Perioperative Considerations for Tracheostomies in the Era of COVID-19

Abstract

AGPs = aerosol-generating procedures; BiPAP = bilevel positive airway pressure; CDC = Centers for Disease Control and Prevention; COVID-19 = coronavirus disease 2019; CPAP = continuous positive airway pressure; ETT = endotracheal tube; Fio 2 = fraction of inspired oxygen; HCWs = health care workers; HEPA = high-efficiency particulate air; ICU = intensive care unit; INR = international normalized ratio; MERS = Middle East Respiratory Syndrome; OR = operating room; Pao 2 = partial pressure of oxygen; PAPRs = powered air-purifying respirators; PCR = polymerase chain reaction; PEEP = positive end-expiratory pressure; PPE = personal protective equipment; SARS = severe acute respiratory syndrome; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; VTE = venous thromboembolism; WHO = World Health Organization C oronavirus infections in humans can vary from mild diseases, such as the common cold, to severe end-organ dysfunction such as acute respiratory distress syndrome. 1 The morbidity, mortality, and blistering pace of transmission, of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)The morbidity, mortality, and blistering pace of transmission of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented worldwide health crisis. Coronavirus disease 2019 (COVID-19), the disease produced by SARS-CoV-2 infection, is remarkable for persistent, severe respiratory failure requiring mechanical ventilation that places considerable strain on critical care resources. Because recovery from COVID-19-associated respiratory failure can be prolonged, tracheostomy may facilitate patient management and optimize the use of mechanical ventilators. Several important considerations apply to plan tracheostomies for COVID-19-infected patients. After performing a literature review of tracheostomies during the severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, we synthesized important learning points from these experiences and suggested an approach for perioperative teams involved in these procedures during the COVID-19 pandemic. Multidisciplinary teams should be involved in decisions regarding timing and appropriateness of the procedure. As the theoretical risk of disease transmission is increased during aerosol-generating procedures (AGPs), stringent infectious precautions are warranted. Personal protective equipment (PPE) should be available and worn by all personnel present during tracheostomy. The number of people in the room should be limited to those absolutely necessary. Using the most experienced available operators will minimize the total time that staff is exposed to an infectious aerosolized environment. An approach that secures the airway in the safest and quickest manner will minimize the time any part of the airway is open to the environment. Deep neuromuscular blockade (train-of-four ratio = 0) will facilitate surgical exposure and prevent aerosolization due to patient movement or coughing. For percutaneous tracheost...

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“…It is recommended to start the HEPA filter up half an hour before the surgical procedure and leave running at least a half hour between the two procedures. 13 …”

Controversies in airway management of COVID-19 patients: updated information and international expert consensus recommendations

“…It is recommended to use the highest level of PPE available in the management of patients with COVID-19, especially during performance of high-risk AGPs such as tracheal intubation, extubation, or tracheostomy. 1 , 12 , 17 , 37 Fit testing and supervised donning and doffing of PPE remain critical steps in the avoidance of cross infection of healthcare workers. It is crucial to note that PPE must be a part of a comprehensive infection control strategy in order to be effective.…”

Pragmatic Recommendations for Safety while Caring for Hospitalized Patients with Coronavirus Disease 2019 (COVID-19) in Low- and Middle-Income Countries

“…None of the articles specifically discussed limiting the number or duration of patient care activities by healthcare workers. [56][57][58][59][60][61][62][63][64][65] One study noted that the median estimated time of overall exposure to the patient was 120 minutes in healthcare workers who became infected with COVID-19 compared with 25 minutes in those who did not become infected. 61 An article that provided recommendations on precautions, indications, prioritization, and protection for patients and healthcare workers involved in cardiovascular imaging procedures posed the important question "will undertaking the study (procedure) substantially change patient management or will it be lifesaving?"…”

“…Another article focused on recommendations for tracheostomy noted the importance of minimizing the number of staff who enter a room to conduct a procedure or provide patient care at any point in time. 65 Staff who enter the room of a patient with known or suspected COVID-19 should adhere to standard precautions and use a respirator or face mask, gown, gloves, and eye protection. 13 Availability, feasibility, affordability, and safety.…”