Editor’s note: Due to the COVID-19 pandemic, the 2021 Triological Society Combined Sections Meeting was held virtually on Jan. 29-30. The physical distance didn’t stop otolaryngologists in every specialty area from discussing the latest treatments, techniques, and issues in otolaryngology research and clinical practice.
At Ohio State University Wexner Medical Center during the early days of COVID-19, doctors tried to quickly fashion a way to think about whether and when to perform tracheotomies on patients who had been stricken with the disease and were on mechanical ventilation, said Laura Matrka, MD, an assistant professor of otolaryngology–head and neck surgery at Ohio State in Columbus. It was no small task—it required balancing important medical and resource needs with the possibly grave infection risks to medical personnel.
To solve the problem, a kind of “ad hoc committee” formed, said Dr. Matrka. “It was just simply all of us emailing in a group email each time a consult came through,” she said. “I remember those days as distinct from where we are now—we came up with some protocols, whether it was open at the bedside or in the OR.”
A panel of laryngologists shared their experience with evolving tracheostomy and COVID-19 processes during a session at the virtual Triological Society Combined Sections Meeting in January. Dr. Matrka, like the rest of the panel, said the comfort level with performing tracheotomies on COVID-19 patients has grown over time, and now they are more likely to perform them more closely to the time of intubation than they did at the start of the pandemic.
“Since then, I think the biggest thing that’s happened is that we all trust PPE now in a way that I don’t think any of us did initially,” Dr. Matrka said. She added that otolaryngologists don’t do any percutaneous tracheostomies at Ohio State unless they’re consulted in certain cases, such as unfavorable anatomy.
Michael Johns III, MD, professor of clinical otolaryngology–head and neck surgery at the Keck School of Medicine of the University of Southern California in Los Angeles, said that early in the pandemic, tracheotomies were considered and handled by a team of all of the services that perform them: otolaryngology, thoracic surgery, pulmonary-critical care, neurocritical care, and respiratory therapy. They developed practices collectively, he said.
“Each service has been performing them for their patients as they would before and according to the group-developed protocols,” he said. “We do both perc trachs and open trachs, mostly in the ICU at the bedside with critical care running meds, a respiratory therapist, a nurse, and a surgical team.”
Julina Ongkasuwan, MD, an associate professor of otolaryngology at the Baylor College of Medicine in Houston, explained that her institution has no set protocol. She said the surgical intensive care unit was performing more percutaneous tracheotomies, and the complication rate rose because the procedure was newer to that unit. “The pendulum has definitely swung back to us doing the open tracheotomies,” she said.
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
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.”
Thomas R. Collins is a freelance medical writer based in Florida.