Elements of Transmission Risk Reduction
In a tracheostomy procedure, risk reduction of SARS-CoV-2 transmission
can be broken down into three components: preparation, personnel, and
process (Figure 2).
- Preparation . Patients who undergo an elective tracheostomy
should receive pre-operative SARS-CoV-2 testing. In emergent airway
settings however, this is not feasible. Several days before the
procedure, the operating room or ICU coordinator must ensure that a
negative pressure room is available and that appropriate personal
protective equipment will be available for the entire OR staff. Before
the procedure is started, we advocate that a dedicated tracheostomy
time-out should be conducted. The time-out functions as a concise,
standardized briefing between the Otolaryngology and Anesthesia teams
as well as the rest of operative room staff. Key aspects of the case
should be discussed at that moment including operative plan, paralytic
and reversal plans, and expected sequences for holding ventilation or
changing circuits. When the surgical team is close to entering the
airway, there should again be a discussion with the anesthesia team
regarding the expected next steps. A part of the tracheostomy time-out
is focused on intra-operative safety measures (Figure 1, light magenta
background); this portion of the time-out should be repeated when
close to entering the airway.
- Personnel . The surgical team personnel should be proficient
at donning and removing PPE carefully. It is recommended that a
spotter be assigned to ensure that providers are properly wearing PPE
and do not accidently contaminate themselves while removing the PPE.
Only the needed personnel should be present for the tracheostomy.
Teamwork is essential, and open communication must be encouraged
between all staff members during the procedure: surgeons,
anesthesiologists, nursing staff, and surgical technologists.
Personnel must feel comfortable with bringing forward any findings of
error or mistakes. This is expected with any proper safety culture and
climate.
- Process . Both the surgical and anesthesiology teams must take
steps to reduce the aerosolization of respiratory secretions during
the case. One must also ensure that the ventilator does not become
contaminated. Whenever the respiratory circuit is open, ventilation
should be held. This is especially important after the tracheotomy
incision is made. Ventilation should be held for the following
sequence: endotracheal tube (ETT) advancement distally before tracheal
incision, tracheal incision and withdrawal of ETT, tracheostomy tube
insertion and cuff inflation, ventilation tubing attachment and
closing of circuit. If ventilation is needed during this sequence, the
surgical and anesthesiology teams should ensure that the cuff of the
ETT or tracheostomy tube is first inflated. With any circuit changes,
the anesthesia team clamps the ETT before reconnecting the circuit.
Suctioning should be limited once the tracheotomy is made. If a
bronchoscopy is needed after tracheostomy tube placement, we recommend
using a side port and holding ventilation. A two-filter system is
suggested by the Anesthesia Patient Safety Foundation; this involves
using a viral filter at the ETT (or tracheostomy tube) and another at
the expiratory limb of the ventilator circuit to prevent machine
contamination8. Additionally, a filter may be placed
at the inspiratory circuit limb if there is concern that the machine
itself may become contaminated in-between patient use. Permitting
availability, we recommend that viral filters be placed on the
patient’s airway, ETT or tracheostomy tube, as well as both limbs of
the respiratory circuit, inspiratory and expiratory. When
transitioning from the ETT to tracheostomy circuit, the contaminated
ETT viral filter should be discarded and a new filter should be placed
at the tracheostomy tube. Once the patient can be weaned off the
ventilator, an HME-filter should be used rather than leaving the
tracheostomy tube open to trach mask.