Early Percutaneous Tracheostomy in the Coronavirus Disease 2019 Era: Shining New Light on Old Questions
Year: 2021
Type: letter
Abstract: To the Editor: Rosani et al (1) provide much-needed data on the outcomes of early percutaneous tracheostomy in critically ill patients with respiratory failure from coronavirus disease 2019 (COVID-19). This evidence, demonstrating that early tracheostomy can be performed with acceptable safety in the midst of a pandemic, is invaluable and perhaps “as good as it gets” (2). The study does, however, raise important questions related to: 1) downsides to routinely performing early tracheostomy, 2) how to tailor the timing of tracheostomy, 3) optimal protocols for decannulation, and 4) generalization of the findings. 1) Routine early tracheostomy can help protect precious resources and therapies for patients during pandemic surges, but in the absence of a surge, timing must be more carefully weighed. Routinely performing tracheostomy before 1 week means that tracheostomy will be performed in some patients who would have recovered swiftly or succumbed to their disease early. Chest physiotherapy is an important adjuvant in critically ill mechanically ventilated patients with COVID-19 (3). Although the pandemic has added major wrinkles to the question of optimal timing, the debate will continue long after the COVID-19 pandemic has subsided. With caveats of personal protective equipment (PPE) use, managing surges, and prone ventilation, the timing of tracheostomy for patients with COVID-19 should reflect indications and standards used for other causes of respiratory failure requiring prolonged mechanical ventilation. 2) Progressive multiorgan failure is a contraindication to tracheostomy; we suggest that there should be evidence of improvement prior to performing the procedure, with demonstration of adequate physiologic reserve. Although not used by Rosani et al (1), apneic tracheostomy suspends ventilation at key steps during percutaneous or surgical procedures and mitigates aerosolization of potentially infectious virus. We recommend a preprocedural apnea test that positions the patient supine and evaluates respiratory physiologic reserve, predicting the response to and tolerance of the apnea required to conduct the procedure safely (4). 3) Decannulation is a key consideration after COVID-19 tracheostomy, as removal of the tracheostomy greatly simplifies care and disposition planning. The authors note the increased frequency of upper airway obstruction with severe acute respiratory syndrome coronavirus 2. Given the known complexities of laryngeal recovery after critical illness, a dynamic evaluation such as fiberoptic endoscopic evaluation of swallow allows for early identification of pathology and a proactive approach to tracheostomy decannulation (5). We commend the authors’ focus on decannulation, but we caution against routine use of methylene blue to color oral secretions to detect aspiration from tracheostomal secretions, given risk of rare, but serious reactions. 4) Generalizing such data has inherent challenges; multidisciplinary teams in developed countries vary in approaches to management of patients before, during, and after tracheostomy. Family engagement is also crucial in care decisions. Generalizing data may be even more challenging for low- and middle-income countries facing severe resource constraints. Often, no PPE is available for staff, and necessary supplies, such as suction or inner cannulas, are lacking. We commend the authors for insights on tracheostomy in the current pandemic. Prospective, comprehensive data collection, as via the Global Tracheostomy Collaborative (www.globaltrach.org), is the next step. Perhaps together we will shine further light on longstanding questions.
Source: Critical Care Medicine
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W3134524933