NTSP Special Interviews (Season 2): Tony Jacob discusses COVID-trach UK at ITS6

Mr Tony Jacob is an ENT Surgeon from London who stepped up to lead the COVID-Trach project in the UK at the start of the COVID-19 Pandemic. Tony spoke about his work at the 6th International Tracheostomy Symposium, held in Manchester UK, in October 2021. This interview is an extract from that meeting.

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Transcript

SPEAKER_00 0:36

We'll hand over to the team on the day and over to Tony.

SPEAKER_01 0:41

Now I can't imagine there's a single person in the world whose life hasn't been affected in some shape or form by the COVID-19 pandemic, either directly or indirectly. At the time we recorded this session, there had been over 220 million cases of COVID-19 worldwide and over four and a half million deaths. And I think we can all accept that that's vastly underreported. Most countries, including our own, have had a second wave of the disease, and probably a third. This graph shows the trajectory of COVID-19 in the UK, the first, second, and the third wave that we're going through now. The light at the end of the tunnel was the launch of the vaccine in December 2020, and we are seeing the effect of that vaccination program now. You can see on this graph the charts, the UK death rate, that in spite of a clear third wave of infections that we saw on the previous graph, the death rate in the UK has remained relatively low. It's worth us taking a step back to the beginning to understand the context in which we began to adapt tracheostomy techniques for COVID-19 patients. You'll see in this graph that by March 2020, the UK, along with other European countries, was hit hard and fast. This meant we had very little time to prepare, and it really forced us to think on our feet. A few weeks into the pandemic, as numbers of ventilated patients rose, there was a real risk of capacity being breached. So discussions started about tracheostomies for these patients, and integral to these discussions were the following key questions. Will it be a useful intervention for this cohort of patients about which we knew very little? And when should it be considered? Is there any chance it could cause more harm? Is it safe, particularly to the healthcare professionals? Because of course we knew a tracheostomy is an inherently aerosol-generating procedure, and we already knew at that time that exposed healthcare workers were dying, both in Europe and here in the UK. So the question was: if it was deemed necessary and appropriate, what modifications to techniques would help to make it as safe as possible? A number of well-intentioned professional associations, including our own, ENTUK, wrote guidelines based on the best possible evidence and expert opinion, because frankly that's all we had. And this formed the basis of how we delivered tracheostomies in the first wave. The key recommendations that flowed from these guidelines were the following to form a local team and to plan utilizing locally available resources, to use PPE. There was some debate about what type, and we'll go into that later. A few guidelines recommended a pre-procedure COVID test to ensure the least risk possible to healthcare workers. The timing of procedure was discussed, techniques were discussed, but more importantly, safe steps were introduced for whichever technique was locally adopted. And finally, there was some discussion about the ideal location. We'll talk a bit more about these recommendations in a minute, but once we had that, we got on with it. But we also realized early on that we would need to rapidly learn from our experience to give it an evidence base and try and streamline best practice. And we agreed that we wanted this to be as multidisciplinary as possible and certainly UK-wide. And at that stage, we weren't able to make this an international effort. So we engaged with various associations and specialties, and to everyone's credit, we were able to come together and agree to collaborate. COVIDTRAC was born and launched on the 15th of April 2020. COVIDTRAC is a UK-wide multi-center prospective cohort study that was designed to evaluate the outcomes of COVID-19 tracheostomies and also to examine the incidence of COVID-19 infection among those involved in the procedure. I'd like to acknowledge in particular my colleague Nick Hamilton, a clinical lecturer at UCL, who's now a fellow in Boston who's done most of the legwork to pull this project together. And all the others on this page are our other co-collaborators in the UK. Although the project is still ongoing, in August last year, after the first wave petered out in the UK, we analyzed the first 1,605 tracheostomies across 126 hospitals in the UK. At the time, this was one of the largest studies of COVID-19 tracheostomies. We then used the data obtained from COVID TRAC to challenge some of the assumptions made in the early guidance documents. We first considered patient selection. This is always difficult and has been even in pre-COVID times. With COVID, we had a virtually unknown disease. In many ways, it was challenging because of multisystem failure. Patients were very sick. A lot of them were needing anticoagulants, and so the bleeding risk was high. And there was an increased reliance on proning to aid lung recruitment. And all of this, of course, had to be balanced with the potential risk to healthcare staff. A multivariable logistic regression model was applied to our data for mortality, and we found that there were some key variables that contributed to poorer prognosis. And you can see these highlighted here. We also applied this to the time taken to wean from a ventilator. And again, quite similar variables were picked up again. What this was saying is that aim to perform a tracheostomy on a patient who is getting better but just needs a bit more time. And this was not too dissimilar to standard practice. But there were a couple of other factors that we needed to consider. The first was the need for a pre-procedural apnea test. Now we knew these patients were very unstable. Often, the moment they came off oxygen, their saturations would drop to their boots. And so early on, an international panel recommended a pre-procedural apnea test, which essentially was testing their physiological readiness, and if nothing else, allowed the teams to anticipate and plan for issues during the tracheostomy. The other thing to consider was the need for proning. More and more patients needed proning for lung recruitment, but it made sense not to offer tracheostomies to these patients as the tracheostomies were more difficult to manage and potentially tube-related issues could be missed. In general, it seemed an effective intervention and certainly did not appear to make things worse. And studies, including one from Birmingham, suggested tracheostomy in this cohort confers a survival benefit, and