• Tracheostomy and SARS-CoV-2 transmission

    Fifty-five studies (94.8%) did not find any HCP who tested positive or developed COVID-19 symptoms following tracheostomy.

    Hospitalized COVID-19 patients who need tracheostomy pose little threat of transmitting SARS-CoV-2 to healthcare professionals (HCPs) wearing enhanced personal protective equipment (PPE), according to a systematic review and meta-analysis published online in JAMA Otolaryngology – Head and Neck Surgery.

    Early tracheostomy in patients with COVID-19 also significantly reduced the stay in the intensive care unit (ICU).

    Investigators from McMaster University in Hamilton, Ontario, Canada, and the University of Toronto in Ontario, Canada, noted that roughly 5% to 15% of patients with COVID-19 require invasive mechanical ventilation (IMV), and sometimes tracheostomy, but that details about the safety and use of tracheostomy to treat COVID-19 continue to evolve.

    In total, 156 studies from EMBASE (Ovid), Medline (Ovid) and Web of Science between January 2020 and March 2021 underwent full-text review. Selection was restricted to English-language studies of patients with COVID-19 who were receiving IMV and tracheostomy. Both observational and randomized clinical trials were eligible; however, no randomized clinical trials were identified.

    Of the 156 studies, only 69 were included in the qualitative synthesis, of which 20.3% (n = 14) were included in the meta-analysis. Most of the included studies were published in the United States (30.4%), the United Kingdom (18.8%) and Italy (17.4%).

    In addition, 84.1% of the studies were observational (either retrospective or prospective) and 84.1% of the studies were performed at a single hospital site, which was mainly a tertiary care center.

    The 69 studies comprised 4,669 patients, with a mean age of 60.7 (range 49.1 to 68.8) and mostly male.

    Among the 58 studies (84.1%) that investigated SARS-CoV-2 transmission among HCPs, 44.8% reported COVID-19 status via a nasopharyngeal swab (NPS) specimen and/or blood testing and 55.2% either used clinical symptoms or did not report testing methods.

    Studies primarily assessed HCPs for COVID-19 infection within 4 weeks of involvement in a tracheostomy.

    55 studies found no HCP with COVID-19 following tracheostomy

    Overall, 55 studies (94.8%) did not find any HCP who tested positive or developed COVID-19 symptoms following tracheostomy. However, 3 of 58 studies (5.17%) identified a small subset of HCPs who developed COVID-19 that was linked to tracheostomy.  Monitoring HCPs for COVID-19 status was reported in eight studies, ranging from 14 to 30 days since tracheostomy.

    The type of PPE used by HCPs was reported in 41 of the 69 studies (59.4%), of which 31.7% used either a N95 or an equivalent mask; 29.3% used a N99 or an equivalent mask; 26.8% used powered air-purifying respirators (PAPRs); and 12.2% did not specify the type of PPE.

    Likewise, 8 of the 69 studies (11.6%) performed tracheostomies in a negative-pressure room, while the remaining studies mostly performed a surgical tracheostomy (ST) in an operating theater and a percutaneous dilational tracheostomy (PDT) at the bedside.

    Patients with COVID-19 who underwent tracheostomy were significantly less likely to die than patients who did not have a tracheostomy: 38.1% of patients vs. 58.8% of patients, respectively. However, statistical heterogeneity was high. The study also found that early tracheostomy (within 14 days of intubation) was associated with faster ICU discharge: a mean difference of 6.17 days; 95% confidence interval (CI): −11.30 to −1.30.

    However, there was no change in IMV weaning (a mean difference of −2.99 days; 95% CI: −8.32 to 2.33), nor a change in decannulation (a mean difference of −3.12 days; 95% CI: −7.35 to 1.12). There was also no connection between mortality or perioperative complications and type of tracheostomy.

    The time to tracheostomy from intubation ranged from 16.8 days to 25.0 days, with the most common patient comorbidity being hypertension.

    Five studies (7.2%) mentioned the presence of therapeutic anticoagulation at the time of tracheostomy and one study reported substantial perioperative complication rates for both PDT 16.7%) and ST (40%), likely due to the low number of tracheostomies performed.

    The follow-up period for all studies ranged from 14 days or less to a maximum of 110 days from intubation.

    In 13 studies of ST that reported perioperative complications, perioperative hemorrhage was the most frequently cited. One of these studies reported bleeding that required revision surgery and three studies identified anticoagulation status at the time of surgery.

    Of the 13 PDT studies that reported perioperative complications, perioperative hemorrhage was the most common. Further, two of these studies reported bleeding that required revision surgery and/or transfusion, whereas four studies cited anticoagulation status at the time of surgery.

    Early tracheostomy and shorter ICU stays

    A shorter ICU stay for COVID patients who have early tracheostomy can greatly aid hospitals in conserving resources.

    Despite the analysis’ finding of earlier ICU discharge with early tracheostomy, the procedure’s clinical use remains controversial, according to the authors, noting that the reduced ICU stay might be secondary to institutions that allow patients who receive ventilation to be discharged from the ICU following tracheostomy.

    Other benefits of early tracheostomy for COVID-19 patients could include improved sedation wean, fewer endotracheal intubation complications, and optimization of prolonged ventilation wean.

    One limitation of the analysis is that viral transmission was based primarily on clinical symptoms, which may have overlooked some transmission events because up to 20% of patients with COVID-19 are asymptomatic.