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Abstract

Objective:

To assess and compare tracheostomy outcomes between COVID-19 patients and non-COVID-19 patients.

Materials and Methods:

This retrospective and prospective cohort study included patients over 18 years of age who underwent tracheostomy at a tertiary care hospital. We divided patients into 2 groups: 41 with COVID-19 and 156 without COVID-19. Primary outcomes were successful tracheostomy tube downsizing and removal, ventilator weaning, length of hospital stay, and mortality rate. Statistical analyses compared outcomes between groups.

Results:

COVID-19 patients achieved higher rates of successful tracheostomy tube downsizing (54.2% vs 9.6%, P < .001) and removal (36.6% vs 7.1%, P = .05) than non-COVID-19 patients. Mortality was lower in COVID-19 patients (29.3% vs 40.4%), although ventilator liberation rates were similar (P = .346). COVID-19 patients had longer hospital stays (64 vs 56 days); however, this difference was not statistically significant. We observed no significant differences in postoperative or long-term complications between groups. COVID-19 infection and age ≤60 years were factors associated with accelerated decannulation. COVID-19 patients demonstrated significantly higher rates of invasive pulmonary aspergillosis (P < .001).

Conclusions:

Despite lower mortality, COVID-19 patients achieved higher rates of tracheostomy tube downsizing and decannulation than non-COVID-19 patients. Ventilator liberation, hospital stay duration, and complication rates remained similar between groups.

Keywords

COVID-19 outcome of tracheostomy tracheostomy tracheostomy in COVID-19

Introduction

The COVID-19 pandemic has spread rapidly worldwide since its emergence in late 2019, including in Thailand.^1
-3 While the majority of COVID-19 patients experience mild symptoms commonly characterized by cough, sore throat, and anosmia, 5% to 15% of cases experience acute respiratory distress syndrome with severe hypoxemia. This syndrome particularly affects older patients and those with underlying conditions, including cardiovascular disease, diabetes, and chronic respiratory disorders.⁴ The significant rise in severe COVID-19 cases has necessitated increased use of invasive respiratory support.^5,6

A large cohort study of critically ill patients with COVID-19 by Auld et al demonstrated an overall mortality rate of 25.8% and 29.7% mortality among the approximately three-quarters of patients who required mechanical ventilation.⁷ Tracheostomy benefits patients requiring prolonged mechanical ventilation, pulmonary care, and airway management by reducing ventilation duration and intensive care unit stays.^8,9 A Spanish study involving 1890 tracheostomized COVID-19 patients revealed that tracheostomy may facilitate recovery in critically ill patients, achieving a ventilator liberation rate of 52.1% and a decannulation rate of 81%; however, ~23.7% of patients died.¹⁰ Other studies reported similar ventilator weaning rates but demonstrated varied decannulation success rates.^5,8 Molin et al compared tracheostomized and nontracheostomized COVID-19 patients and reported no reduction in length of stay or duration of mechanical ventilation; however, patients in the tracheostomy group had significantly lower mortality than those without tracheostomy.¹¹

In addition, studies have reviewed tracheostomy complications and reported no difference compared with patients without COVID-19; however, long-term complications have been the subject of limited studies.^5,8,12,13 Since respiratory pandemic outbreaks may be unpredictable, comparing outcomes between COVID-19 and non-COVID-19 patients offers multiple benefits that contribute to improved patient care, understanding of disease-specific impacts, resource allocation, and medical knowledge. Comparing outcomes helps isolate COVID-19-related factors that influence the course and success of tracheostomy, distinct from other critical illnesses requiring tracheostomy. By comparing the 2 groups, we can identify risk factors for poor outcomes, including high mortality, prolonged ventilator dependence, and decannulation failure that are more specific to COVID-19 patients.

Understanding outcome differences helps clinicians make more informed decisions about tracheostomy timing and patient selection criteria while providing appropriate discharge planning and proper resource allocation for recovery. Regarding the healthcare system, understanding the length of stay in intensive care units and hospitals, plus prolonged ventilator dependence, helps clinicians forecast and allocate critical resources such as intensive care unit beds, ventilators, tracheostomy tubes, and specialized personnel. Identifying knowledge gaps represents another benefit because outcome discrepancies or unexpected findings between groups can highlight areas requiring further research. Comparative studies provide strong evidence to develop and update clinical practice guidelines specifically for tracheostomy management in COVID-19 patients or other future respiratory outbreaks.

