BackgroundTracheotomy, through its ability to wean patients off ventilation, can shorten ICU length of stay and in doing so increase ICU bed capacity, crucial for saving lives during the COVID-19 pandemic. To date, there is a paucity of patient selection criteria and prognosticators to facilitate decision-making and enhance precious ICU capacity.MethodsProspective study of COVID-19 patients undergoing tracheotomy (n=12) over a 4-week period (March-April 2020). Association between pre- and post- operative ventilation requirements and outcomes (ICU stay, time to decannulation, and death) were examined.ResultsPatients who sustained FiO2≤50% and PEEP≤8cm H2O in the 24h pre-tracheotomy exhibited a favourable outcome. Those whose requirements remained below these thresholds post-tracheotomy could be safely stepped down after 48h.ConclusionSustained FiO2≤50% and PEEP≤8cm H2O in the 48h post-tracheotomy are strong predictive factors for a good outcome, raising the potential for these patients to be stepped down early, thus increasing ICU capacity.
IntroductionThe COVID-19 pandemic has resulted in an unprecedented need for critical care intervention. Prolonged intubation and mechanical ventilation has resulted in the need for tracheostomy in some patients. The purpose of this international survey was to assess optimal timing, technique and outcome for this intervention.MethodsAn online survey was generated. Otorhinolaryngologists from both the United Kingdom and Abroad were polled with regards to their experience of tracheostomy in COVID-19 positive ventilated patients.ResultsThe survey was completed by 50 respondents from 16 nations. The number of ventilated patients totalled 3403, on average 9.7% required a tracheostomy. This was on average performed on day 14 following intubation. The majority of patients were successfully weaned (mean 7.4 days following tracheostomy).ConclusionThe results of this brief survey suggest that tracheostomy is of benefit in selected patients. There was insufficient data to suggest improved outcomes with either percutaneous versus an open surgical technique.
Background: An increasing number of COVID-19 patients worldwide will probably need tracheostomy in an emergency or at the recovering stage of COVID-19. We explored the safe and effective management of tracheostomy in COVID-19 patients, to benefit patients and protect healthcare workers at the same time.Methods: We retrospectively analyzed 11 hospitalized COVID-19 patients undergoing tracheostomy. Clinical features of patients, ventilator withdrawal after tracheostomy, surgical complications and nosocomial infection of the healthcare workers associated with the tracheostomy were analyzed.Results: All the tracheostomy of 11 cases (100%) were performed successfully, including percutaneous tracheostomy of 6 cases (54.5%) and conventional open tracheostomy of 5 cases (45.5%). No severe postoperative complications occurred, and no healthcare workers associated with the tracheostomy are confirmed to be infected by SARS-CoV-2. Conclusion: Comprehensive evaluation before tracheostomy, optimized procedures during tracheostomy, and special care after tracheostomy can make the tracheostomy safe and beneficial in COVID-19 patients.
Tracheostomy procedures have a high risk of aerosol generation. Airway providers have reflected on ways to mitigate the SARS-CoV-2 transmission risks when approaching a surgical airway. To standardize institutional safety measures with tracheostomy, we advocate using a dedicated tracheostomy time-out applicable to all patients including those suspected of having COVID-19. The aim of the tracheostomy time-out is to reduce preventable errors that may increase the risk of transmission of SARS-CoV-2.
Background This study describes a novel approach in reducing SARS-CoV-2 transmission during tracheostomy. Methods Five patients underwent tracheostomy between 01 April 2020 and 17 April 2020. A clear and sterile plastic drape was used as an additional physical barrier against droplets and aerosols. Operative diagnosis; droplet count and distribution on plastic sheet and face shields were documented. Results Tracheostomy was performed for patients with carcinoma of tonsil (n=2) and nasopharynx (n=1), and aspiration pneumonia (n=2). Droplet contamination was noted on all plastic sheets (n=5). Droplet contamination was most severe over the central surface at 91.5% (86.7%-100.0%) followed by the left and right lateral surfaces at 5.2% (6.7%-10.0%) and 3.3% (6.7%-10.0%) respectively. No droplet contamination was noted on all face shields. Conclusion Plastic drapes can help reduce viral transmission to health care providers during tracheostomy. Face shields may be spared which in turn helps to conserve resources during the COVID-19 pandemic.
