All patients included in this study were aged >18 years and had a polymerase chain reaction (PCR) confirmed diagnosis of COVID-19.
As is standard practice in our institution, the size and type of tracheostomy selected for insertion remained at the discretion of the senior ICU physician and/or Ear, Nose and Throat (ENT) surgeon. Percutaneous tracheostomy consisted of a small 1–2 cm horizontal incision in the anterior neck, just below the level of the cricoid cartilage. Blunt dissection was performed to the level of the pre-tracheal fascia, followed by cannulation of the trachea under bronchoscope guidance. The “Blue Rhino G2-Multi Percutaneous Tracheostomy Introducer Set” was used for all patients (COOK MEDICAL EUROPE LTD. Europe Shared Service Centre, O’Halloran Road National Technology Park Limerick, IRELAND).
The two patients who required surgical tracheostomies had these performed in the operating theatres. A horizontal incision was followed by dissection of the strap muscles and division of the thyroid isthmus to expose tracheal rings 2–4. Tracheal stay-sutures were applied to the tracheal rings above and below the tracheal incision. The endotracheal tube was then withdrawn with the ventilator placed in apnoea mode, the tracheostomy was inserted and the cuff immediately inflated to minimise aerosolisation. PEEP was maintained as far as possible throughout and apnoeic times, although not recorded, were kept to a minimum.
Staffing for percutaneous tracheostomy insertion comprised the minimum number of staff (three) required to safely perform the procedure (40 (link),60 (link)). This included an experienced ICU nurse, and either two Consultants, or a Consultant and a Fellow. All staff wore full personal protective equipment (PPE) including; FFP3 (N95) mask, full gown, gloves, goggles and hooded face shields (61 (link)-63 ). This complied with local infection control policies and conformed to World Health Organisation and Centre for Disease Control recommendations (44 (link),64 ,65 ). All patients were preoxygenated, sedated and muscle relaxed (62 (link),63 ). Ventilation was ceased prior to tracheal dilatation to minimise aerosolization, and correct positioning was confirmed with bronchoscopy, end-tidal capnography and chest X-ray (30 (link),31 (link),44 (link),48 (link),49 (link),60 (link)-63 ). The apnoea time was not recorded but kept at a minimum to reduce the risk of clinical harm and patient desaturation. Following insertion, cuff pressures were monitored and recorded four hourly and kept in the green zone of the manometer 20–30 cmH2O. Where leaks were apparent, cuffs were inflated to higher pressures to maintain tidal volumes.
We wished to determine the incidence of unplanned tracheostomy change, the reason for the change, and the tracheostomy inserted during the change. Unplanned tracheostomy change was defined as a change in the size or type of tracheostomy necessitated by clinical need, such as persistent leak or patient-ventilator dyssynchrony. Persistent leak and ventilator dyssnychrony was assessed clinically by the Consultant ICU physician. The requirement for tracheostomy change was determined clinically on a case-by-case basis. It did not include tracheostomy changes to facilitate respiratory weaning such as downsizing, or changing a cuffed to an uncuffed tracheostomy.
Each time an unplanned tracheostomy change was undertaken (outside of downsizing for weaning) the patient was deeply sedated and muscle relaxed. The tracheostomy was changed by mounting the introducer over a guidewire from the new sterile insertion set. This is standard practice in our institution. Where upsizing was required, the Blue Rhino dilator was used as described previously.
We also sought to assess time from intubation to tracheostomy insertion, time from ICU admission to tracheostomy, ICU LOS and time to decannulation, and to examine the changes, if any, in FiO2, PEEP and PP at the time of tracheostomy insertion and at days 1, 3 and 5 post insertion. The follow-up time to determine time to decannulation, overall outcome of mortality rate was 6 months post tracheostomy insertion.
As is standard practice in our institution, the size and type of tracheostomy selected for insertion remained at the discretion of the senior ICU physician and/or Ear, Nose and Throat (ENT) surgeon. Percutaneous tracheostomy consisted of a small 1–2 cm horizontal incision in the anterior neck, just below the level of the cricoid cartilage. Blunt dissection was performed to the level of the pre-tracheal fascia, followed by cannulation of the trachea under bronchoscope guidance. The “Blue Rhino G2-Multi Percutaneous Tracheostomy Introducer Set” was used for all patients (COOK MEDICAL EUROPE LTD. Europe Shared Service Centre, O’Halloran Road National Technology Park Limerick, IRELAND).
The two patients who required surgical tracheostomies had these performed in the operating theatres. A horizontal incision was followed by dissection of the strap muscles and division of the thyroid isthmus to expose tracheal rings 2–4. Tracheal stay-sutures were applied to the tracheal rings above and below the tracheal incision. The endotracheal tube was then withdrawn with the ventilator placed in apnoea mode, the tracheostomy was inserted and the cuff immediately inflated to minimise aerosolisation. PEEP was maintained as far as possible throughout and apnoeic times, although not recorded, were kept to a minimum.
Staffing for percutaneous tracheostomy insertion comprised the minimum number of staff (three) required to safely perform the procedure (40 (link),60 (link)). This included an experienced ICU nurse, and either two Consultants, or a Consultant and a Fellow. All staff wore full personal protective equipment (PPE) including; FFP3 (N95) mask, full gown, gloves, goggles and hooded face shields (61 (link)-63 ). This complied with local infection control policies and conformed to World Health Organisation and Centre for Disease Control recommendations (44 (link),64 ,65 ). All patients were preoxygenated, sedated and muscle relaxed (62 (link),63 ). Ventilation was ceased prior to tracheal dilatation to minimise aerosolization, and correct positioning was confirmed with bronchoscopy, end-tidal capnography and chest X-ray (30 (link),31 (link),44 (link),48 (link),49 (link),60 (link)-63 ). The apnoea time was not recorded but kept at a minimum to reduce the risk of clinical harm and patient desaturation. Following insertion, cuff pressures were monitored and recorded four hourly and kept in the green zone of the manometer 20–30 cmH2O. Where leaks were apparent, cuffs were inflated to higher pressures to maintain tidal volumes.
We wished to determine the incidence of unplanned tracheostomy change, the reason for the change, and the tracheostomy inserted during the change. Unplanned tracheostomy change was defined as a change in the size or type of tracheostomy necessitated by clinical need, such as persistent leak or patient-ventilator dyssynchrony. Persistent leak and ventilator dyssnychrony was assessed clinically by the Consultant ICU physician. The requirement for tracheostomy change was determined clinically on a case-by-case basis. It did not include tracheostomy changes to facilitate respiratory weaning such as downsizing, or changing a cuffed to an uncuffed tracheostomy.
Each time an unplanned tracheostomy change was undertaken (outside of downsizing for weaning) the patient was deeply sedated and muscle relaxed. The tracheostomy was changed by mounting the introducer over a guidewire from the new sterile insertion set. This is standard practice in our institution. Where upsizing was required, the Blue Rhino dilator was used as described previously.
We also sought to assess time from intubation to tracheostomy insertion, time from ICU admission to tracheostomy, ICU LOS and time to decannulation, and to examine the changes, if any, in FiO2, PEEP and PP at the time of tracheostomy insertion and at days 1, 3 and 5 post insertion. The follow-up time to determine time to decannulation, overall outcome of mortality rate was 6 months post tracheostomy insertion.
