Tracheostomy in the COVID-19 era: global and multidisciplinary guidance

Abstract

Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.

Figure 1

Typical clinical course, viral PCR, and antiviral antibody detection and infectivity of severe SARS-CoV-2 infection The transparent red box shows the suggested window for tracheostomy, on ICU days 10–21, which corresponds with 16–30 days from symptom onset. The solid bars and curves represent the proportion of all cases. Time zero is symptom onset (the x-axis is not to scale). Timeline data are from authors' local data and published case series., , , , , Pooled data from two studies describing SARS-CoV-2 detection by PCR and antiviral antibody were used to generate stylised curves., 181 patients were included in the pooled viral and antibody data, of whom 32 (18%) were defined as critically ill and 72 (40%) were estimated to have severe disease on the basis of overlapping case series. These data are representative of the population of interest, 16–20% of whom are likely to need admission to the ICU. ICU=intensive care unit. SARS-CoV-2=severe acute respiratory syndrome coronavirus 2.

Figure 2

Considerations for tracheostomy after intubation for COVID-19-associated pneumonitis The window for tracheostomy is 10–21 days after intubation. Bar heights represent relative weights of the factors. Bar heights and positions were proposed and agreed by the consensus working group. ICU=intensive care unit.