Our study aimed to assess both short-term and long-term tracheostomy outcomes in COVID-19 patients compared with non-COVID-19 patients. Short-term outcomes included success rates of tracheostomy tube downsizing and removal, ventilator weaning rates, and hospital stay duration. We also evaluated long-term follow-up results and survival rates.

Materials and Methods

Study Design

This retrospective and prospective observational cohort study was conducted at the Department of Otolaryngology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand, between January 2021 and June 2023. The Institutional Review Board of the faculty approved the study (Si-440/2022).

Patient Enrollment

The inclusion criteria were patients aged ≥18 years, with or without COVID-19 infection, who underwent tracheostomy. The exclusion criterion was patients who underwent tracheostomy due to cancers of the oral cavity, nasal cavity, larynx, pharynx, esophagus, or trachea. Between January 2021 and June 2023, our hospital admitted 3371 COVID-19 patients, with 258 requiring intubation and 41 undergoing tracheostomies. During the same period, 1873 non-COVID-19 patients needed intubation, and 396 underwent tracheostomies. We excluded cancer patients, including 1 from the COVID-19 group and 149 from the non-COVID-19 group. Following sample size calculations, we enrolled 41 COVID-19 patients and 156 non-COVID-19 patients (Figures 1 and 2).

Figure 1.

Flow diagram of COVID-19 patient enrollment and exclusions. ETT, endotracheal tube.

Figure 2.

Flow diagram of non-COVID-19 patient enrollment and exclusions. ETT, endotracheal tube; F, female; M, male.

Data Collection

We collected data from medical records, including medical symptoms, physical examinations, and flexible bronchoscopy findings. Follow-up assessments were conducted ~6 and 12 months posttracheostomy. Patients who had undergone tracheostomy more than 6 months before study initiation were scheduled for a single follow-up ~1 year after surgery, while those who had undergone tracheostomy within 6 months were scheduled for 2 follow-ups at 6 months and 1 year.

Outcome Measures

The primary outcomes were success rates of tracheostomy tube size reduction and decannulation, ventilator liberation rates, hospital stay duration, and mortality rates. Otolaryngologists performed all decannulations following established criteria: patients required no mechanical ventilatory support, had undergone downsizing to 8-mm outer diameter tracheostomy tubes, and had successfully tolerated continuous lumen occlusion for 1 week without respiratory problems. In addition, these patients required normal flexible rhino-laryngo-bronchoscopy findings before decannulation.

The secondary outcomes were short-term and long-term complications, plus time from tracheostomy to successful tube removal in patients with and without COVID-19 infection. Short-term complications were defined as complications occurring within 2 weeks of surgery, including surgical complications (false route, lacerations, bleeding), postoperative bleeding, granulation formation, and infection. Long-term complications were defined as complications appearing more than 2 weeks after surgery that could be related to tracheotomy. Mortality rate was defined as the number of deaths among studied patients occurring within 1 year after the procedures.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics, version 27 (IBM Corp, Armonk, NY, USA), and survival graphs were generated via Stata Statistical Software, release 18 (StataCorp, LLC, College Station, TX, USA). Continuous variables are presented as means and standard deviations or as medians and interquartile ranges, while categorical variables are reported as frequencies and percentages. The chi-square test was used to compare the 2 groups. Kaplan-Meier analysis assessed time to decannulation in both groups. Cox regression analysis and hazard ratios evaluated duration from tracheostomy to decannulation, and multivariable analysis was performed based on independent variables with univariable P < .2. A statistical significance level of P < .05 (2-tailed) was considered significant.

