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\begin{document}

\title{Tracheostomy protocols during COVID-19 outbreak}



\author[1]{Cameron P. Heyd et al.}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Background:} The novel coronavirus, severe acute respiratory
syndrome coronavirus 2 (SARS-Cov-2) is spread through aerosol and fine
droplets, and poses many challenges to medical practitioners.
Otolaryngologists are at an exceptionally high-risk, due to common
aerosol-generating procedures such as tracheostomy. The purpose of this
study was to evaluate clinical guidelines for tracheostomy in reference
to SARS-CoV-2 and provide a collective summary of recommendations.

\textbf{Methods:} Literature review was performed. Articles reporting
clinical practice guidelines for tracheostomy in the context of
SARS-CoV-2 were included.

\textbf{Results:} Tracheostomies are a common surgical procedure
performed by otolaryngologists. There may be expanding indications in
the COVID-19 patient population. Ventilation using a tracheostomy has
many potential benefits and a summary of recommendations for
tracheostomy (elective or emergent) and tracheostomy management in
COVID-19 positive patients are detailed within this article.

\textbf{Conclusions:} In patients testing positive for COVID-19, this
summary of recommendations serves as a guideline along with
institutional protocols.%
\end{abstract}%



\sloppy


\textbf{Authors and affiliations}

\par\null



\textbf{Introduction}

The first cases of severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2), the virus causing coronavirus disease (COVID-19), began as
only a few cases in rural China and has now grown into a global
pandemic. While this virus does not appear to be as deadly as the
coronavirus outbreak in 2003 known as SARS, it unfortunately has proven
to be much more infectious. SARS-CoV-2 has an incubation period of an
estimated 4 days and a relatively slow onset of symptoms, allowing
infected persons to unknowingly transmit the virus (1).

Although most cases range from relatively asymptomatic to mild flu-like
symptoms, approximately 20-30\% of COVID-19 patients require admission
to the intensive care unit (ICU) for respiratory support (2). This rapid
influx of patients has challenged institutions and medical practitioners
alike. In response, many guidelines continue to be updated by the
Centers for Disease Control and Prevention (CDC), World Health
Organization (WHO), and individual societies from around the world.

Due to the spread of SARS-CoV-2 through aerosol and fine droplets,
medical personnel are in direct danger of occupational exposure while
caring for these patients. This is especially true for
aerosol-generating airway procedures which can potentially expose
everyone in the room (3). A report from the outbreak in Wuhan, China
warns that otolaryngologists are exceptionally at risk, citing an event
in which 14 medical personnel contracted COVID-19 during an endoscopic
pituitary surgery (4). Therefore, the risk posed to otolaryngologists
during many commonly performed surgeries cannot be understated. A
statement from American Academy of Otolaryngology -- Head and Neck
Surgery ``strongly recommends that all otolaryngologists provide only
time-sensitive or emergent care'' in order to mitigate this risk (5).
Tracheostomies and tracheostomy care, however, play a critical role in
the management of COVID-19 patients: electively to provide
closed-circuit ventilation in prolonged endotracheal intubation or
emergently for airway access. These interventions are necessary to
provide adequate care, but they also demand special precautions be taken
in order to mitigate occupational risk.

The purpose of this study was to evaluate the current practice
guidelines and recommendations in regards to SARS-CoV-2 as they pertain
to tracheostomy and provide a collective summary of recommendations.
Individual guidelines have been published from groups around the world
to guide medical personnel during aerosol-generating procedures, such as
a tracheostomy. It is essential that all those potentially involved are
aware of these guidelines and implement them when appropriate.

