DECISION FOR TRACHEOTOMY IN PATIENTS WITH COVID-19 (Figure 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.
- If a tracheotomy is to be performed in a COVID-19 positive patient, it
should be conducted with the following in mind:
- 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.
- 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.
- Staff should be minimized and should only include absolutely
essential personnel.
- For open tracheotomy and percutaneous tracheotomy, key
recommendations include minimizing opportunity for aerosolization:
- Complete paralysis to avoid coughing
- Ventilation only with cuff inflation
- Stopping ventilation prior to entering the airway and deflating
the cuff
- Avoiding suctioning once the trachea is incised due to the risk of
aerosolization of high viral load secretions
- Minimizing cautery due to concerns of aerosolization of viral
particles in the smoke plume
- Minimize bronchoscopy time as much as possible (for percutaneous
tracheostomy)
- 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
- For percutaneous tracheotomy, bronchoscopy time should be minimized
as much as possible
- Procedures should be performed in a negative pressure room if
available
- HEPA filter “air scrubber” should be placed in the room, if
available, for tracheotomies on Covid + patients