Early tracheostomy for managing ICU capacity during the COVID-19 outbreak: a propensity-matched cohort study.

Background During the first wave of the COVID-19 pandemic, shortages of ventilators and intensive care unit (ICU) beds overwhelmed healthcare systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ICU stay is controversial. Research question Can "failure-free days" outcomes focused on ICU resources could help decide the optimal timing of tracheostomy in overburdened healthcare systems during viral epidemics? Study design and methods This retrospective cohort study included consecutive patients with COVID-19 pneumonia tracheostomized in 15 Spanish ICUs during the surge, when ICU occupancy modified clinicians criteria to perform tracheostomy in COVID-19 patients. We compared ventilator-free days at 28 and 60 days and ICU- and hospital bed-free days at 28 and 60-days in propensity-score-matched cohorts tracheostomized at different timings (≤7 days, 8-10 days, 11-14 days after intubation). Results Of 1939 patients admitted with COVID-19 pneumonia, 682 (35.2%) were tracheostomized, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days [≤7 vs. >7d (116 patients included in the analysis): median 9 days (IQR 0-15) vs. 3 (0-7), difference between groups 4.5 days, 95%CI (2.3 to 6.7); 8-10 vs. >10d (222 patients analysed): 6 (0-10) vs. 0 (0-6), difference 3.1 days, 95%CI (1.7 to 4.5); 11-14 vs. >14d (318 patients analysed): 4 (0-9) vs. 0 (0-2), difference 3 days, 95%CI (2.1 to 3.9)]. Except hospital bed-free days at 28 days, all other endpoints were better in early tracheostomy. Interpretation Optimal timing of tracheostomy may improve patient outcomes and alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on ventilator may particularly improve ICU availability.