others have shown that it eased the burden on intensive care, requiring less intensive monitoring and nursing requirements and so on. Our analysis showed that nearly 80% of patients who had tracheostomies in the first wave were successfully weaned. If we consider technique and location, there were early advocates for an open technique and others advocating a percutaneous technique, each with minor modifications to minimize healthcare worker exposure to infections. As far as location was concerned, it was recommended that in the context of an aerosol and droplet-mediated infection, a negative pressure room was recommended as the gold standard. And this made sense. Our data showed that there was a reasonably even split between percutaneous and open techniques. And this was interesting because it goes against what has become the norm in the UK in the last few decades, i.e., with the majority of tracheostomies being done percutaneously. And this effect we're seeing here is clearly down to recruitment. And by that, what I mean is essentially surgeons and others trying to be helpful to our hard-pressed intensivist colleagues who had their hands otherwise tied. We looked at complications and found that the commonest complication was of unsettling desaturations during the procedure. And this comes back to the point raised earlier. The second most common was that of bleeding. And again, this relates to the fact that a lot of these patients were on anticoagulants. The complication rate between open and percutaneous techniques wasn't statistically significant, although there was a slightly higher risk of bleeding, of course, with the open technique. We also looked at healthcare worker infection rates across both techniques and found no difference. On the basis of our data, therefore, we couldn't recommend one technique over the other. And the decision over which method to employ should really be locally led and depends on expertise available and the close interdisciplinary working that I'm sure exists. As far as setting is concerned, again, we couldn't recommend one over the other, and it really should be determined by local factors. What we did know is that very few UK hospitals had access to negative pressure environments, but in spite of that, infectivity remained low. So, really, irrespective of what technique was used and where the tracheostomy was actually done, it was important to plan and adopt local protocols. It was certainly important to do the pre-procedural apnea test, to avoid unexpected events during the tracheostomy, and it certainly helped to pause ventilation at key steps during the tracheostomy, and there are publications that outline this very clearly. Full paralysis during the tracheostomy was also helpful to avoid coughing. We next considered PPE. Most early guidance recommended at least an FFP3 respirator mask, and a few went further and recommended a powered respirator. There was also guidance issued for appropriate donning and doffing techniques to minimize aerosol spread. Looking at our data, we can see that over 99% of operators used an adequate mask, either an FFP3 or better. Six healthcare workers tested positive for COVID-19 within two weeks of the procedure, and this was a very, very small incidence. However, there were some caveats to this data. It relied on self-reporting, and so potentially some asymptomatic cases may have been missed. And also because the healthcare workers involved continued to work in other high-risk areas, we couldn't really confirm for sure whether their index exposure was indeed the tracheostomy. However, what we are clear about is that the rate of infectivity is very, very low, and this is in keeping with a number of other publications out there now. By way of a conclusion, therefore, a minimum of an FFP3 mask should be used, along with other procedural steps taken to minimize aerosol dispersion. There was a lot of debate about this, and various early guidance documents recommended delaying a tracheostomy beyond the conventional 8 to 10 days to potentially allow for a lower viral load in these patients and thereby minimize risk to healthcare workers. Utilizing that same logic, there were also one or two guidance documents that recommended at least two COVID-negative swabs to be obtained before proceeding to a tracheostomy. This was an important piece of work published by Brendan McGrath and colleagues in the Lancet. Infectivity and viral load is believed to peak around the time of symptom onset and then gradually decline over the next three to ten days. And if you look at the timeline of these patients, day 10 of their time in intensive care is often day 15 or 16 from the onset of symptoms. And infectivity at that point is probably already on the wane. We therefore looked at all our data and looked at when tracheostomies were done in the 1,600 odd patients that we analyzed. We then applied odds ratio to both mortality and time taken to wean. And we found that there was certainly some evidence that an early tracheostomy done within the first week was associated with increased mortality. Our conclusions, therefore, regarding the timing of tracheostomies is certainly not to consider it too early. And probably the issue here is that prognostic information has not really become clear. To a certain extent, be guided by your intensivus. And if you look back at the previous data, it would suggest that it's almost going back to business as usual. So, in other words, aim for about 10 days post-intubation, as long as all the other parameters support that. And certainly don't delay beyond day 10 just to receive two negative PCR results. It's not something we'd recommend. So just to summarize and to illustrate a few take-home points, I think we've clearly seen and demonstrated that a tracheostomy is a useful procedure to help facilitate weaning and to do it de-escalate patients from high dependency areas in particular times of pressure. It's really helpful and key, really, to form a tracheostomy MDT and in the context of local circumstances like staffing, resources, etc., to then determine where they'll be done and using what technique. Essentially the how and where should really be determined by local factors. It's important to adopt key safety steps as outlined for both open or percutaneous procedures, where adequate PPE, do not delay tracheostomies beyond day 10 of mechanical ventilation, as there's really no evidence to suggest it's beneficial to reduce healthcare worker exposure. And certainly don't wait or insist on COVID-negative swabs. And finally, with patient selection, we've shown evidence to support tracheostomies in patients who are getting better but just may take a bit more time. Perhaps looking at indicators like a downward trending CRP and so on could be helpful. Thank you very much for listening.

SPEAKER_00 16:06

Thanks to Tony and the team for that really useful insight.