Tracheal stenosis in prolonged mechanically ventilated patients: prevalence, risk factors, and bronchoscopic management

Background Various complications may arise from prolonged mechanical ventilation, but the risk of tracheal stenosis occurring late after translaryngeal intubation or tracheostomy is less common. This study aimed to determine the prevalence, type, risk factors, and management of tracheal stenoses in mechanically ventilated tracheotomized patients deemed ready for decannulation following prolonged weaning. Methods A retrospective observational study on 357 prolonged mechanically ventilated, tracheotomized patients admitted to a specialized weaning center over seven years. Flexible bronchoscopy was used to discern the type, level, and severity of tracheal stenosis in each case. We described the management of these stenoses and used a binary logistic regression analysis to determine independent risk factors for stenosis development. Results On admission, 272 patients (76%) had percutaneous tracheostomies, and 114 patients (32%) presented mild to moderate tracheal stenosis following weaning completion, with a median tracheal cross-section reduction of 40% (IQR 25–50). The majority of stenoses (88%) were located in the upper tracheal region, most commonly resulting from localized granulation tissue formation at the site of the internal stoma (96%). The logistic regression analysis determined that obesity (OR 2.16 [95%CI 1.29–3.63], P < 0.01), presence of a percutaneous tracheostomy (2.02 [1.12–3.66], P = 0.020), and cricothyrotomy status (5.35 [1.96–14.6], P < 0.01) were independently related to stenoses. Interventional bronchoscopy with Nd:YAG photocoagulation was a highly effective first-line treatment, with only three patients (2.6%) ultimately referred to tracheal surgery. Conclusions Tracheal stenosis is commonly observed among prolonged ventilated patients with tracheostomies, characterized by localized hypergranulation and mild to moderate airway obstruction, with interventional bronchoscopy providing satisfactory results.

Repeat percutaneous tracheostomy in a COVID-19 patient

A 73-year-old man with history of hypertension and chronic obstructive pulmonary disease was admitted to the emergency department with acute respiratory failure from COVID-19. After 10 days of mechanical ventilation (MV) the patient underwent a successful trial of extubation. However, 3 days later his neurological status deteriorated and required re-intubation. A brain computed tomography (CT) scan showed right cerebellar hemorrhage. Considering extent and location of the hemorrhage we decided to perform a percutaneous tracheostomy on the 18th day. The patient was then successfully weaned from MV (day 47th), and finally decannulated (day 50th). On day 62nd, the patient experienced an episode of septic shock, requiring oro-tracheal re-intubation, for we decided to perform a repeat percutaneous tracheostomy. All the procedure steps were uneventful. The patient was subsequently transferred to another ICU, and then successfully discharged to the Respiratory Ward. Keywords: coronavirus; airways; dilational tracheostomy

Indications and Recommendations for Tracheostomy in Trauma Population With COVID-19 Infection: A Review of the Literature

This review explores the current body of evidence pertaining to tracheostomy placement in COVID-19 seropositive patients and summarizes the research by tracheostomy indications, timing, and procedure. Literature review was performed in accordance with the 2020 PRISMA guidelines and includes 12 papers discussing protocols for adult patients seropositive for COVID-19. The studies demonstrated high mortality rates after tracheostomy, especially in geriatric patients, and suggested a multifactorial determination of whether to perform a tracheostomy. There was inconclusive data regarding wait time between testing seropositive, tracheostomy, and weaning off of ventilation. COVID-19 generally reaches highest infectivity between days 9 and 10; furthermore, high early mortality rates seen in COVID-19 may confound mortality implicated by tracheostomy placement. Due to the aerosol-generating nature of tracheostomy placement, management and maintenance, techniques, equipment, and personnel should be carefully considered and altered for COVID-19 patients. With surgical tracheostomy, literature suggested decreased usage of electrocautery; with percutaneous tracheostomy, single-use bronchoscope should be used. The nonemergent exchange of tracheostomy should be done only after the patient tested negative for COVID-19. Placement of tracheostomy should only be considered in COVID-19 patients who are no longer transmissible, with rigorous attention to safety precautions. Understanding procedures for airway maintenance in a respiratory disease like COVID-19 is imperative, especially due to current shortages in ventilators and PPE. However, because of a lack of available data and its likelihood of change as more data emerges, we lack complete guidelines for tracheostomy placement in COVID-19 seropositive patients, and those existing will likely evolve with the disease.