\textbf{Methods}

\emph{Literature Review and Evidence Collection}

A literature review was performed by one author, searching for all
published English-language literature reporting on clinical practice
guidelines pertaining to tracheostomy in the context of COVID-19. A
search strategy was employed with the following search strings: ``covid
OR covid-19 OR coronavirus'' with ``tracheostomy OR tracheotomy OR
tracheostomy change'' in the last 5 years. Grey literature (literature
that is not commercially published) was identified by searching the
websites of governmental health agencies, professional associations, and
other medical societies. Google search engine was used to search for
additional information. These searches were supplemented by references
of relevant individual articles. Results were limited to articles in the
English language. After the completed search, a total list of records
was obtained, and duplicates removed. A final list of full text articles
was then compiled, and one author independently screened each article.

\textbf{Discussion}

Tracheostomies are a common surgical procedure performed by
otolaryngologists in both the emergent and elective setting.
Additionally, there may be some expanding indications in the COVID-19
patient population. As COVID-19 patients wean off the ventilator, some
may be at high risk for requiring non-invasive ventilation or
reintubation. Both instances have been noted to be aerosol-generating
events, and should be avoided when possible. Ventilation using a
tracheostomy has many potential benefits including providing
closed-circuit respiratory support, allowing for decreased sedation, and
requiring less intensive nursing care (6). Discussion between intensive
care and otolaryngology teams should take place to decide whether
tracheostomy is indicated in this patient population. In patients
testing positive for COVID-19, this summary of recommendations serves as
a guideline along with institutional protocols.

\textbf{Elective Tracheostomy in COVID-19 positive patients}

GENERAL PRECAUTIONS

\begin{itemize}
\tightlist
\item
  Allow adequate time for education and rehearsal with staff prior to
  donning necessary PPE, as N95 masks can make communication difficult.
  This will ensure all involved parties are adequately informed and
  operate smoothly (7-14).
\item
  Tracheostomy should be avoided in patients with respiratory
  instability or heavy ventilator dependence (6).
\item
  If resources allow, test all tracheostomy patients for COVID-19 within
  48 hours prior to surgery (7, 8, 10, 12-14).
\item
  COVID-19 positive patients should postpone elective cases until
  testing negative, if possible (7-16).
\item
  Airborne precautions should be followed by all team members that are
  present (7-16).
\end{itemize}

LOCATION

\begin{itemize}
\tightlist
\item
  The operation should be performed in an ICU room or operating room,
  preferably with negative pressure and a HEPA filtration system. If
  performed in an ICU room, be aware the width of an ICU bed might limit
  surgical access. Consider positioning the patient closer to the
  surgeon prior to beginning the procedure (7, 10, 11, 13-16).
\item
  If necessary to move the patient, care should be taken when
  transporting the patient to the operating room. Designate a team
  member to remain clear of contact with the patient and interact with
  the environment.
\end{itemize}

PERSONNEL

\begin{itemize}
\tightlist
\item
  Reduce team members to only essential staff. Consider one surgeon, one
  anesthesiologist, and one surgical staff member. Additional team
  members may remain on standby outside of the room (7-13).
\item
  Procedure should be performed by the most experienced staff to
  maximize safety and efficiency. Trainees only to be present if no
  attendings available (7-12, 16).
\item
  Consider forming a ``traveling trach team'' to limit inexperienced
  staff during COVID-19 positive procedures (7, 10, 13).
\end{itemize}

EQUIPMENT

\begin{itemize}
\tightlist
\item
  All personnel should be equipped with the proper PPE, including an N95
  mask or purified air purifying respirator (PAPR) device, eye goggles,
  transparent full-face shield, gown, and double gloves (7-16).
\item
  PPE equipment should be readily available in the area where COVID-19
  positive patients are managed (7-16).
\item
  Surgical tracheotomy tray (17).
\item
  Cuffed tracheostomy set (7-12).
\item
  Heat and moisture exchanger (HME) device with viral filter (7-16).
\item
  Closed suction system (7, 8, 10-16).
\end{itemize}

