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Open Access

Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection

Heather Carmichael, Franklin L Wright, Robert C McIntyre, Thomas Vogler, Shane Urban, Sarah E Jolley, Ellen L Burnham, Whitney Firth, Catherine G Velopulos, Juan Pablo Idrovo
DOI: 10.1136/tsaco-2020-000591 Published 19 January 2021
Heather Carmichael
1Department of Surgery, University of Colorado, Aurora, Colorado, USA
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Franklin L Wright
2Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
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Robert C McIntyre
2Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
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Thomas Vogler
1Department of Surgery, University of Colorado, Aurora, Colorado, USA
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Shane Urban
3Trauma Program, University of Colorado Health, Aurora, Colorado, USA
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Sarah E Jolley
4Division of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
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Ellen L Burnham
4Division of Pulmonary and Critical Care Medicine, University of Colorado, Aurora, Colorado, USA
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Whitney Firth
5Surgical/Trauma ICU, University of Colorado Health, Aurora, Colorado, USA
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Catherine G Velopulos
2Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
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Juan Pablo Idrovo
2Department of Surgery, Division of Gastrointestinal, Trauma and Endocrine Surgery (GITES), University of Colorado, Aurora, Colorado, USA
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  • Figure 1
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    Figure 1

    Flow diagram of patients included in the study, outcomes, and discharge disposition. Average time from the tracheostomy procedure to each outcome is reported. COVID-19, coronavirus disease 2019; ICU, intensive care unit; LTAC, long-term acute care; SNF, skilled nursing facility.

  • Figure 2
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    Figure 2

    (A) Percentage of patients on multiple intravenous infusions for sedation, single intravenous infusion, or no intravenous infusions during the 24-hour period prior to tracheostomy, day of tracheostomy (POD0), and first 7 days after tracheostomy (POD1 to POD7). (B) Corresponding proportion of patients on different degrees of ventilator support across the same timeframe. Stars denote significant change in distribution across groups as compared with distribution at baseline according to Fisher’s exact test (*p<0.05, **p<0.01, ***p<0.001). POD, postoperative day.

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    Figure 3

    Average rates of intravenous sedation agents: (A) propofol (mg/kg/minute), (B) dexmedetomidine (mcg/kg/hour), and (C) midazolam (mg/hour) during the 24-hour period prior to tracheostomy, day of tracheostomy (POD0) and first 7 days after tracheostomy (POD1 to POD7). Also displayed are average daily cumulative doses of opioid medications given (D) via intravenous infusion or injection and (E) orally. Results of repeated-measures ANOVA across entire timeframe are displayed in top right corner of each figure. Stars denote significant decrease from baseline (day prior to tracheostomy) according to mixed-effects modeling (*p<0.05, **p<0.01, ***p<0.001). ANOVA, analysis of variance; MME, milligram morphine equivalent; POD, postoperative day.

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  • Table 1

    Characteristics of the population as well as comparison of patients who were or were not ventilator-dependent at 15 days post-tracheostomy

     All patients
    (n=26)
    Ventilator dependence at 15 days (n=9)No ventilator dependence at 15 days (n=17)P value
    Age in years (mean±SD)55±1255±1155±130.96
    Male sex, n (%)21 (81%)5 (56%)16 (94%)0.06
    Obesity (BMI >30), n (%)8 (31%)3 (33%)5 (29%)1.00
    At least one major medical comorbidity, n (%)20 (77%)8 (89%)12 (71%)0.57
    Diabetes, n (%)12 (46%)4 (44%)8 (47%)1.00
    Hypertension, n (%)11 (42%)4 (44%)6 (35%)0.97
    ECMO prior to tracheostomy, n (%)8 (31%)3 (33%)5 (29%)1.00
    CRRT prior to or at time of tracheostomy, n (%)11 (42%)4 (44%)7 (41%)1.00
    History of failed extubation/reintubation, n (%)13 (50%)2 (22%)11 (65%)0.10
    Days of MV before tracheostomy (mean±SD)24±524±625±50.43
    FiO2 >40% at time of tracheostomy, n (%)8 (31%)5 (56%)3 (18%)0.12
    PEEP >8 cm H20 at time of tracheostomy, n (%)4 (15%)2 (22%)2 (12%)0.90
    PaO2 to FiO2 ratio <200, n (%)9 (35%)4 (44%)5 (29%)0.74
    Impaired neurologic status with GCS<8, n (%)7 (27%)6 (67%)1 (6%)<0.01
    • BMI, body mass index; CRRT, continuous renal replacement therapy; ECMO, extracorporeal membrane oxygenation; FiO2, fraction of inspired oxygen; GCS, Glasgow Coma Scale; MV, mechanical ventilation; PEEP, positive end-expiratory pressure.

