Tracheostomy in COVID-19
In the past one and half years, hospitals worldwide have seen an unprecedented number of patients with respiratory failure due to COVID-19. Current studies suggest that 10-15% of patients hospitalized with COVID-19 require invasive mechanical ventilation, frequently for prolonged periods. A significant proportion of patients required mechanical ventilation for more than 21 days. Before the pandemic, patients would generally be considered for tracheostomy after at least ten days of mechanical ventilation, although COVID-19 introduces several complicating factors. Namely, could earlier tracheostomy free up resources when we stretch ICU capacity to the brink? Or should the risk of viral transmission delay tracheostomy until patients are presumably less infectious and assume an increased risk of complications from prolonged trans-laryngeal intubation? Several benefits of tracheostomy are well-established in critical care, including the ability to decrease sedation, improve secretion clearance and promote early mobility. Additionally, one study even suggested a mortality benefit to early tracheostomy. A fair amount of evidence highlights the potential advantages of tracheostomy. In addition to benefits in general critically ill population, tracheostomy may incur incremental benefit in specialized populations, including those with traumatic brain injury and multi-system trauma due to their likelihood of requiring prolonged mechanical ventilation. Patients with COVID-19 could gain similar benefits due to a high incidence of prolonged respiratory failure, high sedation requirements, and prolonged delirium / neuro-cognitive ramifications. Many institutions have recommended a conservative extubation strategy due to a high rate of re-intubation and the associated risk of viral spread. It may further stress a limited pool of intensive care resources, including mechanical ventilators and sedative drugs. In this setting, the performance of tracheostomy in proper candidates has the potential to free up resources across a health system. It may or may not play a role in the decision based on local factors.
We can perform tracheostomy using either open surgical (ST) or percutaneous dilational (PDT) techniques. Evidence to definitively support one type over the other is lacking, and before the pandemic showed a similar incidence of overall complications between ST and PDT. Further, we have proposed several novel modifications to open and percutaneous tracheostomy to reduce viral aerosolization and improve safety. Local expertise should determine which approach to use. If resources allow, tracheostomy should be performed at the bedside in a negative-pressure room in the ICU. Alternatively, the doctor can perform ST in an operative room (with the attendant risk of exposure related to patient transport). Limiting the number of people in the room and recommend using enhanced PPE (powered air-purifying respirators (PAPR)), if available.
#trach tube #tracheostomy care #tracheostomy tube care #what is a tracheostomy tube #what is a tracheostomy #cuffed tracheostomy tube #fenestrated tracheostomy tube #tracheostomy tube size #fenestrated
#COVID 19 #tracheostomy tube change #tracheotomy #tracheostomy tube types #tracheostomy tube sizes
#a nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place #tracheostomy suctioning
#tracheostomy tube uses #tracheostomy tube parts #metal tracheostomy tube #coronavirus
#percutaneous dilatational tracheostomy #percutaneous tracheostomy procedure #percutaneous tracheostomy kit
© 2021 QA Medical Limited. All Rights Reserved