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\begin{document}

\title{Tracheostomy intervention in intubated COVID positive patients: A
survey~ of current clinical practice amongst ENT Surgeons}



\author[1]{Rahul Kanegaonkar, FRCS (ORL-HNS)}%
\affil[1]{Princess Royal University Hospital}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
Introduction

The COVID-19 pandemic has resulted in an unprecedented need for critical
care intervention. Prolonged intubation and mechanical ventilation has
resulted in the need for tracheostomy in some patients. The purpose of
this international survey was to assess optimal timing, technique and
outcome for this intervention.

Methods

An online survey was generated. Otorhinolaryngologists from both the
United Kingdom and Abroad were polled with regards to their experience
of tracheostomy in COVID-19 positive ventilated patients.

Results

The survey was completed by 50 respondents from 16 nations. The number
of ventilated patients totalled 3403, on average 9.7\% required a
tracheostomy. This was on average performed on day 14 following
intubation. The majority of patients were successfully weaned (mean 7.4
days following tracheostomy).

Conclusion

The results of this brief survey suggest that tracheostomy is of benefit
in selected patients. There was insufficient data to suggest improved
outcomes with either percutaneous versus an open surgical technique.%
\end{abstract}%



\sloppy


Ayman D'Souza \textsuperscript{1}

Ricard Simo \textsuperscript{2} FRCS (ORL-HNS)

Alwyn D'Souza \textsuperscript{3} FRCS (ORL-HNS)

Francis Vaz \textsuperscript{4,6} FRCS (ORL-HNS)

Andrew Prior \textsuperscript{5} FRCS (ORL-HNS)

Rahul Kanegaonkar \textsuperscript{5,6} FRCS (ORL-HNS)

~

1~~~~~~~~~ Christ Church, University of Oxford, OX1 1DP

2~~~~~~~~~ Department of Otorhinolaryngology, Guy's and St Thomas' NHS
Foundation Trust, Great Maze Pond London SE1 9RT

3~~~~~~~~~ Department of Otorhinolaryngology, University Hospital
Lewisham, London, SE13 6LH

4~~~~~~~~~ Department of Head and Neck Surgery, University College
Hospital, London, United Kingdom NW1 2PG

5~~~~~~~~~ Department of Otorhinolaryngology, Princess Royal University
Hospital, Orpington, Kent, BR6 8ND

6~~~~~~~~~ Institute of Medical Sciences, Medway Campus, Canterbury
Christ Church University, Kent, ME4 4UF

Contact details:

~

Address ~~~~~ Professor Rahul Kanegaonkar

~~~~~~~~~~~~~~~~~~~~ Department of Otorhinolaryngology

~~~~~~~~~~~~~~~~~~~~ Princess Royal University Hospital

~~~~~~~~~~~~~~~~~~~~ Farnborough

