failure, and 2 were discharged on the ventilator (18%). Average follow-up was 20 days. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. CONCLUSIONS: and Relevance: Percutaneous dilational tracheostomy for COVID-19 patients is safe for healthcare workers and patients despite higher PEEP requirements, and should be performed for the same indications as other causes of respiratory failure.