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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 28-34

Bedside tracheostomy on COVID-19 patients in the intensive care unit: A retrospective study

Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission13-Dec-2020
Date of Acceptance05-Feb-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_62_20

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Introduction: Currently, coronavirus disease 2019 (COVID-19) infection is a global challenge to the medical community, often resulting in acute respiratory distress syndrome and respiratory failure needing mechanical ventilation. Tracheostomy is needed for prolonged ventilation as the severity of respiratory failure often escalates, needing extended ventilation in an intensive care unit (ICU). Objective: The objective of study was to evaluate clinical details of performing tracheostomy including patient profile, surgical steps, complications and precautions by health-care workers in the ICU of a specially assigned hospital for COVID-19 patients. Patients and Methods: This is a retrospective study of 22 COVID-19 patients who underwent bedside surgical tracheostomy in the ICU. Patient profile such as age, gender, comorbidities, complication of tracheostomy, ventilator withdrawal after tracheostomy and nosocomial infections of health-care workers related to tracheostomy were analysed. Results: In the study period of 6 months, there were 12,850 COVID-19 patients admitted to our COVID-designated hospital, of whom 2452 patients needed ICU care. A total of 610 patients needed ventilatory support, with 22 patients aged between 42 and 75 years (mean age of 64 years) undergoing a tracheostomy (16 males and 6 females). The median duration from the day of the orotracheal intubation to the day of tracheostomy was 13 days. Conclusion: Surgical tracheostomy on COVID-19 patients is a high-risk aerosol-generating procedure for health-care workers. It should be performed with close communication between otorhinolaryngologists, anaesthesiologists and intensivists, along with adequate personal protective equipment for smooth management of the airway.

Keywords: COVID-19 infection, intensive care unit, invasive mechanical ventilation, tracheostomy

How to cite this article:
Swain SK, Acharya S. Bedside tracheostomy on COVID-19 patients in the intensive care unit: A retrospective study. Airway 2021;4:28-34

How to cite this URL:
Swain SK, Acharya S. Bedside tracheostomy on COVID-19 patients in the intensive care unit: A retrospective study. Airway [serial online] 2021 [cited 2022 Jun 29];4:28-34. Available from: https://www.arwy.org/text.asp?2021/4/1/28/315167

  Introduction Top

The novel coronavirus disease 2019 (COVID-19) is a rapidly spreading infection amongst humans and is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] The COVID-19 pandemic is leading to an unprecedented disruption of life all over the world, with all countries facing the burden irrespective of the strength and resilience of their health-care system. Hospitals and intensive care units (ICUs) are facing a surge of COVID-19 patients requiring urgent care or invasive ventilation. This virus is seen in high abundance in the mucosa of the upper and lower respiratory tract.[1] It is usually transmitted by close contact, droplets and aerosols from aerosol-generating procedures (AGPs) such as a tracheostomy.[2] Tracheostomy is a commonly performed surgical procedure in ICUs on patients needing prolonged ventilation. Health-care workers are at high risk of contracting infections during this procedure. Currently, performing tracheostomy on a COVID-19 patient is challenging for otorhinolaryngologists and associated health professionals in the ICU because of high chance of spread of SARS-CoV-2 virus not only to personnel involved but also to other patients.[3] Despite surgical tracheostomy being commonly done in routine clinical practice, the risk of exposure to health-care professionals to COVID-19 infection during this procedure is consistent. Because of the direct access to the airway, tracheostomies are high AGPs, placing surgeons or otorhinolaryngologists at the highest risk, along with ICU nurses, intensivists and anaesthesiologists.[3] Surgical tracheostomy on intubated and sedated patients is preferable to performing it on an awake patient as air flow cessation cannot be obtained and droplet emission is inevitably more in the awake patient. Till date, the profile of tracheostomy on the COVID-19 patients in ICU has not been adequately reported in literature. This study aims to evaluate the profile of surgical tracheostomy on COVID-19 patients in the ICU.