Results

Patient Characteristics

A total of 197 patients were enrolled in this study, comprising 41 COVID-19 patients and 156 non-COVID-19 patients. The indications for tracheostomy were similar between groups (P = .55), with prolonged intubation being the primary reason. Baseline characteristics (Table 1) revealed significant differences in age and diabetes prevalence between groups. The COVID-19 group had a mean age of 62.6 years with 56.1% diabetic patients, compared with 75.4 years and 37.2% in the non-COVID-19 group (P < .001 and P = .028, respectively). Smoking habits and other medical conditions were not significantly different.

Table 1.

Demographic and Baseline Characteristics of Patients With and Without COVID-19.

Patient characteristics	Patients, n (%)		P value
Patient characteristics	Non-COVID (n = 156)	COVID (n = 41)	P value
Age (y), mean ± SD	75.38 ± 14.99	62.61 ± 12.55	<.001
BMI, mean ± SD	23.69 ± 5.15	24.82 ± 6.09	.230
Sex, male	77 (49.4)	27 (65.9)	.060
Smoking
No	130 (83.3)	36 (87.8)	.449
Ex	24 (15.4)	4 (9.8)
Current	2 (1.3)	1 (2.4)
Underlying disease
HTN	121 (77.6)	30 (73.2)	.554
DM	58 (37.2)	23 (56.1)	.028
DLP	78 (50.0)	20 (48.8)	.889
CKD	52 (33.3)	12 (29.3)	.621
CAD	28 (17.9)	6 (14.6)	.617
CVA	30 (19.2)	5 (12.2)	.294
CLD	14 (8.9)	3 (7.3)	.737
Indications of tracheostomy
Prolonged intubation	147 (94.2)	39 (95.1)	.55
Prolonged intubation + pulmonary toilet	8 (5.1)	0
Upper airway obstruction	1 (0.6)	2 (4.9)

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CKD, chronic kidney disease; CLD, chronic lung disease; CVA, cerebrovascular accident; DLP, dyslipidemia; DM, diabetes mellitus; HTN, hypertension; SD, standard deviation.

Clinical Outcomes

Table 2 illustrates clinical outcomes following mechanical ventilator weaning and tracheostomy tube size status over months, assessed in a cohort of 122 surviving individuals. Ventilator weaning rates showed no significant difference between COVID-19 patients and non-COVID-19 patients, with rates of 82.8% and 89.2%, respectively (P = .346). However, a significant difference occurred in tracheostomy tube downsizing between the COVID-19 cohort (13 individuals, 54.2%) and the non-COVID-19 group (8 individuals, 9.6%; P < .001).

Table 2.

Ventilator Liberation and Tracheostomy Tube Downsizing Among Survivors at 6-Month Follow-Up.

Clinical outcomes	Patients, n (%)			P value
Clinical outcomes	All (n = 122)	Non-COVID (n = 93)	COVID (n = 29)	P value
Weaned off the ventilator
Dependent on MV/on O₂	15 (12.3)	10 (10.8)	5 (17.2)	.346
Off MV/O₂	107 (87.7)	83 (89.2)	24 (82.8)
Tracheostomy size in 6 mo
Decreased	21 (19.6)	8 (9.6)	13 (54.2)	<.001
Same	86 (80.4)	75 (90.4)	11 (45.8)
Unknown	15	10	5

Abbreviations: MV, mechanical ventilation; O₂, supplemental oxygen.

Data exclude patients with unknown status at 6 months.

Most patients admitted to our respiratory intensive care unit required advanced mechanical ventilatory support or experienced sudden, precipitous deterioration in respiratory function requiring immediate endotracheal intubation and mechanical ventilation. The COVID-19 group demonstrated lower mortality (29.3%) than the non-COVID-19 group (40.4%). Median hospital stay was slightly longer for COVID-19 patients (64 days) than for non-COVID-19 patients (56 days), although the difference was not statistically significant (P = .151; Table 3).

Table 3.

Intensive Care Unit Admission, Mortality, Length of Hospital Stay, and In-Hospital Complications.

