It’s a real thing—the lack of standardized protocols to select which COVID-19 patients receive a tracheostomy and when they receive it means that individuals have to allocate scarce recourses. —Alexander Gelbard, MD
Explore This IssueMarch 2021
Dr. Ongkasuwan, who also treats children, said that at Texas Children’s Medical Center in Houston, on the other hand, decisions are much more commonly made by committee. Even as adults with COVID-19 were cared for there during the worst parts of the pandemic, committees considered the survival implications, emotional implications, and other factors during tracheostomy conferences, and some procedures were turned down after everything was weighed.
Alexander Gelbard, MD, an associate professor of otolaryngology at Vanderbilt University in Nashville, said the pandemic has demonstrated the importance of institutional protocols to allocate resources during crises. “It’s a real thing—the lack of standardized protocols to select which COVID-19 patients receive a tracheostomy and when they receive it means that individuals have to allocate scarce recourses,” he said. “I can really see the merits of institutions that enacted systematic processes to help ease the burden of decision making on individual physicians and surgeons.”
Michael Pitman, MD, chief of laryngology at Columbia University Irving Medical Center in New York City, said the pandemic hit hard early, with “hundreds of trachs that needed to be done.” Surgical teams—otolaryngology, thoracic surgery, and general surgery—would rotate days performing them, “just going from bed to bed to bed to bed.”
Originally, teams would wait 21 days from the time of intubation because of the uncertainty about transmission and a reluctance to risk infection from a patient who still carried a high virus load in the airway. Since then, however, they’ve gone “all the way back to pretty much normal, with about 12 days of intubation,” said Dr. Pitman. This was done, he said, as evidence emerged that the infection risk for providers seemed to be low even when they wore just PPE and not powered air-purifying respirators (PAPRs).
The panelists also described occasional tension around PAPR availability for otolaryngology and not for other departments—meaning that otolaryngologists were being instructed not to use them. But they said the current trend, and certainly the preference from a logistical standpoint, is moving away from PAPRs and toward PPE.
“I’ve used both, and I much prefer to not have the PAPR,” Dr. Pitman said. “We actually had to get communication devices so we could talk to each other because you can’t hear anything. These are some very sick patients, and you need to communicate really well.”
Dr. Ongkasuwan said she and the anesthesiologist were both wearing PAPRs in a procedure when the patient laryngospasmed, and they found it difficult to communicate with one another. “It really turned me off of using PAPRs in surgical cases,” she said.
Dr. Johns said that at USC physicians are more comfortable performing tracheotomies earlier in the course of treatment. “Currently, we’re just advancing to do it whenever the window of opportunity opens,” he said. “These patients have waxing and waning levels of acuity in their care, and there may be a relatively short window where the patient is stable enough to get a tracheotomy. And the tracheotomies are quite hazardous‚ as the patients decompensate very quickly.”
“It appears from the lens of the outside observer that COVID-19 has a much more unpredictable course than the majority of medical illnesses that traditionally landed patients in critical care,” added Dr. Gelbard. “The timing of a tracheostomy has been a challenging question, in large part because even our critical-care colleagues have a hard time predicting the clinical trajectory of severely ill COVID-19 patients.”