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).
  1. 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.
  2. 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.
  3. 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.