Critical Care Guidance for Tracheostomy Care During the COVID-19 Pandemic: A Global, Multidisciplinary Approach

Abstract

Purpose Critical care nurses caring for patients with a tracheostomy are at high risk because of the predilection of SARS-CoV-2 for respiratory and mucosal surfaces. This review identifies patient-centered practices that ensure safety and reduce risk of infection transmission to health care workers during the coronavirus disease 2019 (COVID-19) pandemic. Methods Consensus statements, guidelines, institutional recommendations, and scientific literature on COVID-19 and previous outbreaks were reviewed. A global interdisciplinary team analyzed and prioritized findings via electronic communications and video conferences to develop consensus recommendations. Results Aerosol-generating procedures are commonly performed by nurses and other health care workers, most notably during suctioning, tracheostomy tube changes, and stoma care. Patient repositioning, readjusting circuits, administering nebulized medications, and patient transport also present risks. Standard personal protective equipment includes an N95/FFP3 mask with or without surgical masks, gloves, goggles, and gown when performing aerosol-generating procedures for patients with known or suspected COVID-19. Viral testing of bronchial aspirate via tracheostomy may inform care providers when determining the protective equipment required. The need for protocols to reduce risk of transmission of infection to nurses and other health care workers is evident. Conclusion Critical care nurses and multidisciplinary teams often care for patients with a tracheostomy who are known or suspected to have COVID-19. Appropriate care of these patients relies on safeguarding the health care team. The practices described in this review may greatly reduce risk of infectious transmission.

Tracheostomy Timing and Outcome in Severe COVID-19: The WeanTrach Multicenter Study

“…Several national protocols and international guidelines have published guidance on the management of tracheostomy in COVID-19, despite the scarcity of evidence in the literature [ 16 , 21 ]. During the COVID-19 pandemic, the mean time to tracheostomy has often been longer than usual.…”

“…In COVID-19 cases, the possible complications derived from prolonged endotracheal intubation should be weighed against the risk of viral exposure of hospital staff during aerosol-generating procedures [ 15 ]. The high rate of failed weaning from the ventilator and failed endotracheal extubation in COVID-19 suggests a potential need for early tracheostomy [ 16 ], since it may help shorten the weaning phase and reduce the rate of associated complications [ 4 , 17 ]. Recent guidelines on the management of tracheostomy in COVID-19 recommend using surgical instead of percutaneous techniques to limit aerosol and droplet exposure, although limited data are available on the comparison of these techniques in the COVID-19 population [ 18 , 19 ].…”

Tracheostomy for COVID-19 respiratory failure: timing, ventilatory characteristics, and outcomes

“…Median follow-up time for the cohort was 94 days. Duration Female (%) 23 [36] Race/ethnicity African American (%) 27 [42] Caucasian (%) 26 [41] Asian (%) 2 [3] Other/unknown (%) 9 [14] Body mass index, median (range) 33 VV-ECMO requirement During hospitalization (%) 13 [20] During tracheostomy (%) 11 [11] Sequential Organ Failure Assessment at time of tracheostomy, median (range) Chronic pulmonary disease 21 [33] Congestive heart failure 17 [27] Cerebrovascular disease 12 [19] VV-ECMO, veno-venous extracorporeal membrane oxygenation (n=11). of mechanical ventilation ranged from 20-113 days, with a censored median liberation from mechanical ventilation time of 39.4 days (Figure 1).…”

“…Even a small decrease in need for mechanical ventilation or intensive care per patient could be meaningful during a pandemic with limited critical care resources (4). This must be balanced with increased consumption of personal protective equipment and testing supplies, as well as increased healthcare worker exposure during the procedure itself (41).…”

Surgical Infection Society Guidance for Restoration of Surgical Services during the Coronavirus Disease-2019 Pandemic

“…With much reduced numbers of surgical cases during the surge responses to the pandemic, acute care surgeons changed how and what they communicated regarding the larger numbers of critically ill patients suddenly under their care [23,24], focusing on the provision of critical care and related procedures (e.g., bronchoscopy, percutaneous endoscopic gastrostomy, tracheostomy) that are considered high-risk for viral dissemination [25], and the trauma [26,27] and emergency surgical patients [28] who continued to present. Surgeons of other specialties, who had less to do as the pandemic raged, provided invaluable service to their acute care surgical colleagues [29]; even solid-organ transplantation slowed [30][31][32], in part because of the high prevalence of SARS-CoV-2 amongst listed potential recipients [33].…”