Clinical outcomes	Patients, n (%)		P value
Clinical outcomes	Non-COVID (n = 156)	COVID (n = 41)	P value
ICU admission	110 (70.5)	38 (92.6)	.003
Indications
Required advanced mechanical ventilatory support	69 (44.2)	27 (65.8)
Acute respiratory failure	29 (18.6)	11 (26.8)
Neuromuscular or chest wall disorders	5 (3.2)	0
Airway protection and severe hypoventilation	3 (1.9)	0
Others (ARDS, sepsis, massive pulmonary embolism, etc.)	4 (2.6)	0
Mortality			.001
Dead	63 (40.4)	12 (29.3)
Alive	93 (59.6)	29 (71.7)
LOS in hospital (d), median (P25, P75)	56 (39,78)	64 (47,74)	.151
Complications in hospital			.145
No	136 (87.2)	32 (78.0)
Yes (≥1)	20 (12.8)	9 (22.0)
Minor tracheostomy bleeding	12	6
Major tracheostomy bleeding	3	1
Tracheomalacia	4	0
Tracheal stenosis	1	1
Subglottic stenosis	0	1
Infected tracheostomy stoma	2	0
Respiratory comorbidities			<.001
No	135 (86.5)	17 (41.5)
Yes (≥1)	21 (13.5)	24 (58.5)
ARDS	8	18
Pulmonary aspergillosis	3	10
Atelectasis	5	0
Pneumothorax	3	0
Other #	4	1

Abbreviations: ARDS, acute respiratory distress syndrome; ICU, intensive care unit; LOS, length of stay; P25, 25th percentile; P75, 75th percentile.

“Other” respiratory comorbidities include lung abscess, lower airway bleeding, and interstitial lung disease.

In-Hospital Complications

Hospital complications were not significantly different between groups (P = .145), with minor tracheostomy bleeding being the most prevalent complication in both groups (6 in the COVID-19 group and 12 in the non-COVID-19 group). Tracheomalacia and infected tracheostomy stoma occurred exclusively in non-COVID-19 patients, whereas complications such as tracheal stenosis were rare in both groups. COVID-19 was significantly associated with complications, including acute respiratory distress syndrome and invasive pulmonary aspergillosis (P < .001), with 18 and 10 cases, respectively, out of 24 studied (Table 3).

Long-Term Complications and Readmissions

Table 4 shows complications and readmission rates within 6 months among the 122 survivors. The incidence of complications over the 6-month duration remained relatively low in both groups, with tracheal stenosis/tracheal granulation being the most common, occurring in 3 individuals in each group. Readmission rates for respiratory causes were similar, with 5 individuals (21.7%) in the COVID-19 group and 19 individuals (25%) in the non-COVID-19 group.

Table 4.

Complications and Readmissions Within 6 Months Among COVID-19 and Non-COVID-19 Survivors.

Clinical outcomes	Patients, n (%)		P value
Clinical outcomes	Non-COVID (n = 93)	COVID (n = 29)	P value
Complications in 6 mo
Tracheomalacia	1	0
Tracheal stenosis/tracheal granulation	3	3
Tracheomalacia/tracheal stenosis/tracheal granulation	1	0
Readmission within 6 mo
No	39 (51.3)	16 (69.6)	.231
Yes, respiratory cause	19 (25.0)	5 (21.7)
Yes, nonrespiratory cause	18 (23.7)	2 (8.7)
Unknown	17	6

Factors Associated With Time to Decannulation

Table 5 presents our univariable analysis of time from tracheostomy to decannulation in the 197 surviving individuals. Age was the only factor that significantly impacted time to decannulation (P = .011). Patients aged ≤60 years were more likely to achieve successful tracheostomy tube removal, with a hazard ratio of 2.91 (95% CI, 1.28-6.64). COVID-19 infection demonstrated marginal significance concerning time to successful decannulation, with a hazard ratio of 2.27 (95% CI, 0.995-5.18; P = .051). No other factor was significantly associated with duration to decannulation.

Table 5.

Univariable Analysis of Factors Associated With Time to Decannulation.

