Tracheostomy for treating COVID-19-related respiratory failure

Italian physicians published their management strategies for critical care patients based on their experiences. They acknowledge the resource shortage in Italy, but emphasize the importance of safety in all tracheal intubation procedures including appropriate patient triage based on expected outcome, non-emergent intubation whenever possible, minimizing exposure to staff through essential personnel presence only, maximizing first attempt success, negative pressure room (if available) or isolation room, and proper donning/doffing of PPE. They caution the use of awake tracheal intubation given elevated risk of aerosolization, and suggest that if it is deemed appropriate, using IV sedation may reduce coughing. If awake tracheal intubation fails, they recommend tracheostomy with local anesthesia. If “‘cannot intubate, cannot oxygenate,’’ it is appropriate to consider an emergency front-of-neck airway (cricothyroidotomy).

Additional recommendations include placing high-efficiency particulate air filters between the airway device and breathing circuit, minimizing circuit disconnections, and sedating the patient when disconnecting with the ventilator on stand-by mode (and) with tracheal tube clamped. PPE recommendations for aerosol generating procedures are airborne-level protection including, “helmets, covers or hoods; FFP3 or FFP2/N95 masks, goggles or face shields (if no helmets); hazmat suits or long sleeved fluid‐resistant gowns; double gloves (possibly different colours); and overshoes. Whenever possible, the maximum available protection level should be used, especially for aerosol‐generating procedures.”[1]

ENT Physicians in Singapore did a literature review looking at tracheostomy during the SARS epidemic (Table summarizing case series from the article below) given the high proportion of patients requiring mechanical ventilation during the COVID-19 outbreak. They emphasized the importance of appropriate protective equipment for healthcare workers (N95 mask, surgical cap, goggles, surgical gown, gloves, and face shields to powered air-purifying respirators (PAPRs)). They noted the importance of appropriate donning/doffing technique to avoid contamination. Ideal location is a negative pressure ICU room with anteroom to minimize movement. Consideration should be given to optimizing set-up with recommendation for necessary equipment in a sterile pack. To minimize aerosol exposure: paralyze the patient, stop mechanical ventilation prior to entering the trachea, and minimize suction (if suction is used, use a closed system with viral filter). At the time of the SARS outbreak, open tracheostomy was favored over percutaneous tracheostomy due to increased airway manipulation through dilations as well as increased connecting/disconnecting ventilator during percutaneous tracheostomy procedure. They note that techniques have advanced since this time, but the risk of newer techniques in an aerosolized infectious process have not been elucidated. They recommend an experienced, dedicated team with a plan for set-up/communication. Following the procedure, there should be appropriate disposal of equipment (ideally disposable equipment used during procedure) with appropriate protective gear in place.[2]

The Airway and Swallowing Committee of the American Academy of Otolaryngology- Head and Neck Surgery published tracheotomy recommendations during the COVID-19 pandemic. Possible benefits to tracheotomy include reducing delirium associated with sedation that may facilitate ventilator weaning and shortening ICU stays and duration of mechanical ventilation. The evidence is less clear for reducing risk of tracheal stenosis, ventilator associated pneumonia, or overall mortality with early tracheotomy.

Risks with tracheotomy include possible disease transmission to the procedural team and to those involved with post-tracheotomy care. At this time, there is no clear time point when tracheotomy would be indicated. Time to viral clearance is difficult to predict and there is some concern about test sensitivity. They recommend appropriate PPE with specific concern about lack of data surrounding PPE re-use. Recommendations include avoiding tracheotomy if patient is unstable or has high ventilator dependence; considering tracheotomy if patient’s respiratory status is stable, 2-3 weeks+ after intubation, and ideally after negative COVID19 test; optimizing procedural safety - list of recommendations below.[3]

A group of ENT physicians across the United States and in Singapore submitted safety recommendations for various Head and Neck procedures, including tracheostomy, during the COVID19 pandemic. When tracheostomy is non-emergent, a multidisciplinary team should review the risks/benefits and develop a careful plan. Most should be avoided/delayed beyond 14 days given risk of procedure until the acute infectious period is over. They further recommend consideration when there is a good chance of recovery and when the goal is weaning off the ventilator. They do not recommend early tracheostomy given risk of infection spread (possible higher risk earlier in infection with higher viral load) as well as lack of improved mortality with early tracheostomy (the trial looking at early tracheostomy was not completed in the context of COVID19 infection). Additional specific guidance on performing tracheostomy below.[4]

