NTSP Specials (Season 2): A/Prof Stephen Warrilow reflects on getting back to business post-COVID

Stephen Warrillow is Assistant Professor at the University of Melbourne, Australia, and a senior Intensivist in the city. Stephen has been president of the Australia & New Zealand Intensive Care Society and heavily involved in the GTC since its inception. Stephen spoke about how services were returning to normal at the 6th International Tracheostomy Symposium, held in Manchester UK, in October 2021. This presentation is an extract from that meeting.

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Transcript

SPEAKER_00 0:08

This episode is part of three weeks, so it's the 45th of October 2021 International Capital Exposure. I'm going to hand over to my friend Barbara Balfento, who is part of the NTSPT. Barbara's going to introduce Dr. Stephen Morrow. Stephen is an authentic care physician who works in Melbourne, Australia. And we'd like Stephen to give us some insights about the pandemic from the Australian perspective. Stephen's also going to discuss about how we get things back to normal for our patients with tracheostomy. So over to you, Barbara.

SPEAKER_01 0:43

So my next job is to introduce you to Dr. Stephen Warrillo, who's got a lot of credentials. So he's the director of intensive care at Austin Health and also the director of Critical Care Institute at Epworth Healthcare and the immediate past president of the Australian and New Zealand Intensive Care Society. He also convened the World Congress of Intensive Care in 2019 in Melbourne, which was amazing. We all attended, and we still want to thank you about that. So, Dr. Warrior, to you.

