1. Introduction
The role of tracheostomy for weaning ventilated patients with COVID-19 pneumonitis remains a matter of debate. Controversy exists regarding timing, location, prognosis, techniques to reduce aerosol generation, and risk of transmission to healthcare workers. The mortality rate following admission to critical care with COVID-19 pneumonitis is currently higher than for non-COVID viral pneumonia (50.7% vs 22.0%) as described in the Intensive Care National Audit and Research Centre (ICNARC) report [1]. This must be factored into the decision making process.
ENT-UK currently recommended performing tracheostomy on or after 14 days of intubation [2], and the British Laryngological Association (BLA) recommend deferring until the patient has a positive end-expiratory pressure (PEEP) requirement of ≤ 10cm H20 and an Fi02 of ≤ 0.4 [3]. As yet, there is no evidence-base beyond expert consensus.
Current evidence does not suggest a difference between the outcomes of surgical tracheostomy (ST) and percutaneous tracheostomy (PT) with regard to patient safety and aerosol-generation [4]. Recently some international guidelines have recommended a percutaneous approach [5-6].
Guy’s & St Thomas’ NHS Foundation Trust (GSTT) was one of the first centres in the UK to treat COVID-19 patients, and hence make decisions about tracheostomy. As of 24th April 2020 there were 171 completed critical care admissions with a further 104 currently receiving treatment for COVID-19 pneumonitis. Our mortality rate is currently 33%. In March 2020 we developed a dedicated ENT-led tracheostomy team, through close collaboration with intensive care and anaesthetics. Indications for tracheostomy were agreed, intensive training and simulation was undertaken, and our standardised protocol and recommendation is described in detail in our recent publication [7].
The aim of this paper is to analyse the intra-operative and short-term outcomes associated with tracheostomy for COVID-19 pneumonitis.