Variables	N	Decannulation, n (%)		Median time (mo)	Decannulation, n (%)	P value
Variables	N	Yes (n = 26)	No (n = 171)	Median time (mo)	Crude HR (95% CI)	P value
COVID-19
Non-COVID	156	11 (7.1)	145 (92.9)	18.5	1	.051
COVID	41	15 (36.6)	26 (63.4)	13.6	2.27 (0.995-5.18)
Sex
Female	93	12 (12.9)	81 (87.1)	16.8	1.07 (0.48-2.36)	.872
Male	104	14 (13.5)	90 (86.5)	18.6	1
Age (y)
≤60	40	11 (27.5)	29 (72.5)	11.3	2.91 (1.28-6.64)	.011
>60	157	15 (9.6)	142 (90.4)	18.6	1
BMI
<18.50	26	3 (11.5)	23 (88.5)	15.6	1
18.50-24.99	101	12 (11.9)	89 (88.1)	18.8	0.68 (0.19-2.49)	.562
25.00-29.99	51	8 (15.7)	43 (84.3)	18.6	0.76 (0.19-3.09)	.701
≥30	19	3 (15.8)	16 (84.2)	-	1.48 (0.30-7.35)	.635
Smoking
Never	166	25 (15.1)	141 (84.9)	18.5	2.20 (0.29-7.35)	.446
Ex/current	31	1 (3.2)	30 (96.8)	-	1
DM
No	116	16 (13.8)	100 (86.2)	16.8	1.44 (0.58-3.59)	.436
Yes	81	10 (12.3)	71 (87.7)	18.9	1
CKD
No	133	22 (16.5)	111 (83.5)	18.5	1.82 (0.61-5.37)	.281
Yes	64	4 (6.3)	60 (93.8)	18.9	1
HTN
No	46	11 (23.9)	35 (76.1)	18.5	1.78 (0.79-4.03)	.166
Yes	151	15 (9.9)	136 (90.1)	16.8	1
DLP
No	99	15 (15.2)	84 (84.8)	18.5	1.35 (0.61-2.98)	.466
Yes	98	11 (11.2)	87 (88.8)	18.6	1
CAD
No	163	23 (14.1)	140 (85.9)	18.6	0.95 (0.28-3.28)	.935
Yes	34	3 (8.8)	31 (91.2)	15.6	1
CVA
No	162	24 (14.8)	138 (85.2)	18.5	0.75 (0.17-3.33)	.707
Yes	35	2 (5.7)	33 (94.3)	-	1
CLD
No	180	24 (13.3)	156 (86.7)	18.5	1.36 (0.31-5.87)	.685
Yes	17	2 (11.8)	15 (88.2)	16.5	1

Abbreviations: BMI, body mass index; CAD, coronary artery disease; CI, confidence interval; CKD, chronic kidney disease; CLD, chronic lung disease; CVA, cerebrovascular accident; DLP, dyslipidemia; DM, diabetes mellitus; HR, hazard ratio; HTN, hypertension.

Median time represents months from tracheostomy to successful decannulation. Dashes indicate median time not reached during follow-up period.

Multivariable Analysis

The multivariable analysis included COVID-19 infection and age ≤60 years as factors and adjusted the hazard ratios for decannulation accordingly. The findings indicated a statistically significant association between COVID-19 infection and successful decannulation, with an adjusted hazard ratio of 2.44 (95% CI, 1.08-5.55). Similarly, age ≤60 years presented a significant association with successful decannulation, demonstrating an adjusted hazard ratio of 3.14 (95% CI, 1.37-7.22; Table 6).

Table 6.

Multivariable Analysis of Time From Tracheostomy to Decannulation.

Variables	b	SE (b)	Decannulation	P value
Variables	b	SE (b)	Adjusted HR (95% CI)	P value
COVID-19: yes	0.894	0.418	2.44 (1.08-5.55)	.033
Age: ≤60 y	1.145	0.424	3.14 (1.37-7.22)	.007

Abbreviations: b, Cox’s regression coefficient; HR, hazard ratio; SE, standard error.

The multivariable analysis was based on independent variables with a univariable P < .1.

Kaplan-Meier Survival Analysis

The Kaplan-Meier curves depicted in Figure 3(a) and (b) compare the probability of tracheostomy tube removal over time for patients who underwent tracheostomy, stratified by COVID-19 status and age categories (≤60 and >60 years). The x-axis represents time in months from the date of tracheostomy, whereas the y-axis represents the proportion of patients with tracheostomy tube insertion. Over the follow-up period, the curves revealed a greater probability of decannulation in subgroups characterized by COVID-19 infection and age ≤60 years, because these groups presented shorter time to decannulation than the other groups.

