Procedural steps
We performed 3 PTs at ICU bedside because of 3 COVID-19 patients were
difficult to wean from mechanical ventilation. Patients were aged 47, 67
and 71 years old (1 woman and 2 men) and all reported positive after
nasopharyngeal swabs. Since the COVID-19 outbreak in Italy, from the 10
of March our ICU was completely dedicated to COVID-19 patients. The
rooms had no negative pressure inside. As follow we reported the
procedural steps of PT performed with a guidewire forceps technique.
- The tracheostomy team was formed by two expert ICU physician in airway
procedures and a nurse.
- All personnel were equipped with the proper PPE, including an N99
mask, eye goggles, transparent full-face shield, gown, and double
gloves.
- Before the procedure, patients were anesthetized with midazolam 0.3 to
0.35 mg/kg, fentanyl 0.1 mg, and cisatracurium 0.2 mg/kg.
- Before the beginning of the procedures, volume control ventilation was
set at a respiratory rate of 15 breaths/min with an
FiO2 of 1.0, tidal volume of 500 mL and positive
end-expiratory pressure of 5 cm H2O
- After 5 minutes of preoxygenation with the previous ventilation
settings, the ventilator was switched off by the nurse. The ICU
physician replaced the endotracheal tube (ETT) in place with a smaller
ETT with an internal diameter of 6 mm by using a videolaryngoscope.
- The endotracheal tube was cuffed at the level of the carina (figure1).
Then the ventilator was connected with the endotracheal tube and
switched on.
- By using the videolaryngosocpe to visualize the glottis, the
fiberoptic bronchoscope with an external diameter of 5 mm was passed
through the vocal cords.
- The fiberoptic bronchoscope was kept just under the level of vocal
cords outside the ETT to control the different PT steps.
- PT was performed with the guidewire forceps technique.
- The puncture of the anterior tracheal wall, Seldinger insertion,
dilatation, and cannula positioning were all performed with the
smaller endotracheal tube cuffed and positioned at the carina (figure
2).
- When the cannula was correctly positioned, the ventilator was switched
off and the smaller ETT was removed. The cannula was cuffed and the
ventilator was connected with it and switched on.
- The fiberoptic bronchoscope was removed after the removal of the ETT.
Discussion
To our knowledge, our was the first report describing a modified
percutaneous tracheostomy procedure targeted to COVID-19 critically ill
patients. Ensuring minimal exposure and risk to the staff that perform
the procedures was of paramount importance [7]. Takhar et al
proposed a modified PT technique in COVID-19 [6]: this technique
differed from the standard-one for 1) the clamping of the ETT and
pausing the ventilator while positioning the cuff at the level of the
vocal cords, 2) pausing the ventilator again while removing the dilator
from the trachea and 3) for covering the tracheal puncture site with
gauze [6]. In our opinion, changing catheter mount for bronchoscopy,
repositioning ETT cuff to the level of the vocal cords and removal of
large rhino dilator were three steps associated with an increased risk
of aerosol generation [6]. In the modified procedure proposed by our
team only the exchanging of the ETT with a smaller-one might increase
the risk of aerosol generation. However, our expertise in airway
management allowed us to perform this step by using the
videolaryngoscope as recommended by a recent guideline [8]. Indeed,
using a videolaryngoscope with a separate screen enables the operator to
stay further away from the airway; this technique is recommended only
for those physicians trained in their use [8]. Having the cannula,
the ETT and fiberoptic bronchoscope inside the trachea while removing
the smaller ETT at the end of the procedure may limit the aerosol spread
at this step. Our previous experience demonstrated that the ETT, the
tracheal cannula and the fiberoptic bronchoscope can be simultaneously
inserted inside the trachea [9]. Our modified PT technique was
performed with ETT cuffed at the level of the carina and the fiberoptic
bronchoscope outside it, this allow a stable gas exchange, airway
pressure, ventilation and no spread of aerosol during the procedure
[8].ConclusionsIn COVID-19 critically ill patients a modified percutaneous tracheostomy
technique, including the use of a smaller endotracheal tube cuffed at
the carina and fiberoptic bronchoscope inserted between the tube and the
inner surface of the trachea, just below the vocal cords, may ensure a
better airway management, respiratory function, patient comfort and
great safety for the staff.