~~~~~~~~~~~~~~~~~~~~ Kent

~~~~~~~~~~~~~~~~~~~~ BR6 8ND

Email~~~~~~~~~~~ {rahul.kanegaonkar@nhs.net}

Telephone ~ 07583440215

~

Word count 1226

\textbf{Abstract}

Introduction

The COVID-19 pandemic has resulted in an unprecedented need for critical
care intervention. Prolonged intubation and mechanical ventilation has
resulted in the need for tracheostomy in some patients. The purpose of
this international survey was to assess optimal timing, technique and
outcome for this intervention.

Methods

An online survey was generated. Otorhinolaryngologists from both the
United Kingdom and Abroad were polled with regards to their experience
of tracheostomy in COVID-19 positive ventilated patients.

Results

The survey was completed by 50 respondents from 16 nations. The number
of ventilated patients totalled 3403, on average 9.7\% required a
tracheostomy. This was on average performed on day 14 following
intubation. The majority of patients were successfully weaned (mean 7.4
days following tracheostomy).

Conclusion

The results of this brief survey suggest that tracheostomy is of benefit
in selected patients. There was insufficient data to suggest improved
outcomes with either percutaneous versus an open surgical technique.

\textbf{Introduction}

The global COVID-19 pandemic has resulted in unprecedented demands on
healthcare services.\textsuperscript{1} As of the 14\textsuperscript{th}
April 2020, the World Health Organization reported a global number of
1,844,863 confirmed cases with 117,021 death.\textsuperscript{2} In the
United Kingdom there are currently 88,625 confirmed cases and 11,329 in
hospital deaths.

~This novel betacoronavirus results in pneumonia that may rapidly
progress to a severe acute respiratory syndrome.\textsuperscript{3} In
such situations intubation and mechanical ventilation is frequently
required which has stretched and regularly exceeded capacity in a number
of institution.\textsuperscript{4}

A tracheostomy is classically recognised to be of benefit in those
requiring prolonged ventilation.\textsuperscript{5} Benefits include
weaning and pulmonary toilet in those requiring regular airway suction
in the Intensive Care Unit. Tracheostomy has been usually undertaken
between day 7 and 10 following intubation,\textsuperscript{6} but the
optimal timing for tracheostomy in COVID positive patients remains
uncertain.

Tracheostomy may be undertaken either via an open surgical approach or
percutaneously, usually at the bedside.\textsuperscript{7} Each approach
has its own merits, staffing and equipment requirements.

Recently disseminated ENT UK guidelines have recognised the need for
caution when performing a tracheostomy.\textsuperscript{8} Tracheostomy
is recognised to be an aerosol-generating procedure that increases the
risk of nosocomial amplification to health care workers and other
patients.\textsuperscript{9} Full personal protective equipment (PPE) is
mandatory for the surgical team and assisting staff, and practical
suggestions have been published to reduce the level of aerosol generated
during and following the procedure.\textsuperscript{10} However, there
remains little data as to the optimal approach and subsequent outcome in
COVID positive ventilated patients.

This global pandemic, initially identified in the Wuhan Province in
China, has gradually spread across international borders and has now
been identified in 210 countries and territories around the
world.\textsuperscript{11} Those units initially exposed have developed
a greater understanding of how to best manage COVID-19 positive
patients. Their experience is of benefit to other institutions early in
the pandemic cycle not only in terms of planning patient pathways and
healthcare resources, but also predicting outcomes.

We therefore conducted this international survey to assess tracheostomy
intervention in intubated COVID-19 positive patients amongst ENT
Surgeons. We sought to specifically identify at what point this
procedure was undertaken, the outcome following intervention, and
possible optimal technique.

\textbf{Methodology}

Permission to undertake this survey, considered to be a Service
Development Project, was obtained from the Research and Development
Department of King's College Hospital NHS Foundation Trust, London.

An online questionnaire was constructed on SurveyMonkey\selectlanguage{ngerman}\textbf{®}
consisting of the following questions:

1.~~~~~~~ In which country/region are you based?

2.~~~~~~~ How many ventilated COVID-19 patients have you had at your
hospital?

3.~~~~~~~ What percentage of intubated patients have required a
tracheostomy?

4.~~~~~~~ On average on what day was the tracheostomy performed (e.g.
day 7 of intubation)?

5.~~~~~~~ How long after tracheostomy was the patient weaned off the
ventilator?

6.~~~~~~~ What percentage of patients died despite tracheostomy?

7.~~~~~~~ Were outcomes better with any specific tracheostomy technique
(e.g. percutaneous vs surgical)?

~

An email invitation with a link to the survey was disseminated by three
of the authors to European Colleagues known to them as fellow examiners
