Authors: Dr. Anne-Sophie Laliberté and Dr. Andrew Seely
Collaborators: Dr. Michaeline Mcguinty and Dr. Bill Cameron, ID specialist, The Ottawa Hospital
Revision: Dr. Sean McFadden
COVID-19 pandemic has brought unprecedent challenges for the health care system. In the last few months, we have been facing a lot of unknown about this virus, its impact and prognosis. The health care system has been put under pressure and health care worker have been infected with COVID. A significant proportion of patients requiring ICU admission require intubation and ventilation. Management of these patients involves the critical decision regarding timing of extubation. Due to prolonged hypoxemia requiring ongoing ventilation associated with COVID-19, due to concerns regarding patient risks and financial costs of failed extubation, and concerns regarding aerosolization during reintubation and with a tracheostomy present, the indications for and timing of tracheostomy remains highly controversial. Last, the act of performing a tracheostomy is an aerosol-generating procedure that can but health care worker at risk. Thus, the aim of these recommendations is to highlight the optimal timing to do tracheostomy and the technical key points on this technic to increase the patient and health care worker safety. Careful team planning for this technic is strangely recommended to avoid unnecessary steps and minimize aerosol exposition.
Key points for tracheostomy in COVID-19 pandemic
When is the best timing to do tracheostomy?
Based on cases series and international expert opinion, tracheostomy should be delayed until at least 10 days of mechanical ventilation to assess if the patient may be safely extubated, to give time to ensure survivability, and considered only if patient showed sign of clinical improvement.1 The assessment of whether a patient merits a trial of extubation is highly controversial and based on how patients tolerate spontaneous breathing trials (SBTs). A “cuff leak” test should be performed to ensure no laryngeal edema. Best evidence highlights the value of steroids in all COVID-19 patients with severe hypoxemia, however if some time has lapsed while the patient has completed their steroid therapy, a short two day course of steroids may be considered prior to extubation to decrease the risk of extubation failure.10 However, if the patient fails extubation, most would consider that as an indication for tracheostomy. It remains unclear which patients should not undergo a trial of extubation, and proceed to upfront tracheostomy. There is still controversy around the timing of viral load reduction; testing for SARS-CoV-2 using PCR or NAAT does not distinguish between viable and non-viable virus, and virus can be detected using these methods for weeks to months after clinical illness10. The timing of the tracheostomy should be based on the clinical indication, and should not be deferred on the basis of PCR test positivity.
Health care worker safety strategy
- Room with negative pressure air flow is recommended, though not required.
- Enhanced personal protective device with N95, eye protection, surgical gown and gloves
- The number of persons should be kept at minimum; for example, 3 individuals can safely perform the procedure: one to perform bronchoscopy to guide the removal of the endotracheal tube and placement of the tracheostomy, one to perform the procedure, and one respiratory therapist to manage the ventilator.
- Favor doing it in ICU.
- Dedicated team of the most experienced personnel present
Strategy to minimize aerosol generation
- Sealed ventilator circuit with HEPA filter.
- Continuous sedation infusion, along with paralyzing agent should be used to avoid coughing.
- Pre-oxygenation should be done to permit apnea.
- Ventilation should be held during creation of tracheal window or dilation until the tracheostomy is installed.
- Avoid cautery
Prefer tracheostomy method
- Favor the tracheostomy technique that the dedicated team is the most use to do.
- Percutaneous technique is generally favored to reduce aerolization, reduce the risk of contamination, shorter procedural time and avoid moving patient to the OR.4,6
- If possible, single-use bronchoscopes with a sealed ventilator circuit are preferred for percutaneous tracheostomy.
- Upon removal of bronchoscope, gauze should be used to clean the bronchoscope during removal from the endotracheal tube to diminish risk of aerosolization.
- Suture tracheostomy in place, to avoid decannulation.
- Careful removal of endotracheal tube with disposal to avoid aerosolization should be considered.
Optimal management after tracheostomy to reduce the risk of aerosol generation
- Avoid unnecessary care
- Non fenestrated cuff tracheostomy should be used
- Reduce the frequency of changing the inner cannula and cuff pressure check
- Favor moister exchange filter over adjuncts
- Favor tracheostomy shield over deflating the cuff
- McGrath, B., Brenner, M., Warrillow, S. et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. The Lancet. July 2020: 8;717-725.
- David, A., Russel, M., El-Sayed, I. et al. Tracheostomy guidelines deveoped at a large academic medical center during the COVID-19 pandemic. Head & Neck. 2020;42:1291-1296.
- Radhakrishnan, S., Perumbally, H., Surya, S. et al. Guidelines for Surgical Tracheostomy and Tracheostomy Tube chang During the COVID-19 Pandemic: A review Article. Indian J Otorhinolaryngology and Head and Neck Surg. 2020;72:398-401.
- Schultz, P., Morvan, J-B., Fakhry, N., et al. French consensus regarding precautions during tracheostomy and post-tracheostomy care in the context of COVID pandemic. European Annals of Otorhinolaryngology, Head and Neack Diseases.2020;137:167-169.
- Lamb, C., Desai, N., Angel, L., et al. Use of Tracheostomy During the COVID-19 Pandemic. American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonologu\ Association of Interventional Pulmonology Program Directos Extert Panel Report. CHEST 2020;158:1499-1514.
- Neilipovitz, D., Kovacs, B. and Pagliarello, G. Percutaneous Tracheostomy in COVID-19 Patients. Anaesth Critic Care Med J.2020;5.
- Tay, J., Khoo, M., and Loh, W. Surgical Considerations for tracheostomy During the COVID-19 Pandemic: Lessons Learned From the Severe Acure Respiratory Syndrome Outbreak. JAMA Otolaryngology-Head & Neack. 2020;146 517-519.
- Chiesa-Estomba, C., Lechien, J., Calvo-Henriquez, C. et al. Systematic review of international guidelines for tracheostomy in COVID-19 patients. Oral Oncology.2020;108. 104844.
- Long, S., Chern, A., Feit, N., et al. Percutaneous and Open Tracheostomy in Patients with COVID-19: Comparison and Outcomes of an Institutional Series in New York City. Annals of Surgery.2020 [Ahead of Printing]
- The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19 Preliminary Report. N Engl Med. 2020 DOI:10.1056/NEJMoa2021436.
- Kwak PE, Connors JR, Benedict PA, et al. Early Outcomes From Early Tracheostomy for Patients With COVID-19. JAMA Otolaryngol Head Neck Surg.Published online December 17, 2020. doi:10.1001/jamaoto.2020.4837 – early tracheostomy not worse than late, no transmissions to HCWs.