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Penn Task Force Offers Guidelines for Tracheostomy in Ventilated Patients with COVID19

Tracheotomy image demonstrating tube attachment at neck.

A task force from the Penn Airway Safety Committee has determined that tracheotomy is indicated for a subset of ventilated COVID-19 patients, and has created and refined the Guidelines for the timing and other major considerations for the procedure.

Note: The term tracheotomy refers to the procedure in which an incision is placed in the trachea to provide an alternative airway called a tracheostomy; the terms are often used interchangeably.

See the Penn Airway Safety Committee Guidelines for Tracheotomy in COVID-19

As soon as this task force was convened, it became clear that a timeline for tracheotomy in critically ill COVID-19 patients requiring invasive intubation and mechanical ventilation was needed. These patients are at increased risk for death, and the duration of intubation in these patients is often extended beyond 2-3 weeks.

However, at the outset of the task force work, the prognosis of patients who required prolonged ventilation was difficult to predict given the existing data, in spite of Penn’s involvement in an international consensus discussion. The initial guidelines from Penn stated that tracheostomy timing would likely be at 21 days but might be as early as 10-14 days if additional data was obtained.

Tracheotomy Guidelines for COVID-19

For these reasons, the COVID-19 Tracheotomy Task Force, a working group of the Airway Safety Committee of the Perelman School of Medicine and Penn Medicine, has issued guidelines for the application of tracheotomy in ventilated patients with COVID-19.

The guidelines have the goal of highlighting specific considerations for patients with COVID-19 in the light of evolving standards of care in rapidly changing times when, the authors state, “it is critical to apply and carefully adapt the best existing evidence on this topic to the current pandemic.”

The guidelines, published in the May 2020 issue of Annals of Surgery, contain recommendations for:

  • determining candidacy for tracheotomy in COVID-19 patients;
  • performing the procedure when deemed necessary in this population (with guidelines for protection of providers and PPE parameters) post-operative care; and
  • the provider decision-making process.

Following release of the guidelines, Penn Medicine has performed 40 tracheotomy procedures across five Penn hospitals.

Based on the experience and data obtained by the first 20 patients, the guidelines have been modified slightly to allow for consideration of earlier tracheotomy in more patients (10-14 days instead of 21 days). Both open and percutaneous techniques have been performed. Early outcomes are promising and no health care provider has become infected.

Intubation vs. Tracheotomy

Tracheal intubation involves the insertion of a flexible plastic tube into the trachea from the mouth or nose through the voicebox, and does not typically involve surgery.

Tracheotomy is a surgical procedure involving placement of the tube through the front of the neck directly into the trachea. This procedure is commonly required in patients who are intubated and require mechanical ventilation for a prolonged period of time, but may also be required for people who have airway disorders including head and neck cancer.

Both intubation and tracheotomy are aerosol-generating procedures involving the aerodigestive tract, and thus impose a transmission and infection risk to bedside providers.

However, tracheotomy offers the advantages of facilitating liberation from the ventilator in some patients by:

  • decreasing use of sedation;
  • lessening the work of breathing; and
  • improving pulmonary hygiene.

In addition to benefiting patients, reduction in mechanical ventilation time and ICU stay offer the practical advantages of relieving strain on necessary and potentially limited resources at hospitals. It also reduces the impact of prolonged ventilation, which can cause tracheal and laryngeal stenosis and other long-term laryngeal problems.

Additional Resources

  • View a recent video from Penn ENT resident Tiffany Choa, MD, and Penn anesthesiologist Joshua Atkins, MD, who demonstrate proper PPE procedure.
  • Participate in an online survey to assess whether screening for loss of smell and taste can identify early infection and help slow the spread of COVID-19 (if eligible). Developed by Natasha Mirza, MD, Director of Penn Center for Voice and Swallowing.
  • Watch a video from the April 22 Global Tracheostomy Collaborative Webinar Overcoming COVID-19 Through Science and Teamwork – Lessons from the United Kingdom, Italy and United States, featuring Penn physician Christopher H. Rassekh, MD, Co-Chair, Hospital of the University of Pennsylvania Airway Safety Committee.
  • Read a new article from Dr. Rassekh and colleagues in Head and Neck on the care of immunocompromised patients with head and neck cancer during the COVID-19 pandemic.

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The Penn Physician Blog is a resource for health care professionals featuring Penn Medicine physicians and their research, innovations, programs and events. 

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