  Patients and Methods Top

This a descriptive retrospective study done at a tertiary care teaching hospital located in eastern India attached to a 500-bedded COVID-19 hospital with 125 designated ICU beds. This COVID hospital is one of the hospitals assigned by the state government to treat COVID-19 patients. We retrospectively analysed hospitalised COVID-19 patients who underwent tracheostomy between March and August 2020. The study was approved by the Institutional Ethics Committee of our hospital (reference number IEC/IMS/SOA/12/14 March 2020). A written informed consent was waived by the Ethics Committee of our hospital owing to the rapid emergence of the disease. All COVID-19 patients were admitted on the basis of a positive real-time reverse transcription-polymerase chain reaction (RT-PCR) test from nasopharyngeal swabs. Before performing tracheostomy, the RT-PCR test was repeated as per our institutional policy to know the infectivity of the COVID-19 patient. At the time of treatment, discussion was not done with the patient or relative regarding the risks and benefits of tracheostomy. In this study, we describe surgical tracheostomy done electively by the bedside on patients receiving prolonged ventilatory support in the ICU. In the study period of 6 months, there were 12,850 COVID-19 patients admitted to our COVID-designated hospital. Of these, 2452 patients needed ICU care, and 610 of these patients needed ventilatory support. Over the 6-month period, we performed 22 surgical tracheostomies on patients with COVID-19 infections leading to acute respiratory distress syndrome (ARDS). For performing open or surgical tracheostomy, the Department of Otorhinolaryngology created a COVID-airway team constituted by three senior skilled otorhinolaryngologists. Resident trainees were not involved which is as per current regulations. Even though literature does not clearly define the time of performance of tracheostomy, all tracheostomies were performed after 7 days on a ventilator. In all cases of elective tracheostomy, a cuffed and non-fenestrated tracheostomy tube was used for limiting the diffusion of the virus. Before performing surgical tracheostomy on COVID-19 patients, adequate sedation was given to eliminate the risk of coughing during the surgery. Initial withdrawal of the endotracheal tube was done above the point at which a window was being created on the anterior tracheal wall. Ventilation was stopped before inserting the tracheostomy tube. Due care was exercised for not piercing the cuff of the tracheostomy tube during the surgical procedure. All surgeries were performed by senior author/consultant surgeon and a scrub nurse in the presence of one intensivist/anaesthesiologist donning appropriate personal protective equipment (PPE) to avoid transmission of infection and also to complete the surgery in as short a time as feasible in the relatively uncomfortable ICU setting. All data were recorded and analysed using the Statistical Package for the Social Sciences (SPSS) software (Version 20) (IBM, Chicago, Illinois, U.S.A).

  Results Top

Of the 22 patients aged between 42 and 75 years (mean age of 64 years) who underwent tracheostomy, 16 (72.72%) were male and 6 (27.27%) were female. All of them underwent bedside surgical tracheostomy at our COVID-19-designated hospital ICU. The mean duration between intubation and performing tracheostomy was 13 days. All patients had associated comorbidities as detailed in [Table 1]. The details of tracheostomy in this study including techniques and precautions taken by health-care workers and comparison with others are described in [Table 2]. The prerequisites for personal protection to perform the tracheostomy on study patients are listed in [Table 3]. The mean duration of stay of our study patients in ICU was 25 days. No tracheostomy was done within 7 days of mechanical ventilation. Two patients (9.09%) presented with complication of bleeding during surgery as they were on therapeutic anticoagulation. In this study, except one health-care worker, none of the others associated with tracheostomy and tracheostomy care became infected with COVID-19. Out of 22 patients who underwent tracheostomy, 13 (59.09%) died in the ICU due to causes unrelated to the complications of tracheostomy. Of the nine patients who survived, one faced weaning failure because of the deterioration of cognitive status. Amongst those who recovered, the mean time between tracheostomy and decannulation was 24.5 days (range 16–32 days). Amongst those patients who died, mean time between intubation and death was 23 days and the mean time between the tracheostomy and death was 14.6 days.
Table 1: Profile of corona virus disease-19 patients who underwent tracheostomy