The Australian and New Zealand Intensive Care Society developed guidelines for care of patients during the COVID-19 pandemic. As it relates to tracheostomy, they recommend limiting aerosol generating procedures. If performed, they recommend a negative pressure room if available, and a single room if not. Further, they recommend airborne PPE precautions.[5]

Guidance published in ENT UK: For emergent airway with unknown COVID19 status if there is a reversible airway obstruction, prefer intubation rather than tracheostomy, avoid high flow oxygen/AIRVO, utilize a skilled anesthetist for intubation, a skilled ENT for tracheostomy and reduce the number of staff exposed. For emergency airway with unknown COVID19 status if irreversible airway obstruction exists, recommend tracheostomy with recommended procedure (below). If elective, test for COVID19 before and discuss appropriateness with ENT and ICU teams prior to tracheostomy.[6] ENT UK gave additional step-by-step guidance regarding open tracheostomy procedure (link in references below).[7]

A correspondence from a hospital in Singapore outlined their OR procedure in COVID19 cases, and for operative airway procedures including tracheostomy their policy was for staff to keep PAPR on throughout the procedure.[8]

There were recommendations from an article out of China with the caveat that these were published in Chinese and we had to use Google translate. They suggested weighing risks/benefits and using level three protection with consideration to lengthening oral or nasal intubation time prior to tracheostomy. After establishing airway, the pressure of the balloon should be kept around 25-30cmH2O with the pressure gauge checked every 6-8 hours. From the abstract posted in English from the same article, they recommend using a heat moisture exchanger and avoiding T piece or tracheostomy mask when patients are weaned from the ventilator.[9]

Lastly, there was a video conference with physicians in Italy sharing experiences that was summarized and translated in a news article. It says:

• "Protective ventilation (require high PEEP, even > 15 cm H20, monitor carefully for possible complications such as subcutaneous emphysema, PNX – tolerate pH up to 7.3 – in contrast to classical ARDS, patients usually have good compliance and can be ventilated without high driving pressure).
• Prone position (18-24 hour duration – fundamental principle of management = extremely effective – require up to 7 rotations – do not trust initial improvement and continue this therapy at least until clear signs of progress with therapy).
• Tracheostomy often within 7 days allows for earlier and safer weaning attempts (high risk of relapse)."[10]

Supporting information:

Recommendations from Parker 2020

[3]

• Decision-making in tracheotomy should take into consideration the surgical and ICU team’s discretion as well as institutional policy.
  Avoid tracheotomy in COVID-19 positive or suspected patients during periods of respiratory instability or heightened ventilator dependence.
• Tracheotomy can be considered in patients with stable pulmonary status but should not take place sooner than 2-3 weeks from intubation and, preferably, with negative COVID-19 testing.
• Adhere to strict donning and doffing procedures based on institutional protocol.
• Limit the number of providers participating in tracheotomy procedure and post-procedure management.
• Perform entire tracheotomy procedure under complete paralysis.
• Rely on cold instrumentation and avoid monopolar electrocautery.
• Advance ETT and cuff safely below the intended tracheotomy site and hold respirations while incising trachea.
• Minimize tracheal suctioning during procedure to reduce aerosolization.
• Choose cuffed, non-fenestrated tracheostomy tube.
• Maintain cuff appropriately inflated post-operatively and attempt to avoid cuff leaks.
• Avoid circuit disconnections and suction via closed circuit.
• Place a heat moister exchanger (HME) with viral filter or a ventilator filter once the tracheotomy tube is disconnected from mechanical ventilation.
• Delay routine post-operative tracheotomy tube changes until COVID-19 testing is negative.”[3]

Recommendations from Givi 2020

[4]

• Select the patients carefully. If the tracheostomy is assessed as difficult because of anatomy, history, comorbidities, or other factors, consider postponing the procedure.
• Consideration may be given to percutaneous dilatational tracheostomy if the patient’s anatomy and proceduralist expertise allow it to be done safely with minimal or no bronchoscopy, endotracheal suctioning, and disruption of the ventilator circuit.
  Provide adequate sedation including paralysis to eliminate the risk of coughing during the procedure. Ventilation should be paused (apnea) at end-expiration when the trachea is entered and any time the ventilation circuit is disconnected.
• Choose a nonfenestrated, cuffed, tracheostomy tube on the smaller side to make the tracheostomy hole smaller overall (Shiley size 6 for both men and women is adequate). Keep the cuff inflated to limit the spread of virus through the upper airway.
• Perform tracheostomy suctioning using a closed suction system with a viral filter.
• Use a heat moisture exchanger device instead of tracheostomy collar during weaning to prevent virus spread or reinfection of patients.
• Avoid changing the tracheostomy tube until viral load is as low as possible.”[4]