  • Table 2

    Comparison of current study results to other published series in the literature

     Turri-Zanoni et al20Zhang et al21Broderick et al22Angel et al23Chao et al29Floyd et al24Current study
    Study period2/24–3/151/23–4/6–3/10–4/15–4/1–4/303/1–6/30
    Study locationVarese, ItalyWuhan, ChinaManchester, UKNew York, USAPhiladelphia, USANew York, USADenver/Aurora, USA
    Number of patients32111098533826
    Time from intubation to tracheostomy in days (mean±SD or (range))15 (9–21)17 (6–36)17±511±520±724 (20–28)25±5
    Percutaneous10 (31%)6 (55%)098 (100%)*19 (55%)026 (100%)
    Complications
     Bleeding0005 (5%)1 (2%)4 (11%)2 (8%)
     Wound infection02 (18%)0–1 (2%)00
    Follow-up after tracheostomy in days (mean±SD or (range)))21 (8–37)–14±711±6––49±23
    Ventilator support at discharge or follow-up, n (%)
     Full support––1 (10%)40 (41%)––3 (12%)
     Partial support––2 (20%)19 (19%)––2 (8%)
     No ventilatory support–9 (82%)7 (70%)32 (33%)30 (57%)21 (55%)21 (81%)
    Time to liberation from ventilator (mean±SD or (range))–7 (2–19)––12±7109±6
    Tracheostomy status, n (%)
     Downsized–––19 (19%)14 (26%)7 (18%)18 (73%)
     Decannulated1 (3%)–6 (60%)8 (8%)7 (13%)16 (65%)
    Time to decannulation
    (mean±SD)
    ––10±417±51420±10
    Disposition
     Deceased5 (16%)007 (7%)6 (11%)2 (5%)4 (15%)
     ICU––4 (40%)76 (78%)––0
     Non-critical care––4 (40%)11 (11%)––0
     Discharged––2 (20%)4 (4%)16 (30%)–22 (85%)
    • *Majority performed using a “novel” percutaneous dilation technique.

    • ICU, intensive care unit.

Supplementary Materials

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    [tsaco-2020-000591supp001.pdf]

Additional Files

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    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    • Data supplement 1
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Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection
Heather Carmichael, Franklin L Wright, Robert C McIntyre, Thomas Vogler, Shane Urban, Sarah E Jolley, Ellen L Burnham, Whitney Firth, Catherine G Velopulos, Juan Pablo Idrovo
Trauma Surg Acute Care Open Jan 2021, 6 (1) e000591; DOI: 10.1136/tsaco-2020-000591

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Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection
Heather Carmichael, Franklin L Wright, Robert C McIntyre, Thomas Vogler, Shane Urban, Sarah E Jolley, Ellen L Burnham, Whitney Firth, Catherine G Velopulos, Juan Pablo Idrovo
Trauma Surg Acute Care Open Jan 2021, 6 (1) e000591; DOI: 10.1136/tsaco-2020-000591
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Early ventilator liberation and decreased sedation needs after tracheostomy in patients with COVID-19 infection
Heather Carmichael, Franklin L Wright, Robert C McIntyre, Thomas Vogler, Shane Urban, Sarah E Jolley, Ellen L Burnham, Whitney Firth, Catherine G Velopulos, Juan Pablo Idrovo
Trauma Surgery & Acute Care Open Jan 2021, 6 (1) e000591; DOI: 10.1136/tsaco-2020-000591
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