Importance:
Many ventilated COVID-19 patients require prolonged ventilation. We do not know if tracheostomy will improve their care. Given the paucity of data on this topic, the optimal surgical approach has yet to be elucidated.
Objective:
To determine the optimal surgical strategy for performing tracheostomy in COVID-19 patients.
Design:
Cohort study of 143 ventilator dependent COVID-19 patients undergoing tracheostomy at an academic medical center from April 15th to May 15th, 2020, with follow up until June 1, 2020.
Setting:
A New York City (NYC) academic quaternary referral center during its peak of COVID-19.
Participants:
Adult patients admitted to a NYC medical center with COVID-19 who required invasive mechanical ventilation for greater than 2 weeks who were unable to be extubated and determined to have reasonable chance of recovery and fit defined tracheostomy candidate criteria.
Exposure:
Patients had either a percutaneous tracheostomy (PT) or open surgical tracheostomy (ST) performed by one of three surgical services.
Main Outcome and Measure:
The primary aim of the study was to evaluate the safety and results of tracheostomy for both patients with COVID-19 and the surgeons performing the tracheostomy. Specifically, tracheostomy complications, inpatient mortality, disposition of patients, and transmission of COVID-19 to surgeons were measured.
Results:
143 patients underwent tracheostomy, 58 (41%) via a ST, and 85 (59%) via a PT. There were no significant differences in patient characteristics between the two groups, except that more patients who had a history of extracorporeal membrane oxygenation (ECMO) underwent PT (11% vs 2%, p=0.049). There were no statistical differences observed between the PT and ST groups with regard to bleeding complications (3.5% vs 10.3%, p=0.099), tracheostomy related complications (5.9% vs 8.6%, p=0.528), inpatient death (12% vs 5%, p=0.178), discharge from hospital (39% vs 36%,p=0.751) or surgeon illness (0% v 0%, p=1).
Conclusion and Relevance:
The rapid formation of a multi-disciplinary team allows for the efficient evaluation and performance of a large volume of tracheostomies in a resource-limited setting. Bedside tracheostomy in COVID-19 does not cause additional harm to patients if performed after 2 weeks from intubation. It also appears to be safe for proceduralists to perform in this timeframe. The manner of tracheostomy does not change outcomes significantly if it is performed safely and efficiently.