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Table 2: Comparison of case series of surgical tracheostomies done during corona virus disease-19 pandemic

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Table 3: Requisites for performing tracheostomy on coronavirus disease-19 patients

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  Discussion Top

COVID-19 is a highly infectious disease of the respiratory tract due to beta coronavirus called SARS-CoV-2. The first case of COVID-19 infection was reported at Wuhan, China, in late December 2019.[7] By 27th February 2020, more than 82,000 COVID-19-positive cases (with mortality more than 2800) had been reported, of which approximately 95% of positive cases and 97% of deaths were in China.[8] By 26th March 2020, there were 4,62,684 patients with COVID-19 infections reported in 199 countries.[7] By 16th August 2020, over 1.8 million new cases of COVID-19 and 39,000 new deaths were reported by the WHO, bringing the cumulative total to 21.2 million confirmed cases of COVID-19 including 761,000 deaths.[9] The novel SARS-CoV-2 virus is transmitted from one person to another by respiratory droplets or contact with an infected person. Procedures on the nose, nasopharynx, oral cavity, pharynx, larynx and trachea generate respiratory droplets which lead to high risk for infections.[10] The common clinical symptoms of COVID-19 patients are cough, fever, fatigue and dyspnoea.[10] There are some patients who are asymptomatic and considered as silent carriers in this pandemic. Hence, health-care professionals should be aware about this clinical scenario to prevent infection transmission to them and other patients. SARS-CoV-2 often affects the lower respiratory tract and leads to pneumonia in human beings.[11] In the hospital setting, patients of COVID-19 infections may develop respiratory failure needing prolonged ventilatory support and a subsequent tracheostomy. The noninvasive methods for ventilation include continuous positive airway pressure, bi-level positive airway pressure and high flow nasal oxygen therapy, all of which are useful to correct hypoxaemia without endotracheal intubation and delay intubation with its potential complications. However, conventional mechanical ventilation through an endotracheal tube was done in all of our study cases with ARDS. Early orotracheal intubation may be better than late as performing emergency orotracheal intubation in rapidly deteriorating COVID-19 patients may be associated with higher risk, both for the health-care professionals and the patient.[12] In our study, tracheostomy was done after 7 days of intubation. As long-term mechanical ventilation in critically ill patients often requires tracheostomy, the current pandemic is likely to increase the number of patients requiring tracheostomy. Tracheostomy is an AGP and creates a risk to surgeons and other health-care workers in the vicinity of the patient. A study conducted during the SARS epidemic suggested that health-care staff or surgeons who performed tracheostomy had a fourfold increased chance of developing COVID-19 infection.[13] Adequate PPE must be used during the tracheostomy to prevent transmission of infection to medical personnel.[14]

