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. 2020 Sep;110(3):1006-1011.
doi: 10.1016/j.athoracsur.2020.04.010. Epub 2020 Apr 25.

Novel Percutaneous Tracheostomy for Critically Ill Patients With COVID-19

Luis Angel  1 , Zachary N Kon  2 , Stephanie H Chang  2 , Samaan Rafeq  3 , Saketh Palasamudram Shekar  3 , Brian Mitzman  2 , Nancy Amoroso  3 , Ronald Goldenberg  3 , Kimberly Sureau  2 , Deane E Smith  2 , Robert J Cerfolio  4
Affiliations

Novel Percutaneous Tracheostomy for Critically Ill Patients With COVID-19

Luis Angel et al. Ann Thorac Surg. 2020 Sep.

Abstract

Background: Coronavirus 2019 (COVID-19) is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy is not recommended by current guidelines as it is considered a superspreading event owing to aerosolization that unduly risks health care workers.

Methods: Patients with severe COVID-19 who were on mechanical ventilation for 5 days or longer were evaluated for percutaneous dilational tracheostomy. We developed a novel percutaneous tracheostomy technique that placed the bronchoscope alongside the endotracheal tube, not inside it. That improved visualization during the procedure and continued standard mechanical ventilation after positioning the inflated endotracheal tube cuff in the distal trachea. This technique offers a significant mitigation for the risk of virus aerosolization during the procedure.

Results: From March 10 to April 15, 2020, 270 patients with COVID-19 required invasive mechanical ventilation at New York University Langone Health Manhattan's campus; of those, 98 patients underwent percutaneous dilational tracheostomy. The mean time from intubation to the procedure was 10.6 ± 5 days. Currently, 32 patients (33%) do not require mechanical ventilatory support, 19 (19%) have their tracheostomy tube downsized, and 8 (8%) were decannulated. Forty patients (41%) remain on full ventilator support, and 19 (19%) are weaning from mechanical ventilation. Seven patients (7%) died as a result of respiratory and multiorgan failure. Tracheostomy-related bleeding was the most common complication (5 patients). None of health care providers has had symptoms or tested positive for COVID-19.

Conclusions: Our percutaneous tracheostomy technique appears to be safe and effective for COVID-19 patients and safe for health care workers.

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Figures

Figure 1
Figure 1
Percutaneous dilational tracheostomy in COVID-19 patients using novel visualization technique. (a) Three team members positioning in the patient’s room. (b) View of vocal cords using flexible bronchoscopy. (c) Visualization of trachea and cartilaginous rings anterior to endotracheal tube through bronchoscope. (d) Bronchoscopic visualization of needle insertion. (e) Wire insertion under bronchoscopic visualization. (f) Technique of dilation with Ciaglia Blue Rhino (Cook Medical, Bloomington, IN) dilator with endotracheal tube in place.
Figure 2
Figure 2
Number of patients diagnosed with coronavirus disease 2019 (COVID-19) and intubated at New York University (NYU) Langone Health between March 15 and April 15, 2020, those evaluated for tracheostomy and deemed appropriate for bedside percutaneous tracheostomy, and number successfully placed by the novel technique. (ENT = ear, nose, throat.)
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