Figure 3.

KM survival curves for time to successful decannulation. (a) Comparison between COVID-19 and non-COVID-19 patients. (b) Comparison between age groups (≤60 vs >60 years). The y-axis represents the proportion of patients with tracheostomy tubes remaining in place. Numbers at risk indicate patients still under observation at each time point. KM, Kaplan-Meier.

The median time to successful tube removal for COVID-19 patients was 13.6 months, whereas those without COVID-19 experienced a longer duration until decannulation, with a median time of 18.5 months. In addition, the median time for patients aged ≤60 years was shorter than that for those aged >60 years (11.3 vs 18.6 months; Table 5).

Discussion

This study examined the clinical outcomes of tracheostomy in patients with and without COVID-19 infection. The primary objectives were decreased tube size and decannulation rate, ventilator cessation rate, length of hospital stay, and survival rate. Our findings revealed significant differences in tracheostomy tube downsizing over months between the COVID-19 and non-COVID-19 groups (P < .001). After ~1 year of follow-up, more COVID-19 patients achieved decannulation than non-COVID-19 patients (15 individuals [36%] vs 11 individuals [7.1%]; P = .051). This result contrasts with the study by Bahk et al,¹⁴ where no difference in decannulation rates between groups was observed. However, most patients in both groups who needed more than 1 year with a tracheotomy had multiple underlying diseases, including diabetes mellitus, chronic lung disease, and body mass index >25, and required pulmonary toilet for long-term respiratory care.

The decannulation rate in our study aligns with outcomes from a narrative review by Al Omari et al⁵ and a retrospective cohort study by Bui et al,¹⁵ each reporting a success rate for tube removal of ~40%. However, our results differ from findings by Chao et al,¹⁶ where only 14% of patients achieved decannulation. This discrepancy may result from our longer follow-up period, which allowed more time for successful tube removal, and the generally younger baseline age of individuals with COVID-19 infection (P < .001).

The proportion of ventilator liberation in the comprehensive review was ~40% to 60% across the studied population.¹⁷ Our study yielded similar results, with 58% of COVID-19 patients successfully liberated from ventilation when the ventilation rate was calculated across all patients. The mortality rate in the COVID-19 group was 29.3%, similar to rates reported by several studies.^10,11,17 Interestingly, the mortality rate in patients without COVID-19 was moderately higher at 40.4%, possibly because of factors such as older age and underlying health conditions.

The duration of hospital stay in the COVID-19 group (64 days) was slightly longer than in the non-COVID-19 group (56 days), although this difference did not reach statistical significance. Battaglini et al¹⁷ reported that the estimated length of hospital stay for COVID-19 patients was 38.8 days; however, no studies to date have directly compared these results.

Both in-hospital and long-term complications were observed. The rate of postoperative complications in the COVID-19 group (22%) was slightly greater than in the non-COVID-19 group (12.8%), although this difference did not reach statistical significance (P = .145). Minor tracheostomy bleeding was the most common event in both groups. Other complications included major tracheostomy bleeding, tracheomalacia, infected stoma, tracheal stenosis, and subglottic stenosis. Various studies have reported tracheostomy complications in both COVID-19 and non-COVID-19 patients, consistently supporting the finding of no significant difference in complications between the 2 groups.^6,8,12,13 In addition, Tang et al⁸ reported that minor bleeding from tracheostomy occurred in 17.5% of patients and major bleeding occurred in 5%.

Long-term complications were also examined, but the reported numbers were relatively low. Only 3 patients in each group experienced tracheal stenosis. Among the 3 COVID-19 patients, 2 presented with severe stenosis requiring end-to-end anastomosis. Gervasio et al¹⁸ also reported 2 cases of tracheal stenosis in COVID-19 patients who had undergone tracheostomy, with 1 case involving severe stenosis that necessitated tracheal resection. These instances should be acknowledged as potential complications, emphasizing the importance of careful and thorough follow-up.