In one study, 6.3% of COVID-19 patients required tracheostomy during the pandemic.[15] Studies show that 7.3%–32% of COVID-19 patients progress to severe respiratory failure or become critically ill needing a tracheostomy.[16] As the medical community is facing unprecedented challenges while dealing with airway procedures such as tracheostomy during the current pandemic, University of California, San Francisco COVID-19 working group has recommended that patients should be negative before performing a tracheostomy (patient must have two negative COVID-19 RT-PCR tests before the procedure).[17] However, as this may not be practically possible, all our patients had an RT-PCR test done to know the status of the infectivity for performing the tracheostomy. Because of the overburden on ICU beds, performing early tracheostomy helps earlier and safer weaning attempts and then patients can be managed in recovery rooms or wards or high-dependency units. Performing early tracheostomy may reduce the use of sedatives. However, as the crisis is evolving very rapidly, the exact timing (early or late) for tracheostomy in COVID-19 patients is as yet undefined. The decision for performing tracheostomy is made on a case-to-case basis after multidisciplinary assessment of the severity of the clinical condition, risk-benefit considerations for performing a tracheostomy and resources of the hospital. Performing a percutaneous tracheostomy involves more extensive airway manipulations such as serial dilatation during the tracheal entry and bronchoscopy, thereby increasing the chances of exposure to the aerosols and secretions.[18] Patients with high ventilatory settings need repeated disconnection from and reconnection to the ventilatory circuit in case of percutaneous tracheostomy. Such disconnections may lead to increased aerosolisation risks as compared to a conventional surgical tracheostomy where entry into the trachea is done very quickly with an incision and the risks of aerosolisation can be minimised by several methods. Thus, open or surgical tracheostomy is preferred to percutaneous tracheostomy in COVID-19 patients.[5],[6] The general complication rates in percutaneous tracheostomy are largely similar to the open/surgical tracheostomy.[19] On the basis of the aerosol exposure to the health-care staff, open tracheostomy is safer than percutaneous tracheostomy. In our centre, surgical tracheostomy was preferred over percutaneous tracheostomy for COVID-19 patients by the otorhinolaryngologist.

All surgical/open tracheostomies were performed at the bedside in the ICU for avoiding unnecessary transport of the patients, thereby minimising the risk of contaminating the surroundings. Use of electrocautery is avoided as much as possible as its use can generate small particles which act as a vehicle for the SARS CoV-2 virus. Hence, it is better to control bleeding with a harmonic scalpel. As the majority of the COVID-19 patients in the ICU receive high-dose heparin infusion, there is increased chance of bleeding.[20] In this study, two patients (9.09%) presented with bleeding during tracheostomy as they were on therapeutic anticoagulation. We used only cuffed non-fenestrated tracheostomy tubes in all our patients as it helps to prevent spread of infection. During the tracheostomy, surgeons and assisting staff used enhanced PPE, which consisted of the standard PPE with shoe cover and helmet with positive air-powered respirator to create a complete barrier from patients. During the study period, we performed 22 surgical tracheostomies where the median timing for tracheostomy was 13 days after intubation. As the surgical/open tracheostomy is an AGP and carries a high risk for contamination through exposing health-care staff to airway secretions, this procedure requires a thorough plan and proper execution to ensure the safety of the staff and patient.[20] The overall surgical procedure for tracheostomy should be thoroughly planned and explained to all concerned staff. It should be executed as planned in order to ensure safety of the staff and patients.[21] Early tracheostomy is avoided in COVID-19 patients because of the high viral load. Early tracheostomy does not reduce mortality nor does it reduce the period of stay in the ICU.[22] Before performing surgical tracheostomy on COVID-19 patients, adequate sedation or even neuromuscular blocking agents should be used to eliminate the risk of coughing during the surgery. While performing tracheostomy, there is high chance of creating aerosols around the surrounding persons, especially the surgeon. Therefore, to avoid such aerosolisation, the endotracheal tube should be pushed beyond the location chosen for the tracheal stoma. The endotracheal tube should be advanced such that the tip reaches the carina, so the cuff will be distal to the tracheostomy site, thereby providing extra security for the health-care staff involved. Before opening the trachea, 5 mL of 2% lignocaine can be injected intratracheally through the tracheal wall for reducing the cough reflex.

