Combined Tracheostomy and Gastrostomy Tube Placement in Critically Ill COVID-19 Patients

Studies in several countries have shown that a substantial number of COVID-19 patients admitted to the ICU with severe respiratory failure required prolonged mechanical ventilation. Tracheostomy and gastrostomy tubes help wean patients from ventilation and allow them to be transferred sooner into a rehabilitation environment.

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Several medical societies recommend tracheostomy placement in COVID-19 patients after 10 to 14 days of mechanical ventilation. However, there is no consensus about the optimal technique or setting for placing these tubes or gastrostomy tubes.

Catherine L. Oberg, MD, of UCLA Medicine, and Colleen Keyes, MD, MPH, and Erik Folch, MD, MSc, clinicians in the Division of Pulmonary and Critical Care Medicine at Massachusetts General Hospital, recently reported their procedure for placing tracheostomy tubes with or without gastrostomy tubes in adults with COVID-19. They report excellent outcomes in the Journal of Intensive Care Medicine. 

Study Methods

The prospective study involved 58 COVID-19 patients who underwent percutaneous tracheostomy with (n=50) or without (n=8) percutaneous endoscopic gastrostomy (PEG). They were included between April 5 and June 15, 2020, and followed through August 6, 2020.

Of the 50 combination placements, 49 were completed during the same procedure (same anesthetic episode). 56 patients tested positive for SARS-CoV-2 at the time of the procedure.

All procedures were done by the interventional pulmonology service at the bedside in the ICU. Two to three health care professionals conducted each procedure (including combined procedures). The article describes other steps taken to reduce aerosol generation and exposure to the patient and health care professionals.

Procedural Data

• Median apnea time during tracheostomy placement was 90 seconds
• For PEG placement, median mouth-to-stomach time was 30 seconds and the median total time was 14.5 minutes
• Procedural complications were minor bleeding in 12 patients, site irritation in six and repeat procedure needed in five
• There were no serious complications such as organ perforation or periprocedural death

Outcomes

• Median length of stay—19 days in ICU before the procedure, 10 days in ICU after the procedure, 45 days total hospitalization
• Mortality at 14, 30 and 60 days—5.2%, 6.9% and 10.3%
• Of the 52 patients alive at 60 days, 51 (98%) were successfully weaned and 49 (96%) were ultimately decannulated; in the interval, 39 (77%) had the tracheostomy downsized
• Median time from tracheostomy to downsizing was 17 days, to decannulation 25 days and to hospital discharge 25 days

Physician Follow-up

In a follow-up to this study, the physicians who primarily performed the procedures tested negative for SARS-CoV-2 IgM and IgG antibodies, indicating they probably had not been exposed.

Additional Rationale for Combined Procedures

19% of patients required preprocedural transfusions (1–6 units transfused) and 40% were on therapeutic anticoagulation that had to be briefly discontinued prior to the procedure(s). Combined tracheostomy and gastrostomy tube placement potentially cut both the number of transfusions and the number of interruptions of anticoagulation in half.

In another paper published on Respiratory Care, the team describes an approach for seamless transition from tracheostomy to decannulation while avoiding aerosolization.

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