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.
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.