Airway Management and Tracheotomy
Patients presenting with acute airway obstruction should be managed as
if they are COVID-19 positive as diagnostic testing is not feasible in
an emergent clinical situation. All clinical personnel should wear
enhanced PPE. The use of high-flow nasal cannula is contraindicated in
patients with unknown, suspected, or positive COVID-19 status due to
high risk of virus aerosolization.24,25 Extreme
caution should be utilized when performing awake fiberoptic intubation
due to instrumentation of the nasopharynx and the potential for aerosol
generation, however intubation via any means is preferable to emergent
tracheotomy. A high-efficiency hydrophobic filter should be placed
between the face mask and breathing circuit or reservoir bag, the
patient should be pre-oxygenation, and rapid sequence intubation
techniques should be used to minimize viral particle
aerosolization.25 When available, video laryngoscopes
should be used to maximize intubation success rate and disposable
laryngoscopes to minimize infectious spread.24,25
To minimize intubation time and exposure to the oropharynx, the 2015
Difficult Airway Society Guidelines26 should be
followed with the exception that intubation should be performed only by
the most senior practitioner available using enhanced PPE.
Second-generation laryngeal mask airways should be used, if indicated,
as these provide an improved seal compared to first-generation
devices.25 If a “can’t intubate, can’t oxygenate
scenario” is declared, emergent extra-corporeal membrane oxygenation
(ECMO) may be preferred over emergent surgical airway to reduce the risk
of virus aerosolization, though this may not be readily available.
Indications for primary emergent tracheotomy include obstructive
laryngeal lesions, severe trismus precluding the ability to perform
direct laryngoscopy, massive oropharyngeal bleeding, other conditions
precluding intubation, and other emergent conditions anticipated to
require long-term means to secure the airway where ECMO would not be
appropriate.
When caring for a patient with unknown, suspected, or positive COVID-19
status, clinical staff should be limited to essential personnel (i.e.
senior attending anesthesiologist, experienced attending surgeon, senior
surgical resident/clinical fellow, surgical technologist, and registered
nurse) fully equipped with enhanced PPE in a negative pressure operating
room with HEPA filtration 24. Technical pearls to
consider when performing tracheotomy in a patient with unknown,
suspected, or positive COVID-19 status include avoiding electrocautery
usage to minimize aerosolization of viral particles, advancing the
endotracheal tube prior to incising the anterior tracheal wall to
prevent cuff rupture and maintain a closed circuit, and holding
ventilation until placement of cuffed non-fenestrated tracheotomy tube
is confirmed with end-tidal CO2 and lung sound auscultation. Further
details regarding safe tracheotomy have been outlined by Wei et
al. and Harrison et al .27,28
Postoperatively, the tracheotomy tube should not be changed or
manipulated until the COVID-19 status has been addressed with infectious
disease. Routine tracheotomy tube care as delineated by ENT-UK should
includes maintenance of a closed circuit, exclusively in-line
suctioning, frequent cuff leak checks, and avoiding
humidification.28 At this time elective tracheotomy is
contraindicated for patients with unknown COVID-19 status and should
only be performed once COVID-19 status has been determined with
appropriate quarantine and the merits of tracheotomy are discussed as it
is a high-risk, aerosol-generating procedure.29Likewise, percutaneous dilation tracheotomy is contraindicated in
patients with unknown, suspected, or positive COVID-19 status. This
contraindication is due to the need for simultaneous bronchoscopy
(itself a high-risk procedure), and longer period of exposure to an open
tracheostomy site during serial dilation resulting in increased risk of
virus aerosolization.
There is limited information regarding management of tracheotomy
patients no longer requiring ventilator support in the setting of
COVID-19. The use of filters over the open tracheotomy, such as
humidification-moisture exchangers (HMEs) may be beneficial and reduce
aerosolization. Alternatively, Chan et al. describe using a
closed circuit system identical to that used for a mechanical ventilator
for all tracheotomy patients, including those not requiring ventilator
support.4 Ultimately, the choice of device may be
dependent on the COVID-19 status of the individual patient and the
ability to provide appropriate isolation to minimize the spread of
aerosols.