EXPERIENCE OF SURGICAL TRACHEOSTOMY IN COVID-19 HOSPITAL

Objective: To share our experience of tracheostomy in COVID-19 positive patients. Study Design: Prospective observational study. Place and Duration of Study: Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Apr to Jul 2020. Methodology: A total of 94 COVID-19 positive cases admitted to the Intensive Care Unit of this hospital, placed on ventilatory support and who ultimately underwent tracheostomy (whether percutaneous or surgical) were included in the study. Patients were included irrespective of any age group or gender. Results: Out of 94 patients placed on ventilator, tracheostomy was performed only in 17 patients. Male predominance was 13 (76%), with mean age of patients as 55.59 ± 12.93 in 12 patients, surgical tracheostomy was performed (70.58%) whereas in 5 (29.4%) cases percutaneous tracheostomy was done. On post-operative follow-up 8 out of 17 (47%) patients recovered and were successfully decannulated whereas 9 (52.9%) patients could not survive. Tracheostomy was successfully performed as early as 8th day of mechanical ventilator support. Health Care Workers (HCWs) involved were subjected to RT-PCR and remained negative for SARS- CoV-2. There was statistically significant association between the type and indication oftracheostomy, p=0.002. Conclusion: Tracheostomy, in COVID-19 positive patients, being aerosol- generating procedure remains a medical hazard for the HCWs. By following strict safety protocols according to the medical resources available and training of the HCWs, it can be performed with complete safety. It can be done as early as 8th day of ventilator support.

I gel versus endotracheal intubation for percutaneous tracheostomies: a randomised study to ascertain amicable approach

Background: Percutaneous tracheostomy or percutaneous dilation tracheostomy (PDT) is an airway management procedure routinely performed in critically ill patients, requiring prolonged ventilation. It is safely performed bedside by anaesthesiologist/intensivist in ICUs. Complications as endotracheal tube (ET) damage, loss of airway due to accidental extubation and piercing of guide wire through ET tube during procedure has led to exploration of safer/effective and viable airway alternatives while performing the procedures.Methods: In this study we randomised 60 patients to group E (ET) and group I (I gel) 30 each and studied ease of carrying out procedure and associated complication rates in both groups.Results: In ET group (group E), 9% of patients suffered with potentially catastrophic complications, e.g. loss of airway, inadequate ventilation of lungs, haemorrhage, airway leak due to ET tube cuff rupture and accidental extubation. In ETT group there was incidence of 18% cuff puncture by guide wire (p=0.025) and 3% accidental tracheal extubation. Group I witnessed lower incidence of haemorrhage (3%) and the incidence of guide wire piercing airway device was nil. Group I also demonstrated better hemodynamic stability attributed to lesser tissue trauma and airway manipulation.Conclusions: This study demonstrates enhanced safety with usage of I gel for PCDT, with less complication, better hemodynamic stability and shorter procedure duration.

Combined Percutaneous Tracheostomy and Endoscopic Gastrostomy Tubes in COVID-19: A Prospective Series of Patient Outcomes

Background: A significant number of patients with severe respiratory failure related to COVID-19 require prolonged mechanical ventilation. Minimal data exists regarding the timing, safety, and efficacy of combined bedside percutaneous tracheostomy and endoscopy gastrostomy tube placement in these patients. The safety for healthcare providers is also in question. This study's objective was to evaluate the effectiveness and safety of combined bedside tracheostomy and gastrostomy tube placement in COVID-19 patients. Design and Methods: This is a single arm, prospective cohort study in patients with COVID-19 and acute respiratory failure requiring prolonged mechanical ventilation who underwent bedside tracheostomy and percutaneous endoscopic gastrostomy placement. Detailed clinical and procedural data were collected. Descriptive statistics were employed and time to event curves were estimated and plotted using the Kaplan Meier method for clinically relevant prespecified endpoints. Results: Among 58 patients, the median total intensive care unit (ICU) length of stay was 29 days (24.7-33.3) with a median of 10 days (6.3-13.7) postprocedure. Nearly 88% of patients were weaned from mechanical ventilation postprocedure at a median of 9 days (6-12); 94% of these were decannulated. Sixty-day mortality was 10.3%. Almost 90% of patients were discharged alive from the hospital. All procedures were done at bedside with no patient transfer required out of the ICU. A median of 3.0 healthcare personnel total were present in the room per procedure. Conclusion: This study shows that survival of critically ill COVID-19 patients after tracheostomy and gastrostomy was nearly 90%. The time-to-event curves are encouraging regarding time to weaning, downsizing, decannulation, and discharge. A combined procedure minimizes the risk of virus transmission to healthcare providers in addition to decreasing the number of anesthetic episodes, transfusions, and transfers patients must undergo. This approach should be considered in critically ill COVID-19 patients requiring prolonged mechanical ventilation.