Tracheostomy protocols during COVID-19 outbreak

,


Introduction
The first cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing coronavirus disease (COVID-19), began as only a few cases in rural China and has now grown into a global pandemic.While this virus does not appear to be as deadly as the coronavirus outbreak in 2003 known as SARS, it unfortunately has proven to be much more infectious.SARS-CoV-2 has an incubation period of an estimated 4 days and a relatively slow onset of symptoms, allowing infected persons to unknowingly transmit the virus (1).
Although most cases range from relatively asymptomatic to mild flu-like symptoms, approximately 20-30% of COVID-19 patients require admission to the intensive care unit (ICU) for respiratory support (2).This rapid influx of patients has challenged institutions and medical practitioners alike.In response, many guidelines continue to be updated by the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and individual societies from around the world.
Due to the spread of SARS-CoV-2 through aerosol and fine droplets, medical personnel are in direct danger of occupational exposure while caring for these patients.This is especially true for aerosol-generating airway procedures which can potentially expose everyone in the room (3).A report from the outbreak in Wuhan, China warns that otolaryngologists are exceptionally at risk, citing an event in which 14 medical personnel contracted COVID-19 during an endoscopic pituitary surgery (4).Therefore, the risk posed to otolaryngologists during many commonly performed surgeries cannot be understated.A statement from American Academy of Otolaryngology -Head and Neck Surgery "strongly recommends that all otolaryngologists provide only time-sensitive or emergent care" in order to mitigate this risk (5).Tracheostomies and tracheostomy care, however, play a critical role in the management of COVID-19 patients: electively to provide closed-circuit ventilation in prolonged endotracheal intubation or emergently for airway access.These interventions are necessary to provide adequate care, but they also demand special precautions be taken in order to mitigate occupational risk.
The purpose of this study was to evaluate the current practice guidelines and recommendations in regards to SARS-CoV-2 as they pertain to tracheostomy and provide a collective summary of recommendations.Individual guidelines have been published from groups around the world to guide medical personnel during aerosol-generating procedures, such as a tracheostomy.It is essential that all those potentially involved are aware of these guidelines and implement them when appropriate.

Literature Review and Evidence Collection
A literature review was performed by one author, searching for all published English-language literature reporting on clinical practice guidelines pertaining to tracheostomy in the context of COVID-19.A search strategy was employed with the following search strings: "covid OR covid-19 OR coronavirus" with "tracheostomy OR tracheotomy OR tracheostomy change" in the last 5 years.Grey literature (literature that is not commercially published) was identified by searching the websites of governmental health agencies, professional associations, and other medical societies.Google search engine was used to search for additional information.These searches were supplemented by references of relevant individual articles.Results were limited to articles in the English language.After the completed search, a total list of records was obtained, and duplicates removed.A final list of full text articles was then compiled, and one author independently screened each article.

Discussion
Tracheostomies are a common surgical procedure performed by otolaryngologists in both the emergent and elective setting.Additionally, there may be some expanding indications in the COVID-19 patient population.As COVID-19 patients wean off the ventilator, some may be at high risk for requiring non-invasive ventilation or reintubation.Both instances have been noted to be aerosol-generating events, and should be avoided when possible.Ventilation using a tracheostomy has many potential benefits including providing closed-circuit respiratory support, allowing for decreased sedation, and requiring less intensive nursing care (6).Discussion between intensive care and otolaryngology teams should take place to decide whether tracheostomy is indicated in this patient population.In patients testing positive for COVID-19, this summary of recommendations serves as a guideline along with institutional protocols.

LOCATION
• The operation should be performed in an ICU room or operating room, preferably with negative pressure and a HEPA filtration system.If performed in an ICU room, be aware the width of an ICU bed might limit surgical access.Consider positioning the patient closer to the surgeon prior to beginning the procedure (7,10,11,(13)(14)(15)(16)).• If necessary to move the patient, care should be taken when transporting the patient to the operating room.Designate a team member to remain clear of contact with the patient and interact with the environment.

PERSONNEL
• Reduce team members to only essential staff.Consider one surgeon, one anesthesiologist, and one surgical staff member.Additional team members may remain on standby outside of the room (7-13).• Procedure should be performed by the most experienced staff to maximize safety and efficiency.

Emergency Tracheostomy in COVID-19 positive or unknown patient
In the event of an airway emergency in which endotracheal intubation is unable to be achieved and a tracheostomy is indicated, the guidelines above should be followed.An emphasis should be placed on safety of medical personnel through the proper use of PPE.Reviewal and implementation of these guidelines can limit confusion and unnecessary occupational exposure to staff (7,12,17).

GENERAL PRECAUTIONS
• Patients should be managed as patients with COVID-19 who require oxygenation/hospitalization (7).
• Encourage the patient to perform as much of the cleaning and care as they are comfortable (7).
• Tracheostomy change procedures should be delayed until patient no longer tests positive, if possible (6,7,12).

VENTILATED PATIENTS
• Avoid disconnecting patient circuit from ventilator.If necessary, clamp tubing distal to HME filter prior to disconnecting (8-12, 14, 15).• Use inner cannula if thick secretions or on open system.If used, limit inspection/cleaning of inner cannula (7).• Cuff deflation when weaning from ventilator will result in aerosol generation.Ensure patients are in isolation or in a cohort room with other COVID-19 patients (7).
• Should supplemental oxygenation be needed, a trach collar is preferred due to its protection against droplet spread (7).

Limitations
This study evaluated the current practice guidelines and recommendations for tracheostomy during the SARS-CoV-2 outbreak to provide a collective summary for otolaryngologists in this difficult time.However, we acknowledge the inherent limitations of this study.Although we included all published literature to date, this was limited only to those published before March 31st, 2020.As more is learned about SARS-CoV-2 and more data becomes available, it is possible that the guidelines may change or be altered as a result.Still, this is the most up-to-date collection of clinical guidelines for tracheostomy with respect to the SARS-CoV-2 outbreak available at this time.Further studies are needed to determine the efficacy of these guidelines, and in order to establish recommendations for similar viral epidemics in the future.