Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline

Abstract

Purpose Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. Methods This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. Results Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. Conclusion COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.

Tracheostomy, ventilatory wean, and decannulation in COVID-19 patients

“…If appropriate, a one-way valve was then trialled. To proceed with decannulation, patients had to tolerate 24 h with their cuff deflated and 12 h with a one way valve, have minimal/ no tracheal suctioning requirements and ideally be able to independently cough secretions to their mouth without any evidence of upper airway obstruction, bronchopulmonary infection, or high oxygen requirements [32]. All patients with suspected hyperinflammatory COVID-19 underwent joint evaluation with our lung inflammation service for consideration of immunomodulation therapy with methylprednisolone [33].…”

Guidelines for tracheostomy in COVID-19 pandemic

“…He should be able to independently cough out secretions without any evidence of any bronchopulmonary infection, upper airway obstruction or high oxygen requirements. 34 Patients with suspected hyper-inflammatory conditions and lung inflammation signs should be considered for immunomodulation therapy with methylprednisolone. 35…”

Consideraciones clínicas para fonoaudiólogos en el tratamiento de personas con COVID-19 y traqueostomía. Parte I: Deglución

“…Aproximadamente 70% de las personas con COVID-19 que ingresan a Unidades de Cuidados Intensivos (UCI) requieren de ventilación mecánica, permaneciendo conectados a esta por una media de 13 días, con un rango intercuartilico de 7 a 19 días (Rovira et al, 2020). Bajo esta condición, un número significativo de personas que cursan con COVID-19 requieren de una traqueostomía (TQT) en el curso de su evolución clínica (Takhar et al, 2020).…”

“…Dicha situación ha requerido, muchas veces, que los procedimientos vinculados al manejo y tratamiento de personas con TQT sean realizados tempranamente. La necesidad de un manejo temprano de la TQT, implica ciertas consideraciones especiales para la atención de personas con COVID-19 y TQT que incluyen; evitar la desconexión del circuito, utilizar sistemas de aspiración cerrada, mantener el cuff insuflado, utilizar sistemas con puerto de aspiración subglótica cuando sea posible y minimizar la realización de PGA (Rovira et al, 2020); disminuyendo con aquello la propagación del virus a través del flujo espiratorio de la persona (Chan et al, 2020). Consideraciones que no exentan al EdS del correcto uso de los elementos de protección personal (EPP) para todo PGA (Ferioli et al, 2020;Rovira et al, 2020).…”

“…El objetivo de este artículo es, por tanto, revisar nuestra experiencia obtenida, proporcionar la evidencia y la justificación que soporta nuestro abordaje, y, en última instancia, entregar recomendaciones clínicas que permitan optimizar la atención de las personas con TQT afectadas por COVID-19. Para lo anterior se ha utilizado una metodología similar a la declarada en otros artículos que plantean recomendaciones para personas con COVID-19 y que adaptan su proceder en concordancia con la urgencia que es requerida la información (Kimura et al, 2020;Miles et al, 2020;Rovira et al, 2020). Así, se ha desarrollado una revisión narrativa de las publicaciones existentes a la fecha, con un análisis pragmático de la evidencia disponible para el manejo seguro y adecuado de la deglución en esta población.…”