PHILADELPHIA — Tracheostomy was associated with better in-hospital survival for intubated patients with severe COVID-19 infection compared with intubated patients who did not receive a tracheostomy, a study has shown. Multivariate analysis revealed certain patient characteristics associated with receiving a tracheostomy.
During his presentation here at the American Academy of Otolaryngology-Head and Neck Surgery annual meeting, Ahab Alnemri, BA, a second-year medical student at the University of Pennsylvania in Philadelphia, explained that “tracheostomy is often performed in patients for the anticipated prolonged course of intubation to minimize sedation, facilitate ventilator weaning, or to address other clinical complexities.”
However, he said that the clinical benefit of tracheostomy during severe COVID infection is not fully understood, thus leading him to conduct a retrospective, multicenter observational cohort study of patients who were intubated at the University of Pennsylvania Health System between 2020 and 2021.
For all patients who were still intubated 5 days after intubation, 78.5% of those who subsequently received a tracheostomy (n = 185) survived hospitalization, whereas only 42.9% of those who remained intubated (n = 312) survived hospitalization (odds ratio = 2.79; P < .0001). The study used the 5-day cutoff point to eliminate consideration of potential confounders: patients who either had died or were extubated before then.
On univariate analysis, several demographic and clinical background details correlated with patients receiving a tracheostomy. On multivariate regression analysis, only male gender, being on extracorporeal membrane oxygenation (ECMO), non-COVID pulmonary disease, and immunocompromise predicted tracheostomy.
Table. Risk factors associated with receiving a tracheostomy (multivariate analysis)
| Risk factor | Odds ratio (95% CI) | P value |
|---|---|---|
| Male gender | 1.55 (1.01 – 2.39) | .045 |
| Patient on ECMO ** | 185.29 (37.24 – 3378.76) | < .001 |
| Non-COVID pulmonary disease | 1.65 (1.00 – 2.70) | .048 |
| Immunocompromise | 3.86 (1.98 – 7.57) | < .001 |
**ECMO: extracorporeal membrane oxygenation
The mean time from endotracheal intubation to tracheostomy was 17.3 ± 9.7 days. “Notably, on multivariate analysis, there was no association between timing of tracheostomy and in-hospital survival, which is an interesting detail because there is some controversy in the literature regarding whether early or late tracheostomy is associated with better outcomes,” Alnemri said.
Kwang Sung, MD, associate professor of otolaryngology-head and neck surgery at Stanford University in Stanford, California, commented to Medscape Medical News that he found the study results “almost counterintuitive…because the patients with more preexisting comorbidities were the ones who got tracheostomy, but they had better results in terms of mortality than the patients who did not get tracheostomy.” He raised the possibility of unknown confounding factors.
Sung, who was not involved in the study, said the patients on ECMO were probably some of the sickest “but also maybe had more potential for recovery, which is why they got put on ECMO. But I’m not really sure.”
Sung said one may question what the selection criteria were for performing a tracheostomy and if there was some sort of bias. Thus, he added, without seeing more data it is difficult to fully interpret the results. “But it is very interesting in terms of how we think about whether or not to do tracheostomy for COVID patients.”
He described the triggers for performing a tracheostomy and at what timepoint as “very institutional-dependent.” He estimated that at Stanford, intubated patients typically get a tracheostomy around 10-14 days after intubation, and with COVID, it could be prolonged to 20 days or more.
Alnemri and Sung reported no relevant financial relationships.
American Academy of Otolaryngology-Head and Neck Surgery 2022. Presented September 12, 2022.
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