SPEAKER_02 1:17

Hello from Melbourne. It's lovely to join you again. My name is Stephen Morilo, and despite being lockdown and on call, I think I can get 10 minutes of uninterrupted time to share some insights with you regarding the role of tracheostomy in these challenging COVID times. In terms of my interests, I'm the Director of Intensive Care at Austin Health in Melbourne, and I've got affiliations with the University of Melbourne and the Australian and New Zealand Intensive Care Society. I would also like to acknowledge that I live and work on the traditional lands of the Rindry Willem people of the Coolan Nation, and I pay my respects to their elders, past, present, and emerging. It's fair to say that those of us who've chosen to work in critical care are used to hard work and various challenges. Nonetheless, there's been something else hanging around in the last 18 months that's been rather unsettling. Until a short time ago, this guy, SARS-CoV-2, was entirely unheard of, certainly in clinical practice, and even the SARS viruses were really the domain of epidemiologists, virologists, and maybe veterinarians, certainly not really clinicians, except for a couple of unfortunate encounters back in the early 2000s, which we'll touch on later. The implications of COVID on RCU practice have been vast. But for COVID-affected ventilated patients, it's not just the absolute numbers that have proven challenging, but also the number of bed days that they occupy. Many require several weeks of mechanical ventilation, plenty of time for them to inquire various complications and develop a full-blown RCU type syndrome of deconditioning and potentially multiple organ failure, but also impacts on our ability to care for other patients, including non-COVID affected. It seems ultimately likely that, as for so many of our other long-term ICU patients who need perhaps a slow win from mechanical ventilation, that COVID-affected patients in a similar situation are likely to benefit from a tracheostomy. There's no specific patient-centred reason really to alter our usual process of selection or clinical decision making. The impact of COVID for clinicians caring for COVID patients, however, is quite profound and presents a new, jarring and very challenging scenario. Firstly, there's an understandable, powerful fear of droplet and airborne transmission. It has really important safety considerations for our healthcare workers, as well as having an impact on issues such as furlough and service provision and ability to care for other patients. And it has meant that we've had to take on a complex reconsideration of balancing patient-centered care with essential requirements to protect our teams. This influences considerations such as the timing for tracheostomy and lets us rerun the early versus late debate. Also the approach to tracheostomy itself. Is there a role for maybe preferring a surgical approach versus percutaneous? As well as the location. Does it happen in the RCU or the bedside, or do we move back to the operating room? And also what precautions are really necessary? Is an N95 mask with full PPE acceptable? Or do we need to move to more sophisticated, complex, and indeed costly approaches such as portable air purifying devices? And ultimately, what is the right balance and who is at risk? For patients, we pretty much accept that prolonged translaryngulin tubation is associated with potentially preventable complications. So going too late isn't really ideal for the patient. That said, for our staff, the inadvertent and maybe avoidable exposure to droplets and aerosol generating procedures and exposing them to the risk of acquiring COVID and becoming ill or being furloughed has a profound psychological impact. And in addition, they'll also be worried about taking it home to their family. So where can we seek guidance on these complex issues during trying times? Well, at least initially, we're kind of forced to seek expert opinion and eminence-based recommendations from experienced clinicians and august societies and colleges. These initial recommendations were appropriately, indeed necessarily, very conservative, and had an extremely strong focus on protecting healthcare workers. The reasons are perhaps obvious, but bear repeating. SARS-CoV-2 was a novel pathogen. Its true virulence was unclear, and there was great uncertainty as to how transmissible it really was. There was a strong obligation to protect the clinical team, because ultimately no team equals no patient care for anyone, including those affected by COVID. These concerns were not ill-founded or made up. If we reflect back to 2003, with the very serious outbreak of a related virus, SARS, a number of healthcare workers lost their lives. And I'll provide an extract of those affected there, but it included medical staff, nursing staff, techs, other healthcare workers, including paramedics, that had a profound impact on those systems, which resonates to this day. Common elements of these early recommendations were an emphasis on avoiding aerosol generating procedures. For example, therapies such as high flow oxygen therapy in non-intubated intubated patients. Use of non-invasive ventilation such as CPAP or BIPAP was frowned upon. And it was suggested that we should really intubate very early and maybe bypass these kinds of interventions. In terms of the use of tracheostomy, some recommended avoiding it completely or at least delaying it until perhaps the patient was no longer infectious. It was also suggested that perhaps it would be safer to do it in the operating room and the intensive care bedside approach should be avoided, and that maybe it would be safer to use a surgical technique and best to avoid a percutaneous approach. However, such planning can make a lot of sense at the time, but not necessarily survive the reality of encountering the enemy, as was understood by Helmut von Moltke, a Prussian military commander, and perhaps put a little more succinctly by Mark Tyson in his famous phrase, everyone has a plan until they get punched in the mouth. So what have we learned? Well, there's been some really important discoveries on this journey. Firstly, and quite reassuringly, it turns out the personal protection equipment is really quite effective. I think many of my staff would agree that they feel safer at the bedside in the COVID pod than they do at the tea room. Also, as it turns out that maybe the issue of aerosols and airborne transmission, whilst real, can nonetheless be managed in the highly controlled critical care environment. And finally, an emerging realization that patients may actually be harmed if clinical decision making is distorted or that we avoid good normal practices. And evidence-based therapies are withheld, such as the use of non-invasive therapy for COPD or heart failure patients, due to a non-reasonable or extreme focus on risk. And helpfully, we've had a number of studies starting to come through, including this one performed by the Queen Elizabeth Hospital in Birmingham, which have actually documented their approach to safe tracheostomy management in this particular patient population. Let's look briefly at what this team from Birmingham found. There's was a prospective observational study of 100 patients who underwent tracheostomy. Now, of course, it has some potential for selection bias and some other limitations, but nonetheless, a very useful addition to our knowledge base. They incorporated a particularly specialized team who performed 90% of all of the tracheostomies, which were mostly percutaneous and in the operating room. They did not have explicit criteria for tracheostomy, but really just a consensus of clinical decision making by experienced specialists. And they had no particular consideration for checking for patient infectiousness at the time of tracheostomy. It's also worth noting that they had quite a high utilization of tracheostomy in their patient cohort at 61%, which is give or take about four times as has been reported in other case cohorts. Most notably and reassuringly, however, there was no instances of transmission to staff, although to be fair, there might have been some limitations with the testing regime used. They also indicate that there may have been a 30-day survival benefit and a reduced length of stay if done within two weeks. So how does living and working with COVID affected patients for 18 months and the published experience of groups such as that from Birmingham influence our current thinking? Well, in terms of patient selection, it's kind of similar to what we normally do. The patients need to be improving and not in the hot phase of their critical illness, and certainly it's not helpful to put a tracheostomy in patients who might be actually dying. In terms of the timing of tracheostomy, I think we've now shifted back to doing it a little earlier, and it's far more consistent with our business as usual approach, perhaps. And maybe as it turns out, while the risk of aerosol generating procedures is clearly real, maybe it's actually a little less than we previously considered. Although I guess we need to be a little bit cautious on that front in terms of the potentially increased infectiousness of emerging variants. With regard to technique, I think you're increasingly suggesting do whatever your unit does best. Both surgical approaches and percutaneous approaches may be made safer through modest changes in techniques, such as pausing positive pressure ventilation at key moments during the procedure. But really, I think I would suggest do what you do best and stick with it. In terms of the location, I think both the operating room and the bedside can be made safe. There's pros and cons with both. In terms of aftercare, the approach should strongly resemble the care that we provide to any patient with a tracheostomy, regardless of COVID status. The best approach is likely to be multidisciplinary and team-based, incorporate people with particular skills who are well trained and educated in tracheostomy management, should be proactive in monitoring and watching for complications, and have an approach that emphasizes early escalation of concerns to highly trained relevant experts. So, in reflecting on our current recommendations, whilst it's true that COVID-19 has produced an immense shock to the system, there is a slow but welcome transition from eminence-based recommendations, which were very, very conservative early on, to hopefully what might be evidence-based practice for tracheostomy decision-making and care. It's increasingly clear that tracheostomy will have an important role for some patients with COVID, and that a business as usual approach is probably the right one. Just make sure the PPE is utilized very well. Now there's still more to learn about the impact of new COVID variants, patient selection and charming of tracheostomy, but many of those considerations apply to our general patient population anyway.

SPEAKER_00 11:41

Thanks to Stephen and the team for that talk. Fascinating to hear how things are done in Australia and the global perspectives arising from that work. As ever, the views and opinions we discussed on the podcast are our own and don't necessarily represent those of our areas of players. You can follow us at our social media pages and find more episodes by our podcast web pages on UK or WebDW Podcast website.