As an aerosol and droplets generating procedure, tracheostomy increases contamination risks for health workers in the coronavirus disease context. To preserve the health care system capacity and to limit virus cross-transmission, protecting caregivers against coronavirus infection is of critical importance. We report the use of external fixator equipment to set up a physical interface between the patient’s neck and the caregiver performing a tracheostomy in COVID-19 patients. Once the metal frame set in place, it is wrapped with a single-use clear and sterile cover for surgical C-arm. This installation is simple, easy and fast to achieve and can be carried out with inexpensive material available in every hospital. This physical interface is an additional safety measure that prevents the direct projection of secretions or droplets. It should, of course, only be considered as a complement to strict compliance with barrier precautions and personal protective equipment.
Brett A. Miles DDS MD1, Bradley Schiff MD2, Ian Ganly MD MS PhD3, Thomas Ow MD MS2, Erik Cohen MD5, Eric Genden MD MPH1, Bruce Culliney MD1, Bhoomi Mehrotra MD6, Steven Savona MD6, Richard J. Wong MD3, Missak Haigentz MD5, Salvatore Caruana MD7, Babak Givi MD8, Kepal Patel MD8, Kenneth Hu MD81Icahn School of Medicine at Mount Sinai, New York, NY2Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY3Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York,4Cancer Institute at St. Francis Hospital, New York, NY5Morristown Medical Center, Leonard B. Kahn Head and Neck Cancer Institute, Morristown, NJ6Northwell Cancer Institute, Monter Cancer Center, Lake Success, NY7Columbia University, New York, NY8NYU Langone Health, New York, NY
Background: During the SARS-CoV-2 pandemic, tracheostomy may be required for COVID-19 patients requiring long term ventilation in addition to other conditions such as airway compromise from head and neck cancer. As an aerosol generating procedure, tracheostomy increases healthcare worker exposure to COVID-19 infection. Performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care.Methods: A multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. Modifications to support clinical-decision making in the context of COVID-19 were derived by consensus and available evidence. Results: Modified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of COVID-19 are presented. Discussion: During the various phases of the COVID-19 pandemic, clinicians must carefully consider the indications, procedural precautions, and post-operative care for tracheostomies. We present guidelines to mitigate risk to healthcare workers while preserving the quality of care.
Background: The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) is spread through aerosol and fine droplets, and poses many challenges to medical practitioners. Otolaryngologists are at an exceptionally high-risk, due to common aerosol-generating procedures such as tracheostomy. The purpose of this study was to evaluate clinical guidelines for tracheostomy in reference to SARS-CoV-2 and provide a collective summary of recommendations.Methods: Literature review was performed. Articles reporting clinical practice guidelines for tracheostomy in the context of SARS-CoV-2 were included.Results: Tracheostomies are a common surgical procedure performed by otolaryngologists. There may be expanding indications in the COVID-19 patient population. Ventilation using a tracheostomy has many potential benefits and a summary of recommendations for tracheostomy (elective or emergent) and tracheostomy management in COVID-19 positive patients are detailed within this article. Conclusions: In patients testing positive for COVID-19, this summary of recommendations serves as a guideline along with institutional protocols.
As the novel coronavirus (Covid-19) globally spreads, the Covid-19 pandemic is straining healthcare workers worldwide. In hospitalized patients with severe Covid-19, endotracheal intubation is one of the most common and indispensable life-saving interventions. For patients in need of long-term endotracheal intubation, tracheostomy may be considered. Some patients with unfavorable neck anatomy, such as short neck, enlarged thyroid, and neck cicatricial contracture, are not suitable for percutaneous tracheostomy, a minimally invasive method1. In these circumstances, conventional open tracheostomy is the primary option for surgeons. However, it is one of the most hazardous procedures, because the direct airway opening and the coughing of patients causes aerosolization of the virus potentially exposing healthcare workers2. To prevent healthcare-associated infections, we are willing to share our modified tracheostomy procedures with other surgeons worldwide.Detailed optimized procedures are illustrated in Figure 1. There are three distinct steps to protect healthcare workers from the virus spreading in the surgical environment during tracheostomy. First, all procedures should under general anesthesia, with deprivation of spontaneous respiration and application of muscle relaxants (Figure 1A), regardless of whether patients had spontaneous breathing or not. This step is to restrain the cough reflex caused by tracheal stimulation. Second, after the cervical trachea is exposed and immediately before an incision is made in the trachea, the endotracheal tube (ETT) is inserted deeper, positioned with the tip close to carina of the trachea (Figure 1B). This step would prevent the ETT cuff leak due to an accidental damage to the cuff when making the tracheal opening. Third, when the opening is complete, brief interruption of the ventilator is essential. Then the ETT is pulled out, and subsequently the tracheostomy tube quickly inserted into the opening (Figure 1C). Almost simultaneously, the tracheostomy tube cuff is inflated and the tube rapidly connected to the ventilator, with immediate resumption of the ventilator (Figure 1D). Suspension of ventilation support was usually not more than 15 seconds, with satisfactory oxygen saturation.This report describes the optimized procedures in tracheostomy for Covid-19 patients. The three major modifications can avoid the aerosolization of secretions, and protect healthcare workers. Thus, we strongly recommend the modified procedures to be a choice for all surgeons when tracheostomy is considered for Covid-19 patients. It is important to protect healthcare workers from coronavirus during the intraoperative period for their own health and for preservation of the healthcare workforce.Figure
Background: This case highlights challenges in the assessment and management of the “difficult airway” patient in the SARS-CoV-2 (COVID-19) pandemic era. Methods: A 60-year-old male with history of recent TORS resection, free flap reconstruction and tracheostomy for p16+ squamous cell carcinoma presented with stridor and dyspnea one month after decannulation. Careful planning by a multidisciplinary team allowed for appropriate staffing and personal protective equipment, preparations for emergency airway management, evaluation via nasopharyngolaryngoscopy, and COVID testing. The patient was found to be COVID negative and underwent imaging which revealed new pulmonary nodules and a tracheal lesion. Results: The patient was safely transorally intubated in the operating room. The tracheal lesion was removed endoscopically and tracheostomy was avoided. Conclusions: This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other “difficult airway” patients during the COVID-19 epidemic.
