Optimal timing of tracheostomy may improve outcomes, alleviate ICU strain during pandemic

Early tracheostomy for patients with COVID-19 pneumonia may improve outcomes and alleviate capacity strain in the ICU during the pandemic without increasing mortality, researchers reported in Chest.

“Expert recommendations on timing tracheostomy during the COVID-19 pandemic vary widely. One panel concluded that no specific timing could be recommended; other panels recommend 7 days, 10 days, 14 days or 21 days after intubation,” Gonzalo Hernandez, MD, PhD, with the department of critical care at Virgen de la Salud University Hospital in Toledo, Spain, and colleagues wrote. “These recommendations aim to balance the benefits of earlier tracheostomy for patients and health care systems based on evidence from before the COVID-19 pandemic, while minimizing risk for health care professionals, because infectivity declines over time.”

The retrospective cohort study analyzed 1,939 consecutive patients admitted with COVID-19 pneumonia who underwent tracheostomy in 15 ICUs in Spain during the surge of the pandemic when ICU occupancy modified clinician criteria in performing tracheostomies for patients with COVID-19. Researchers compared ventilator-free days as well as ICU and hospital bed-free days at 28 and 60 days in matched cohorts that underwent tracheostomy at 7 days or less, 8 to 10 days and 11 to 14 days after intubation.

Thirty-five percent of patients underwent tracheostomy, with 56% of procedures performed within 14 days of intubation.

Early tracheostomy initiation was associated with more ventilator-free days by day 28:

• 9 days for those who underwent tracheostomy within 7 days compared with 3 days for those who underwent tracheostomy more than 7 days after intubation (difference = 4.5 days; 95% CI, 2.3-6.7);
• 6 days for those who underwent tracheostomy 8 to 10 days after intubation compared with 0 days for those who underwent tracheostomy more than 10 days after intubation (difference = 3.1 days; 95% CI, 1.4-4.5); and
• 4 days for those who underwent tracheostomy 11 to 14 days after intubation compared with 0 days for those who underwent tracheostomy more than 14 days after intubation (difference = 3 days; 95% CI, 2.1-3.9).

Early tracheostomy was also associated with more ventilator-free days by day 60 among those who underwent tracheostomy within 7 days compared with more than 7 days after intubation (median, 41 vs. 35 days; difference = 5.4; 95% CI, 0.6-10.2) and among those who underwent tracheostomy 11 to 14 days after intubation compared with more than 14 days after intubation (median, 36 vs. 25 days; difference = 9; 95% CI, 6.4-11.6).

In addition, researchers observed better outcomes with early tracheostomy for all other endpoints except hospital bed-free days at day 28. There were no significant differences in mortality between the cohorts.

“Regardless of the timing, tracheostomy showed a positive impact on the availability of ICU resources. The earlier the tracheostomy, the higher the improvement,” the researchers wrote. “The greatest benefits for ICU resources were found in the group that underwent tracheostomy within 7 days after intubation, suggesting that the mechanisms involved are time dependent.”