Early tracheostomy noninferior to late tracheostomy in patients with COVID-19

By Denise Baez

DG Alerts

Among patients with coronavirus disease 2019 (COVID-19) who were treated during the first 2 months of the pandemic in New York City, early tracheostomy was noninferior to late tracheostomy, and was associated with improvement in some outcomes, according to a study published in JAMA Otolaryngology – Head and Neck Surgery.

“Within the first weeks of the pandemic, at least 7 sets of guidelines emerged from academic journals in otolaryngology, anaesthesia, and thoracic surgery, rooted in expert consensus and opinion,” wrote Paul E. Kwak, MD, New York University (NYU) Langone Health, New York, New York, and colleagues. “Most recommended delaying or avoiding tracheostomy to minimise risk of infection to clinicians and because the pulmonary manifestations and clinical trajectory of the disease, and therefore the anticipated benefit of tracheostomy, were unclear.”

“This cohort study from the first 2 months of the pandemic in New York City provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19,” the authors continued. “Findings demonstrated noninferiority of early tracheostomy and challenges recommendations to categorically delay or avoid tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of the novel coronavirus, this approach may optimise outcomes from tracheostomy while keeping clinicians safe.”

The analysis included data from 148 patients (mean age, 58.1 years) with laboratory-confirmed COVID-19 who required mechanical ventilation at a single tertiary-care medical centre in New York City between March 1 and May 7, 2020. Patients were predominantly male (81%) and obese (mean body mass index, 30.57).

Mean time from symptom onset to intubation was 10.57 days, mean time from symptom onset to tracheostomy was 22.76 days, and mean time from endotracheal intubation to tracheostomy was 12.23 days.

At the completion of the study period, 108 (73%) patients had discontinued mechanical ventilation, 94 (64%) had been decannulated, 107 (72%) had been discharged, 54 (36%) had documented stoma closure, and 30 (20%) had died. Ten patients (7%) remained mechanically ventilated without a specified disposition at the completion of the study period.

When looking at the timing of tracheostomy, the median time to discontinuation of mechanical ventilation from intubation was 26.5 days for the early tracheostomy group (procedures performed prior to day 10 of intubation) and 31 days for the late tracheostomy group (procedures performed at day 10 of intubation or later). The median time to decannulation was 27.5 days for the early group and 24 days for the late group.

The mean length of stay for all patients was 51.29 days. Timing of tracheostomy was significantly associated with length of stay, with a median length of stay of 40 days among patients who underwent early tracheostomy and 49 days among patients who underwent late tracheostomy.

In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation (hazard ratio = 0.84; 95% confidence interval, 0.55-1.28).

There were no intraoperative or intraprocedural complications in any of the patients.

Of the 3 pulmonologists who performed the tracheostomy procedures, none contracted COVID-19.

“This analysis points toward a more multifaceted decision-making process about timing of tracheostomy in patients with COVID-19…[and] provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19,” the authors concluded. “These data demonstrate that with thoughtful selection of patients, there is no countervailing evidence to recommend categorically delaying tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of severe acute respiratory syndrome coronavirus 2, thoughtful selection of patients can optimise outcomes from tracheostomy while keeping safe the clinicians who are committed to their care.”

Dr. Kwak and colleagues will continue to follow this patient cohort to assess additional and longer-term outcomes.