DECISION FOR TRACHEOTOMY IN PATIENTS WITH COVID-19 (Figure 1)
  1. Tracheotomy in patients with active COVID-19 and severe respiratory failure should be exceedingly rare. In patients with prolonged intubation, elective tracheotomy can be delayed well beyond the usual 14-day timeline. Despite concern for airway stenosis due to prolonged intubation, recent data suggests early tracheotomy may be less crucial and the safety issues around the pandemic outweigh the risks of late airway stenosis10.
  2. If a tracheotomy is to be performed in a COVID-19 positive patient, it should be conducted with the following in mind:
  3. Procedures should be completed in the ICU at bedside to avoid risk of exposure during transport. Furthermore, there may be more access to negative pressure rooms in the ICU setting.
  4. It is unclear whether open tracheotomy or percutaneous tracheotomy produces less aerosolized viral particles. Each procedure should be permitted until more data is available. Percutaneous tracheotomy has been performed in the ICU setting in our institution for a number of years11.
  5. Staff should be minimized and should only include absolutely essential personnel.
  6. For open tracheotomy and percutaneous tracheotomy, key recommendations include minimizing opportunity for aerosolization:
  7. Complete paralysis to avoid coughing
  8. Ventilation only with cuff inflation
  9. Stopping ventilation prior to entering the airway and deflating the cuff
  10. Avoiding suctioning once the trachea is incised due to the risk of aerosolization of high viral load secretions
  11. Minimizing cautery due to concerns of aerosolization of viral particles in the smoke plume
  12. Minimize bronchoscopy time as much as possible (for percutaneous tracheostomy)
  13. Minimal PPE worn by staff should include N95, mask with shield, surgical gown, double gloves. PAPR and/or AAMI level 4 suit (ie- Stryker T4) is preferable if available
  14. For percutaneous tracheotomy, bronchoscopy time should be minimized as much as possible
  15. Procedures should be performed in a negative pressure room if available
  16. HEPA filter “air scrubber” should be placed in the room, if available, for tracheotomies on Covid + patients