on the European Board Examination in Otorhinolaryngology. Those
contacted were also invited to disseminate the invitation to Clinicians
who may wish to contribute.

The questionnaire was disseminated on the 27\textsuperscript{th} March
2020 and data accepted until the 15\textsuperscript{th} April 2020.

Survey data collected was downloaded and transferred to a
Microsoft\textbf{®} Office Excel spreadsheet for analysis.

Patient and public involvement

Patients and the public were not involved in the production of this
survey or paper.

\textbf{Results}

An initial 90 practicing European Consultant Otorhinolaryngologists were
contacted. The survey was completed by a total of 50 respondents from
both the United Kingdom (n=8) and International units (note figure 1.)

~

The number of ventilated patients totalled 3403 with a mean of 68
patients per Hospital Unit/Trust (range 0--600).

The percentage of intubated patients requiring tracheostomy was on
average 9.65\% (range 0-100\%) with a tracheostomy performed following
intubation at a mean of 14.4 days (range 7-21). This was drawn from 28
respondents from a pool of 2701 intubated and ventilated patients.

Patients were successfully weaned post tracheostomy on average after 7.4
days (range 1-16 days). Despite undergoing a tracheostomy on average
13.5\% of patients died (drawn from 14 respondents from a population of
1687 intubated and ventilated patients).

With regards to tracheostomy technique and outcome, 3 out of 50
respondents gave preference to a percutaneous tracheostomy.~ An open
surgical approach was favoured by 8 out of 50 respondents. Other
respondents (20/50) stated neither preference, with a remaining 19/50
unable to contribute.

\textbf{Discussion}

The COVID-19 pandemic has resulted in unparalleled demand on critical
care services and the need for intubation and mechanical
ventilation.\textsuperscript{1} Those who become critically ill do so
due to rapid progression of pneumonia to a severe acute respiratory
distress syndrome leading to respiratory failure and
death.\textsuperscript{12-14}~ Data from Wuhan suggests the median time
from hospital admission to death was 5 days, the mean 11
days.\textsuperscript{1}

The results of this survey would suggest that approximately 1 out of
every 10 intubated and ventilated patients require a tracheostomy.
Furthermore, this intervention is of benefit with patients successfully
weaned with only the minority dying following this intervention.

Current guidelines published by the American Academy of
Otorhinolaryngology-Head and Neck Surgery recommend that tracheostomy
should not be performed prior to 14 days of
intubation.\textsuperscript{17} The results of this survey would suggest
that units are adopting a similar policy with few undertaking early
tracheostomy routinely.

One should, however, be aware of the potential risks of prolonged
ventilation in those who may be weaned. These include late tracheal
ulceration, stenosis and tracheo-oesophageal
fistula.\textsuperscript{5}~ Acquired critical care illness is also
likely to become more prevalent.\textsuperscript{18}~ More patients will
require prolonged ventilation and the muscular atrophy associated may
prolong or prevent weaning.\textsuperscript{19} Anecdotal reports of
glottic and supraglottic swelling and ulceration may also prohibit
extubation and prolong the need for intubation, sedation and
ventilation, that may be overcome by tracheostomy.

This survey failed to establish any clear benefit with regards to
tracheostomy technique. Comments included by respondents generally
explained that intervention was taken on a case by case basis and
dependent on local surgical experience.

The results of this survey represent a snapshot of the current activity
of several international units in a rapidly changing clinical
environment. Limitations include the number of respondents with COVID
positive patients concentrated in specific units. The management of this
novel infection remains supportive with no clear evidence from recently
initiated research trials.

During this time of stretched resources and limited personnel the
authors are immensely grateful to those who have taken the time to
respond to this survey to support the decision making of colleagues
throughout the world.

\textbf{Conclusions}

This survey was undertaken to assess the current Otorhinolaryngology
practice of tracheostomy intervention in COVID patients ventilated in
Intensive Care Units.

Whilst this survey represents a snap-shot of current activity in a
rapidly changing clinical environment, it does nonetheless suggest that
there is a place for tracheostomy intervention in COVID-19 positive
intubated patients, but that this intervention is performed later (on
average day 14) than would be classically recommended (days 7-10).

There is no convincing data to support outcomes to be superior with
either open surgical versus percutaneous approaches, and at present the
decision depends on surgical experience and what is deemed to be safest
for both patient and staff.1

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\par\null

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