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