INTRAOPERATIVE TECHNIQUES

\begin{itemize}
\tightlist
\item
  Limit use of electrical cautery (17).
\item
  Maintain adequate preoxygenation (100\%) for 5 minutes (8-11, 13, 16).
\item
  Establish complete paralysis using neuromuscular blockade to prevent
  coughing and aerosol dispersion (3, 5, 6, 10, 13, 14).
\item
  Hold ventilation prior to puncturing airway (7, 12).
\item
  Once tracheostomy placement is confirmed, connect patient to
  ventilator with HME/viral filter (8-11, 13-16).
\item
  Suture the tube to the skin and strap separately (17).
\item
  After removing endotracheal tube, place facemask on patient to protect
  against dispersion should the patient cough (14).
\item
  Check for proper inflation and monitor any evidence of cuff leaks (6,
  7, 12, 15).
\item
  Doffing of PPE and disposal of tools according to institutional
  protocol (6-17).
\end{itemize}

\textbf{Emergency Tracheostomy in COVID-19 positive or unknown patient}

In the event of an airway emergency in which endotracheal intubation is
unable to be achieved and a tracheostomy is indicated, the guidelines
above should be followed. An emphasis should be placed on safety of
medical personnel through the proper use of PPE. Reviewal and
implementation of these guidelines can limit confusion and unnecessary
occupational exposure to staff (7, 12, 17).

\textbf{Tracheostomy management in COVID-19 positive patients}

GENERAL PRECAUTIONS

\begin{itemize}
\tightlist
\item
  Patients should be managed as patients with COVID-19 who require
  oxygenation/hospitalization (7).
\item
  Encourage the patient to perform as much of the cleaning and care as
  they are comfortable (7).
\item
  Staff caring for this patient set should be properly educated on
  COVID-19 airway management (such as using closed suctioning, cannula
  care), as these are high-risk (to staff) scenario (7, 12).
\item
  PPE and airborne/droplet precautions should be followed according to
  institutional protocol (6-17).
\item
  Tracheostomy change procedures should be delayed until patient no
  longer tests positive, if possible (6, 7, 12).
\end{itemize}

VENTILATED PATIENTS

\begin{itemize}
\tightlist
\item
  Avoid disconnecting patient circuit from ventilator. If necessary,
  clamp tubing distal to HME filter prior to disconnecting (8-12, 14,
  15).
\item
  Use inner cannula if thick secretions or on open system. If used,
  limit inspection/cleaning of inner cannula (7).
\item
  Cuff deflation when weaning from ventilator will result in aerosol
  generation. Ensure patients are in isolation or in a cohort room with
  other COVID-19 patients (7).
\end{itemize}

NON-VENTILATED PATIENTS

\begin{itemize}
\tightlist
\item
  Cuffed, non-fenestrated tracheostomy tubes should be used and remain
  inflated to limit aerosol generation (7-9, 11, 12, 17).
\item
  Humidification with a simple HME device, along with a viral filter
  should be placed on the tracheostomy tube (6-17).
\item
  A simple facemask should be placed on the patient (7, 13-15).
\item
  Any suctioning should be done using a closed system (7-12, 14-17).
\item
  Should supplemental oxygenation be needed, a trach collar is preferred
  due to its protection against droplet spread (7).
\end{itemize}

\textbf{Limitations}

This study evaluated the current practice guidelines and recommendations
for tracheostomy during the SARS-CoV-2 outbreak to provide a collective
summary for otolaryngologists in this difficult time. However, we
acknowledge the inherent limitations of this study. Although we included
all published literature to date, this was limited only to those
published before March 31st, 2020. As more is learned about SARS-CoV-2
and more data becomes available, it is possible that the guidelines may
change or be altered as a result. Still, this is the most up-to-date
collection of clinical guidelines for tracheostomy with respect to the
SARS-CoV-2 outbreak available at this time. Further studies are needed
to determine the efficacy of these guidelines, and in order to establish
recommendations for similar viral epidemics in the future.

\textbf{References}

1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical
Characteristics of Coronavirus Disease 2019 in China. The New England
journal of medicine. 2020.