Dear Editor,At 29th of February the World Health Organization (WHO) reported 85403 confirmed globally confirmed case of COVID-19 . COVID-19 is dramatically increasing in Italy, the last report from the ministry of health on the 9th of march reported the presence of 9172 confirmed cases and 733 patients in intensive care unit (ICU) . We agree with Chan et al that physicians managing airway procedures are at particularly high risk to contract the COVID-19 infection . We support the authors that claimed for a full protective wearing including N95 respirator, gown, cap, eye protection, and gloves, during aerosol generating procedures (AGP) . However, we’d like to focus the attention on the tracheostomy procedures in COVID-19 patients since otolaryngologists, anesthesiologists and intensive care physicians are at high risk of contracting the infection during tracheostomy . Tracheostomy is required in case of prolonged mechanical ventilation and intensive care unit (ICU) stay . Surgical tracheostomy is an AGP associated with an increased risk severe acute respiratory distress (SARS) infection . Strict adherence to infection control guidelines in SARS is mandatory in performing tracheostomy in ICU or operating room .Few years ago, we proposed the double lumen endotracheal tube (DLET) for percutaneous tracheostomy in critically ill patients . DLET was equipped with an upper channel that allows passage of a bronchoscope during the percutaneous tracheostomy and with a lower channel exclusively dedicated to patient ventilation . The lower channel is equipped with a distal cuff positioned just above the carina that may allow a safe mechanical ventilation by keeping stable gas-exchange and limiting the spread of aerosol during the procedure . During the percutaneous procedure, the puncture of the anterior tracheal wall, Seldinger insertion, dilatation, and cannula positioning were all performed with the DLET correctly placed in the trachea. The DLET was removed at the end of the tracheostomy when the cannula is inserted and correctly positioned with the FFB .Surgical tracheostomy in COVID-19 patients should be done with a close collaboration between otolaryngologists, preforming the surgical procedure, and anesthesiologists or intensive care physicians managing the general anesthesia and the airway.When a surgical tracheostomy is done under general anesthesia, just before the surgeon makes the tracheal stoma, the endotracheal tube is withdrawn, so that the cuff of the tube is not in the surgical field . But when the surgeon makes the tracheal incision, ventilation is lost and the surgeon has to be quick enough to create the soma and insert the tracheostomy tube in a short time . During this procedure a large spread of aerosol may occur. To avoid the aerosol, we suggest to push down the endotracheal tube beyond the site chosen for the tracheal stoma at the beginning of the procedure. The endotracheal tube should reach the tracheal carina so the cuff is surely distal to the tracheostomy site. By checking the airway pressure and the end-tidal CO2, on the mechanical ventilator we can realize if the endotracheal tube is still in the lower tract of the trachea or in the endobronchial tract. Our previous experience with the DLET demonstrated that the endotracheal tube and the tracheal cannula can be simultaneously inserted inside the trachea . According to this, pushing down the endotracheal tube and cuffed it at the level of the carina may avoid the spread of aerosol and, then, may add an extra security for the medical staff during a procedure at high risk of generating aerosol.ReferencesCoronavirus disease 2019 (COVID-19) Situation Report – 40.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200229-sitrep-40-covid-19.pdfItalian Minister of Health. 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