Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients

Abstract

Purpose: COVID-19 patients requiring mechanical ventilation can overwhelm existing bed capacity. We aimed to better understand the factors that influence the trajectory of tracheostomy care in this population to facilitate capacity planning and improve outcomes.

Methods: We conducted an observational cohort study of patients in a high-volume centre in the worst-affected region of the UK including all patients that underwent tracheostomy for COVID-19 pneumonitis ventilatory wean from 1st March 2020 to 10th May 2020. The primary outcome was time from insertion to decannulation. The analysis utilised Cox regression to account for patients that are still progressing through their tracheostomy pathway.

Results: At the point of analysis, a median 21 days (IQR 15-28) post-tracheostomy and 39 days (IQR 32-45) post-intubation, 35/69 (57.4%) patients had been decannulated a median of 17 days (IQR 12-20.5) post-insertion. The overall median age was 55 (IQR 48-61) with a male-to-female ratio of 2:1. In Cox regression analysis, FiO₂ at tracheostomy ≥ 0.4 (HR 1.80; 95% CI 0.89-3.60; p = 0.048) and last pre-tracheostomy peak cough flow (HR 2.27; 95% CI 1.78-4.45; p = 0.001) were independent variables associated with prolonged time to decannulation.

Conclusion: Higher FiO₂ at tracheostomy and higher pre-tracheostomy peak cough flow are associated with increased delay in COVID-19 tracheostomy patient decannulation. These finding comprise the most comprehensive report of COVID-19 tracheostomy decannulation to date and will assist service planning for future peaks of this pandemic.

Keywords: COVID-19; Decannulation; Peak cough flow; SARS-CoV-2; Tracheostomy; Tracheotomy.

Fig. 1

Boxplot representing landmarks in tracheostomy care. The boxes represent interquartile ranges with thick lines representing medians. Whiskers represent the lowest and highest observations ≤ 1.5 times the inter-quartile range from the box and orange dots (outside boxes) represent outliers. Purple dots (inside boxes) represent means

Fig. 2

Illustrative boxplots to peak cough flow confounding factors. a Age compared to last PCF before tracheostomy by decannulation group; b gender compared to last PCF before tracheostomy by decannulation group. F female, M male, PCF peak cough flow, y.o. years old