Risk Reduction Strategies
Flow charts of strategies aimed at minimizing risk of transmission are
shown below in Figures 1 and 2. The cornerstones of these
recommendations include the use of closed-circuit ventilation whenever
possible, cuffed tracheostomy tubes, judicious use of heat moisture
exchange units (HMEs) as tolerated, appropriate personal protective
equipment (PPE) for providers and patients at all times, and minimal
manipulation of tracheostomy tubes. These strategies are described below
in more detail.
Closed Circuit Ventilation with in-line suction: Closed circuit
ventilation, particularly in cases of known or suspected COVID-19, may
decrease risk of aerosolization and droplet
formation.[1] Cuffed tracheostomy tubes should be
used in these circumstances to decrease leaks in the circuit. Use of
in-line suction, even for patients who may not require chronic
closed-circuit ventilation, may also decrease risk of aerosolization and
droplets.[17] Nebulizer treatments should be
avoided or used with caution as well to minimize risk of
aerosolization.[11]
Heat Moisture Exchange Units (HMEs): HMEs may reduce both
aerosolization and droplet formation. Whenever tolerated, HMEs should be
used instead of open tracheostomy collar with humidified air. Atos
Medical has recently developed the Provox Micron HME filter that may
be a helpful option for patients with suspected or confirmed COVID-19.
While efficacy for COVID-19 has not specifically been tested, previous
viral filtration efficacy was demonstrated to be
99%.[18] While the Micron was initially designed
for patients following laryngectomy, it may be used with a 15mm hub
adaptor for patients with tracheostomy. Standard HMEs without viral
filtration may be used for patients without known infection or symptoms.
Cuffed tracheostomy tubes are ideal for SARS-CoV-2 positive patients as
they may decrease leak around the HME and tracheostomy tube and can
decrease airflow through the oropharynx and nasopharynx. However, these
potential benefits must be balanced against the increased suction
requirements while the cuff is up as patients will be less able to
self-clear secretions.
Appropriate use of PPE: PPE is essential to mitigate risk of
transmission.[19,20] Proper fit testing is
essential for effective filtration with N95 masks. For all patients with
tracheostomy/TL who are known to be SARS-CoV-2 positive or under
investigation, the clinician should wear appropriate aerosolization PPE,
including at a minimum an N95 mask, face shield, gown, and gloves at all
times. For patients who are asymptomatic and/or SARS-CoV-2 negative,
providers should at minimum wear droplet precaution PPE, including a
surgical mask with face shield, gown, and gloves at all times while in
the room. If there are any procedures that may lead to aerosolization
(i.e. trach change and/or suctioning without an inline suction) then the
provider should wear aerosolization PPE, including an N95 respirator,
regardless of patient SARS-CoV-2 status due to unknown false negative
COVID PCR testing rates at this time and high rates of asymptomatic
carriers. Removal of PPE after exposure to an individual infected with
COVID is one of the highest risk periods for
contamination.[21] Apart from provision of PPE,
prior training of proper gown up and gown down of PPE must be provided
to all health care workers involved in caring for patients with
suspected or confirmed SARS-CoV-2.[22] All staff
should be vigilant in adhering to the gown up and gown down protocol.
Patients should also wear PPE to decrease risk of transmission. Any
patient known to be SARS-CoV-2 positive or under investigation should
wear a surgical mask over nose and mouth, regardless of tracheostomy/TL
status. Patients not on a closed ventilation circuit should also wear a
surgical mask over their stoma if tolerated as this may decrease spread
of droplets from leakage around the stoma and/or HME. Any SARS-CoV-2
negative or asymptomatic patients who are immunocompromised (i.e.
patients receiving active chemotherapy, active radiation, active
immunotherapy, with a history of lung transplant, less than one year
status post solid organ or bone marrow transplant, or with neutropenia)
should wear a mask over the nose and mouth at all times while in the
healthcare setting to decrease their own risk of becoming infected.
Hygiene: While the importance of hand hygiene to minimize
transmission is well-established, patients with tracheostomy and TL have
some special considerations. Apart from acquiring the virus from
inhalation of droplets infected with the virus, tracheostomy and TL
patients may become infected if their hands contaminated with the virus
touch the respiratory mucosa of the tracheostoma. Thorough hand hygiene
should be performed immediately prior to and following any contact with
the tracheostomy or laryngectomy stoma. Patients who use a
tracheoesophageal voice prosthesis (TEP) should use an HME interface for
voicing to minimize hand to stoma contact. Patients using an
electrolarynx should clean their device frequently with disinfectant
wipes and those using a pneumatic tube or Taiwan tube artificial larynx
should clean the device with hydrogen peroxide following each
use.[23]
Minimize Exposures and Procedures: All nonurgent procedures that
can be reasonably delayed (i.e. elective tracheostomy tube change or TEP
exchange) should be postponed and manipulation of the tracheostomy
and/or laryngectomy site should be minimized. TEP leakage may be managed
by temporary use of a plug or thickened liquids when possible.
Similarly, all nonurgent clinic visits should be postponed and/or
converted to telehealth visits when possible. The absolute minimum
number of providers required to safely care for and evaluate each
patient should be used.
SARS-CoV-2 Screening: When PCR testing for the virus becomes more
widely available in the surgeon’s practice, preoperative testing for all
patients scheduled for tracheostomy and/or TL should be strongly
considered. There may also be a role for testing patients staying for an
extended period of time for SARS-CoV2, but this may vary based on the
individual patient’s risk, hospital setting, and other considerations
such as endemic risk.