The surgeon and assistants should use adequate PPE such as FFP3 or N95 mask along with goggles and face shield. Use of a double gown is preferred along with gloves. Head protection with a hood cap is better than a simple cap in order to prevent any skin exposure. A full-face shield/visor or airtight protective glasses should be used, and the head light should be covered by a head cap. As it is not sterile, an impermeable protective apron or an overcoat must be worn under the surgical gown. The surgical team must ensure that all required equipment such as suction catheter, cannula and all surgical instruments required for surgery along with cuffed tracheostomy tube are available. If possible, a sterile transparent interface should be present between the patient and surgeon for minimising the risk of contamination. Ventilation should be paused when the trachea is entered and anytime the ventilator circuit is disconnected. The cuff is inflated to limit the spread of the virus through the upper airway. Clinicians or nursing staff should perform tracheostomy suctioning using a closed suction system with a viral filter. A heat-and-moisture exchanger should be used instead of a tracheostomy collar during weaning for preventing the spread of the virus. Change of tracheostomy tube is avoided until the viral load is as low as possible. The tracheostomy tube is usually sutured if prone positioning is planned. The performance and care of tracheostomies in our study are comparable with other studies in terms of techniques and precautions.[4],[23],[24]

Some patients with tracheostomy during the COVID-19 pandemic may develop complications such as ulcers in the pharynx and bleeding from the stoma or tracheostomy tube which need further care by otorhinolaryngologists. Tracheostomy should be avoided or delayed even beyond 2 weeks because of the high chance of the infections during the procedure and subsequent tracheostomy care.[25] When the acute phase of infection has subsided or the likelihood of the recovery of infection is high, tracheostomy can be done with less likelihood of infection transmission. Early tracheostomy should be avoided in case of COVID-19 patients because of the higher viral load. Early tracheostomy is not related to the improved survival or shorter ICU stay.[26] In all our patients, tracheostomies were done after 7 days of orotracheal intubation.

For tracheostomy care, the British Association of Otorhinolaryngologists-Head and Neck Surgery (ENT-UK) has made a recommendation for decreasing the risk of aerosolisation and contamination to the surrounding environment by keeping the cuff inflated and delay tracheostomy change till the COVID-19 pandemic has passed.[25] Another recent guideline for performing tracheostomy on COVID-19 patients recommends the following: (a) tracheostomy should be considered when prolonged mechanical ventilation is anticipated though no specific timing has been favoured; (b) RT-PCR is not recommended routinely before performing tracheostomy in patients of COVID-19 infection-related respiratory failure; (c) enhanced PPE should be used by health-care experts while performing the procedure to prevent the risk of infections to health-care professionals; (d) tracheostomy should be performed by a team consisting of the least number of providers with highest level of experience; (e) patient should be maintained on a closed circuit during the procedure.[27] With the exception of a preoperative RT-PCR test that was done in our patients as per institutional policy, all other principles outlined in the guidelines were followed in our patients. In this current crisis with the COVID-19 pandemic in the world, clinicians should consider the local hospital resources. Hence, early cuff deflation and change of the tracheostomy tube may facilitate the steps towards the rehabilitation. During tracheostomy care, health-care professionals should be equipped with full PPE. In this study, except one nursing staff, none of the team members were infected SARS-CoV-2.

Our study has the limitation that all data have been derived from a single centre, resulting in a relatively small number of patients eventually receiving a tracheostomy. However, considering that 12,850 patients were admitted with suspicion of COVID-19 during the period of the study and 610 of them needed ventilator support, we believe the trend identified in our study will definitely provide the right direction for future research in bedside tracheostomy on COVID-19 patients in an ICU.

  Conclusion Top

Health-care professionals are presently facing a huge challenge from COVID-19 infections. In the current global COVID-19 pandemic, ARDS and respiratory failure requiring mechanical ventilation is a common problem. Tracheostomy is considered as a high-risk AGP because of the exposure to droplets and leakage of aerosols that carry the SARS-CoV-2 during performance of the surgical procedure. An increasing number of tracheostomies are expected to be performed because of the globally increasing number of COVID-19 patients with acute respiratory distress. Otorhinolaryngologists and intensivists should pay meticulous attention to infection control, reduce cross-contamination and minimise their own risk for contracting the infection. Tracheostomy with adequate PPE helps to reduce droplet and aerosol exposure to the surgeon and other health-care workers.

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  [Table 1], [Table 2], [Table 3]

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