2. Yang X, Yu Y, Xu J, Shu H, Xia Ja, Liu H, et al. Clinical course and
outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan,
China: a single-centered, retrospective, observational study. The Lancet
Respiratory Medicine. 2020.

3. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol
generating procedures and risk of transmission of acute respiratory
infections to healthcare workers: a systematic review. PloS one.
2012;7(4):e35797.

4. Zara M. Patel MJF-M, MD; Peter H. Hwang, MD; Jayakar V. Nayak, MD,
PhD; Robert Dodd, MD, PhD; Hamed Sajjadi, MD; Robert K. Jackler, MD.
Precautions for endoscopic transnasal skull base surgery during the
COVID-19 pandemic. 2020.

5. Otolaryngologists and the COVID-19 Pandemic. American Academy of
Otolaryngology - Head and Neck Surgery. 2020.

6. Noah P. Parker MBAS, MD; Mark A. Fritz, MD; Sarah K. Rapoport, MD;
Sam Schild, MD; Kenneth W. Altman, MD; Albert L. Merati, MD; Maggie A.
Kuhn, MD. Tracheotomy recommendations during the COVID-19 Pandemic.
American Academy of Otolaryngology - Head and Neck Surgery. 2020.

7. NTSP considerations for tracheostomy in the Covid-19 outbreak.
National Tracheostomy Safety Project. 2020.

8. COVID-19 Resources for Anesthesiologists. American Society of
Anesthesiologists. 2020.

9. Anaesthesiologists WFoSo. Coronavirus - guidance for anaesthesia and
perioperative care providers 2020.

10. David J Brewster NCC, Thy BT Do, Kirstin Fraser, Chris J
Groombridge, Andy Higgs, Matthew J Humar, Timothy J Leeuwenburg, Steven
McGloughlin, Fiona G Newman, Chris P Nickson, Adam Rehak, David Vokes
and Jonathan J Gatward. Consensus statement: Safe Airway Society
principles of airway management and tracheal intubation specific to the
COVID-19 adult patient group. The Medical Journal of Australia. 2020.

11. Kong DoAaIC-TCUoH. Infographic for Principles of Airway Management
in COVID-19. 2020.

12. Laura Harrison JR, Stuart Winter. Guidance for surgical tracheostomy
and tracheostomy tube change during the COVID-19 Pandemic. ENT UK. 2020.

13. Wax RS, Christian MD. Practical recommendations for critical care
and anesthesiology teams caring for novel coronavirus (2019-nCoV)
patients. Canadian Journal of Anesthesia/Journal canadien d'anesth\selectlanguage{ngerman}ésie.
2020.

14. Xiangdong Chen MD, Ph.D.; Yanhong Liu, M.D., Ph.D.; Yahong Gong,
M.D.; Xiangyang Guo, M.D., Ph.D.; Mingzhang Zuo, M.D., Ph.D.; et al.
Perioperative Management of Patients Infected with the Novel
Coronavirus: Recommendation from the Joint Task Force of the Chinese
Society of Anesthesiology and the Chinese Association of
Anesthesiologists. Anesthesiology. 2020.

15. {[}Expert consensus on preventing nosocomial transmission during
respiratory care for critically ill patients infected by 2019 novel
coronavirus pneumonia{]}. Zhonghua jie he he hu xi za zhi = Zhonghua
jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory
diseases. 2020;17(0):E020.

16. Liana Zucco NL, Desire Ketchandji, Mike Aziz, Satya Krishna
Ramachandran. Perioperative Considerations for the 2019 Novel
Coronavirus (COVID-19) Anesthesiology Patient Safety Foundation. 2020.

17. Wei WI, Tuen HH, Ng RWM, Lam LK. Safe tracheostomy for patients with
severe acute respiratory syndrome. The Laryngoscope.
2003;113(10):1777-9.

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