The variables associated with successful decannulation in our study were COVID-19 infection and age ≤60 years, with adjusted hazard ratios of ~2 and 3, respectively. Pijls et al⁴ reported that patients aged 70 years and above have a heightened risk of severe COVID-19, potentially influencing the success rate of decannulation. Beyond these factors, we did not identify any other variables significantly associated with the rate of successful tube removal. The Kaplan-Meier curve also revealed shorter time from tracheostomy to decannulation in the COVID-19 group and in individuals aged 60 years and younger.

Several factors may explain why COVID-19 patients achieved faster decannulation, and the exact interplay of these factors could be complex. Tracheostomy in non-COVID patients could be performed for various reasons, including chronic respiratory failure, multiple organ dysfunction, and neurological impairment, where the underlying condition itself might necessitate prolonged tracheostomy dependence. In COVID-19, the primary goal was often weaning from mechanical ventilation due to acute lung injury; therefore, once lung function began recovering, decannulation could be pursued more directly. The lung injury in COVID-19 is primarily an acute inflammatory process, and once this acute response resolves, the underlying lung tissue may have good capacity for functional recovery, allowing relatively quick decannulation. Younger individuals generally had greater physiological reserve, were less likely to have pre-existing comorbidities, and possessed stronger respiratory muscles and a more effective cough reflex. These factors allowed them to better withstand the acute insult of severe COVID-19 and recover more effectively from critical illness, leading to improved lung mechanics crucial for ventilator weaning and decannulation.

An important finding in our study was the pronounced statistical significance of invasive pulmonary aspergillosis (P < .001). This condition occurred in 10 out of 24 individuals and was observed more frequently in patients with COVID-19 than in non-COVID-19 patients. This phenomenon may be attributed to steroid administration, commonly used in severe COVID-19 cases; however, conclusive evidence supporting this association is currently lacking. Further investigations are warranted to explore this relationship and establish a clearer understanding of the potential role of steroid use in contributing to the increased incidence of invasive pulmonary aspergillosis in individuals with severe COVID-19.

Limitations

This study has several limitations that should be considered when interpreting the results. The number of patients who were lost to follow-up after 6 months was moderately high, impacting our ability to investigate long-term outcomes and complications comprehensively. Several confounding factors also existed: COVID-19 patients were significantly younger and had higher diabetes prevalence, whereas non-COVID-19 patients were older and more likely to have neurological causes for intubation. These baseline differences could inherently influence decannulation and mortality rates independent of COVID-19 status. Additionally, while the COVID-19 group included all eligible patients, the non-COVID-19 group was filled to meet sample size via consecutive sampling, which may not perfectly represent the broader non-COVID-19 tracheostomy population. Finally, results may not apply to smaller hospitals, different healthcare systems, or countries with other demographics, resources, and care protocols.

Conclusions

Compared with non-COVID-19 patients, patients with COVID-19 infection demonstrated a greater reduction in tracheostomy tube size and a greater success rate of decannulation. Despite exhibiting lower mortality, COVID-19 patients did not show significant differences in ventilator liberation, length of hospital stay, or complications compared with their non-COVID-19 counterparts. The factors associated with successful and quicker decannulation were identified as COVID-19 infection and age 60 years or younger. This study highlighted a significant association between COVID-19 infection and invasive pulmonary aspergillosis, underscoring the need for further investigation.

Footnotes

The authors express appreciation to Assistant Professor Chulaluk Komoltri for statistical analysis,and to Ms Jeerapa Kerdnoppakhun and Miss Sirakorn Pothipakdee,our research assistants,for their help with reference search,manuscript format,and reference management.

ORCID iDs

Phawin Keskool

Vannipa Vathanophas

Paiboon Sureepong

Ethical Considerations

The Institutional Review Board of the faculty approved the study (Si-440/2022).

Funding

The authors disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This research project was supported by Faculty of Medicine Siriraj Hospital,Mahidol University,Bangkok,Thailand (grant number: (IO)R016531071).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Data Availability Statement

The data supporting this study’s findings are available from the corresponding author upon reasonable request.

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