Well-timed tracheostomy could ease the strain experienced by intensive care units (ICUs) during the COVID-19 pandemic without increasing deaths, according to the results of a study published in Chest.
Researchers in Spain sought to determine the best time for tracheostomy in hospitals overburdened by the CVOID-19 pandemic. The outcome of failure-free days—a composite outcome including ventilator-free days and ICU and hospital bed-free days—was used to measure the effectiveness of tracheostomy in freeing up ICU and hospital resources. Toward that end, the researchers conducted a retrospective cohort study of patients with COVID-19 who had undergone tracheostomy in 15 ICUs at a time of high ICU occupancy during the pandemic. The investigators compared ventilator-free days at 28 and 60 days after intubation and ICU- and hospital bed-free days at 28 and 60 days after ICU or hospital admission in propensity score-matched cohorts who underwent tracheostomy at different points in time (≤7 days, 8-10 days, and 11-14 days after intubation).
Of 1939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (≤7 days vs >7 days [116 patients included in the analysis]: median, 9 days [interquartile range (IQR), 0-15 days] vs 3 days [IQR, 0-7 days]; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs >10 days [222 patients analyzed]: 6 days [IQR, 0-10 days] vs 0 days [IQR, 0-6 days]; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs >14 days [318 patients analyzed]: 4 days [IQR, 0-9 days] vs 0 days [IQR, 0-2 days]; difference, 3 days; 95% CI, 2.1-3.9 days).
For all endpoints other than bed-free days at 28 days, outcomes were better with early tracheostomy. Moreover, the researchers found that ventilator- and bed-free days with early tracheostomy were not correlated with death rates. This paucity of correlations could be due to increased complication rates during the ICU stay in match cohorts who later received tracheostomy.
The investigators found on further analysis that ICU length of stay and hospital length of stay increased with longer mechanical ventilation as related to tracheostomy timing, which supported the hypothesis that the length of mechanical ventilation impairs recovery in COVID-19 patients.
The most benefit in ICU resources occurred in those who received tracheostomy within 7 days after intubation. The authors suggested that timing could have selected for patients with decreased severity of illness, although they took steps to avoid this bias.
This study had certain limitations. First, its retrospective design doesn’t allow for conclusions about causality. Second, a higher percentage of patients in the current cohort received tracheostomy vs other cohorts. Third, the results of the current study may not be extended to settings that are not strained by capacity. Importantly, overwhelmed ICUs may have impacted standard of care protocols.
“Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality,” concluded the authors. “Tracheostomy within the first week receiving ventilation in particular may improve ICU availability.”
Hernandez G, Ramos FJ, Añon JM, et al. Early tracheostomy for managing ICU capacity during the COVID-19 outbreak: a propensity-matched cohort study. Chest. Published online June 17 2021. doi:10.1016/j.chest.2021.06.015.