GUIDELINES FOR TRACHEOTOMY IN THE COVID PATIENT

PREOPERATIVE PHASE

Determine Candidacy for Tracheotomy: Tracheotomy may be considered in patients intubated more than 21 days who are without significant comorbidities and have a good prognosis.

A multidisciplinary discussion should be held between the primary team, procedure team, palliative care team, and family to establish the goals of care, overall prognosis, and expected benefits of tracheotomy. DNR status should be determined. The Ethics Committee can be consulted as needed.

Tracheotomy in the COVID patient is high risk for aerosolization. It requires numerous providers to work in close proximity to one another and the patient.

We must balance the competing interests of providing high-quality patient care while simultaneously protecting personnel. It is reasonable to consider patient benefit against the risk to the surgical team.

The decision to proceed is customized for the individual patient on a case by case basis. Prohibiting factors may include: • Hemodyamic status +/- pressors/inotropes • Coagulation status • Risk of instability during transport or surgery

Tracheotomy before 21 days should not be routinely performed but may be considered in patients with increased requirement for pulmonary toilet, high levels of sedation or known difficult airway.

Summary: Tracheotomy is indicated if it is necessary for continued care, typically when an ETT and weaning difficulty are the rate limiting step to improvement. Tracheotomy is not indicated in patients who require a high level of hemodynamic support.

Preoperative Testing: A sputum sample, obtained by closed endotracheal suctioning, is sent on Ventilator Day 14 to ensure the result is available by Ventilator Day 21. The result reflects patient clearance of the virus and guides use of resources. A positive result does not mandate case cancellation.

Coagulation Status: This should be carefully assessed, well in advance, to facilitate hemostasis and minimize electrosurgery. Anticoagulants may be held, dose and timing adjusted, or transitioned between drug class. Testing may help with decision making.

OR Team Members Meet: As soon as practical, members of the surgical, anesthesia and nursing teams should meet to discuss the case with an emphasis on personal protection and fire prevention.

The anesthesia team should be prepared to reintubate from above.

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Replacement endotracheal and tracheotomy tubes should be available. Provide size options for the same.

During any part of the operation there must be a plan to manage: • Cuff rupture • Desaturation • Cardiac arrest • Fire

INTRAOPERATIVE PHASE

High Risk for Fire: All tracheotomies are high risk for fire. Abide by all fire prevention and management strategies.

Open Tracheotomy is Indicated: The open approach, compared to percutaneous, will decrease aerosol generation and is preferred.

Location: The procedure should be performed in an operating room, not bedside. Negative pressure is preferred. Neutral pressure is the next best choice.

PPE: Tracheotomy has been shown to be an aerosol generating procedure. Proper use, donning and doffing of PPE for each person in the room is essential. Minimize aerosolization during the procedure.

The surgeon and first assistant are closest to the smoke plume and open trachea. Their PPE will include one of the following: • PAPR Hood, Blower and Filter • Orthopedic Hood with N95 mask, without blower

Note: The risk of PAPR exhaust contaminating a surgical field, that is presumed already to be contaminated, does not outweigh the benefit of protecting the surgeon and first assistant from aerosolization.

Verbal Communication is Critical: Personnel will be wearing extra layers of PPE.

Eliminate music and unnecessary conversation. Minimize ambient noise.

Speak clearly and with sufficient volume. Acknowledge when you are spoken to. Use concise phrasing.

The surgeon and anesthesiologist must maintain instantaneous verbal communication after skin incision. The interaction is carefully choreographed.

The surgeon can direct that ventilation be held or resumed. If held, the anesthesiologist will not deliver any form of positive pressure to the breathing circuit.

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The surgeon directs when the: • ETT is advanced or withdrawn, and the distance • ETT cuff deflated or inflated

Procedure: The patient should be fully paralyzed at all times, guarantee zero patient movement.

Minimize use of electrosurgery.

FI02 should be at the lowest level to maintain adequate oxygenation.

A non-fenestrated cuffed tracheotomy tube with a disposable inner cannula should be used.

The ETT cuff should be advanced distal to the tracheotomy site to the level of the carina.

Cuffs, when inflated, should be snug, but not overdistended.

Holding ventilation means that the ETT remains attached to the anesthesia breathing circuit, ventilator is set to manual, adjustable pressure limiting valve is wide open and PEEP is allowed to dissipate.

Ventilation is held if the ETT cuff is deflated or ruptured.

When the tube position is adjusted, ventilation should be held before the cuff is deflated until it is fully reinflated.

Ventilation should be held prior to incision of the trachea.

If ventilation needs to be resumed via the ETT after the trachea is incised, the cuff should be inflated.

Ventilation is held as the ETT is withdrawn in preparation for tracheotomy tube insertion.

If cuff position could not be previously confirmed via palpation, ventilation should be held and the cuff fully deflated while the trachea is incised. The cuff position can then be adjusted through the tracheal opening before reinflation.

Traction sutures into the trachea are recommended.

Insertion of the tracheotomy tube should be accurate and quick to minimize open airway time. The cuff should be immediately inflated and tracheotomy tube connected to a closed circuit, after which ventilation may resume.

Tube placement should be confirmed with end tidal CO2 and appropriately secured.

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POSTOPERATIVE PHASE

INFECTION RISK CONTINUES: Remember, the tracheostomy is a higher risk for aerosolization than an ETT.

PPE should be worn.

A viral filter should be used in the ventilator circuit.

Closed in-line suctions should be used.

Disposable inner cannulas should be disposed of and replaced per the manufacturer’s guidelines. They should not be cleaned and replaced.

Avoid trach collars, unnecessary suctioning and pulmonary lavage.

If the tracheostomy tube is dislodged, call surgery, call anesthesia for reintubation, call for help. Ensure adequate PPE before room entry.

Changing the inner cannula or tracheostomy tube is a high risk procedure. This should be deferred until the patient is no longer infectious. Guidance may be obtained from the Infectious Disease Team.

References:

Chao, TN, Braslow, BM, Martin, ND, et al. Tracheotomy in ventilated patients with COVID 19. ANNALS OF SURGERY. 2020.

Tay, JK, Li-Chung Khoo, M, Woei,SL. Surgical Considerations for Tracheostomy During the COVID 19 Pandemic. JAMA Otolaryngology. 2020.

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