Aerosol Exposure During Surgical Tracheotomy in SARS-CoV-2 Positive Patients

Abstract

the novel coronavirus SARS-CoV-2 has been spreading worldwide. Since the main route of infection with SARS-CoV-2 is probably via contact with virus-containing droplets of the exhaled air, any method of securing the airway is of extremely high risk for the health care professionals involved. We evaluated the aerosol exposure to the interventional team during a tracheotomy in a semiquantitative fashion. In addition, we present novel protective measures. Patients and Methods: To visualize the air movements occurring during a tracheotomy, we used a breathing simulator filled with artificial fog. Normal breathing and coughing were simulated under surgery. The speed of aerosol propagation and particle density in the direct visual field of the surgeon were evaluated. Results: La-Laminar air flow (LAF) in the OR reduced significantly the aerosol exposure during tracheostomy. Only 4.8 AE 3.4% of the aerosol was in contact with the surgeon. Without LAF, however, the aerosol density in the inspiratory area of the surgeon is 10 times higher (47.9 AE 10.8%, P < 0.01). Coughing through the opened trachea exposed the surgeon within 400 ms with 76.0 AE 8.0% of the aerosol-independent of the function of the LAF. Only when a blocked tube was inserted into the airway, no aerosol leakage could be detected. Discussion: Coughing and expiration during a surgical tracheotomy expose the surgical team considerably to airway aerosols. This is potentially associated with an increased risk for employees being infected by airborne-transmitted pathogens. Laminar airflow in an operating room leads to a significant reduction in the aerosol exposure of the surgeon and is therefore preferable to a bedside tracheotomy in terms of infection prevention. Ideal protection of medical staff is achieved when the procedure is performed under endotracheal intubation and muscle relaxation.

Inanimate surface contamination of SARS-CoV-2 during midfacial fracture repair in asymptomatic COVID-19 patients

“… [1] The transmission risk is assumedly increased because cervicofacial mucosa and/or the airway contain high viral loads in the upper aerodigestive tract. 15 , 16 , 17 A Brazilian series showed an infection rate of 75% (15 of 20) among front-line CMF surgeons during April and June 2020, and the “post-COVID-19 syndrome” or “long COVID” persisted up to 5 months. [18] Experimental data, however, discarded the spread risk during several head and neck procedures, such as tracheostomy [16] , craniotomy/craniostomy 9 , nasogastric tube insertion, swallowing testing in dysphagia patients (including endoscopy and fluoroscopy), upper airway suctioning, endoscopic sinus surgery (ESS), cautery, and nasendoscopy [19] , if standard PPEs are used.…”

Surgical tracheostomy in a cohort of COVID-19 patients

“…Tracheostomy is a common procedure in critically ill patients who require prolonged mechanical ventilation and cannot be extubated. In COVID-19 patients, the optimal time point for tracheostomy is matter of considerable debate, mainly because of the high risk for virus transmission during the procedure [2,21,38].…”

“…fore potentially increase the availability of ICU beds [14,18]. However, in COVID-19 patients, tracheostomy itself and the optimal time point is a matter of considerable debate, mainly because of the increased risk for contamination of the medical staffduring the procedure [2,21]. The American Academy of Otolaryngology-Head and Neck Surgery suggests delaying tracheostomy in these patients for as long as possible [9].…”

The role of airborne particles and environmental considerations in the transmission of SARS-CoV-2

“…The SARS-CoV-2 in dentistry and otolaryngology is found to be associated with the aerosol produced by mechanical oral transmission or coughing ( Becker et al, 2020 , Ralli et al, 2020 ). The airway operation (non-invasive positive, tracheal intubation and extubation, tracheostomy) during surgery will also produce the aerosols containing SARS-CoV-2 ( Loth et al, 2020 , Dhillon et al, 2021 ). The aerosols may also be produced when the anesthesiologist assists with airway management (e.g., mask ventilation, chest cavity) and CPR ( Wong et al, 2020c ).…”