2. Delay timing of tracheostomy until 21 days post intubation if
feasible.
When determining the appropriate time of tracheostomy in the SARS-CoV-2
patient a variety of factors are considered, and certainly individual
cases may have mitigating circumstances which lead to the decision to
perform tracheostomy. However, for the majority of patients, health care
teams should seek to capitalize on the intersection of the risk of
contamination/infection and decreasing viral load in the upper and lower
airway over time with the risks of prolonged intubation(i.e. tracheal
stenosis). While the overall risk of tracheal stenosis secondary to
prolonged intubation depends on a variety of factors, reported rates of
severe, symptomatic stenosis are generally in the 1-2% range when
modern low-pressure cuffs are utilized.[28-32] Therefore in light of
the relatively low risk of clinically relevant stenosis, and despite the
traditional 10-day cutoff for increased stenosis risk used by many
practitioners in the general population, when dealing with a SARS-CoV-2
patient the risk for symptomatic or severe tracheal stenosis is
acceptable in light of the significant risks of tracheostomy in the
acute phase of the infection during periods of highest viral loads. The
decreasing viral load, while logarithmic in nature is somewhat variable
and high viral loads have been observed somewhat late in the course of
the infection in critically ill patients.[23, 24, 33](Figure
1,2) Therefore when feasible, waiting until approximately 21 days after
intubation is recommended prior to consideration of tracheostomy for the
majority of cases in order to avoid exposing health care teams to
increased risk. Certainly, earlier tracheostomy may be medically
indicated in some situations depending on the clinical situation and we
recognize the potential need to perform tracheostomy more urgently.
Tracheostomy should not be delayed regardless of SARS-CoV-2 status in
life saving situations, or in situations where the tracheostomy would
significantly improve the prognosis of the patient. Alternative emerging
strategies in the management of SARS-CoV-2 critically ill patients, such
as extracorporeal membrane oxygenation, antiviral therapy, and
convalescent plasma therapy may also be considered by the team but the
available data and decision making regarding this is beyond the scope of
these recommendations.[34-38] Clearly these are multidisciplinary
decisions which will be individualized depending on the patient and
institutional expertise.
In addition, it should be noted that avoiding tracheostomy in high
mortality risk patients is critical. If the primary team managing the
patient determines that there is an extremely high risk of mortality in
the near future, or that the patient has a high likelihood of withdrawal
of care, the risks of tracheostomy should be avoided in this situation.
Patients, with significant medical comorbidities, ARDS/severe
respiratory failure, and a low chance of recovery who are infected with
SARS-CoV-2, should be carefully evaluated, and discussions with family
members, consultants, institutional ethics committees, and the treating
team should focus on overall prognosis and goals of care, prior to
performing tracheostomy as a routine matter of care. These decisions are
highly individualized and rely on solid communication amongst team
members managing these high-risk patients.
3. Tracheostomy Technical Considerations and Recommendations.
While the exact technical details regarding tracheostomy will depend on
the situation and procedural protocols and technical expertise, there
are some specific technical aspects related to the SARS-CoV-2 (and other
viral pandemics) which should be considered. Ideally the procedure
should be performed at bedside in the ICU in a negative pressure room or
using a portable HEPA filtration system to avoid patient transportation
and contamination of other areas in the medical center. If it is
necessary to perform the procedure in the OR, a specific OR cluster
should be designated to avoid contamination of additional OR resources
for non- infected patients.
In addition to standard airborne and droplet
precautions, techniques to minimize aerosolization of the virus during
the procedure include the following: paralysis to prevent coughing,
consider glycopyrrolate to reduce secretions, preoxygenation and
cessation of ventilation during the tracheostomy procedure, utilization
of closed suctioning systems, avoiding monopolar electrocautery and
using cold instrumentation when feasible, minimizing suctioning and
bronchoscopy during the procedure, and ensuring the cuff is inflated
prior to resuming ventilation so the circuit is closed.
In addition to standard open tracheostomy, percutaneous/dilational
tracheostomy techniques have been evaluated extensively in the
literature and have been shown to be a safe alternative to traditional
open surgical tracheostomy.[39-41] Understandably, the techniques
utilized when performing tracheostomy will vary based on patient
characteristics, provider expertise, and institutional experience. While
data is limited, techniques which avoid opening the airway and are
closed such as a percutaneous dilational technique, may be preferential
in the setting of active SARS-CoV-2 infection.[42, 43] Therefore if
there are no anatomical or other contraindications, percutaneous
dilational tracheostomy may be considered if the expertise is available.
It should be kept in mind that the decrease in aerosolization during
percutaneous tracheostomy only holds true if airway manipulation (i.e.
bronchoscopy) is not performed, and while there have been some
associated higher complication rates with blind percutaneous
tracheostomy compared to bronchoscopic technique, ultrasound guided
techniques have been shown to be non-inferior to bronchoscopic
techniques.[44-46]. Therefore, if considering a percutaneous
tracheostomy, a closed ultrasound guided technique is recommended for
SARS-CoV-2 patients.
4. Use of appropriate PPE during tracheostomy procedures for
active SARS-CoV-2.
While there is limited data on the current pandemic to fully inform
current recommendations, certainly performing tracheostomy in an
actively infected SARS-CoV-2 patient is a high-risk procedure for health
care workers. [47] Health care personnel performing the tracheostomy
should wear at minimum: Waterproof cap, goggles with an anti‐mist
screen, N95 mask, impermeable operating room surgeon’s gown and gloves,
and a transparent plastic facial shield worn outside the goggles and N95
effective to filter 99.5% particles larger than 0.75 μm.[48] The
minimum number of health care workers required to perform the procedure
should be present to prevent unnecessary exposures.
The effectiveness of the N95 mask in the prevention of SARS-CoV-2
infection during tracheostomy procedures remains unknown, but given the
high risk consideration for power air purifying respirator (PAPR)
systems for personnel performing tracheostomy should be entertained, and
these systems should be used when available in situations of active
infection, or suspicion of high viral loads, as there is some evidence
of superior protection (PAPR provides 2.5 to 100 times greater
protection than the N95, when staff are appropriate trained.[47, 49,
50] Certainly the effectiveness of N95 and PAPR in this situation has
not been compared in a head to head trial, and therefore the use of PAPR
vs. N95 will depend on institutional resources and policy, and the
clinical situation.
5. Avoid emergent tracheostomy if possible.
Techniques to manage the acute airway with endotracheal intubation,
video laryngoscope and fiberoptic intubation should be utilized if
possible to avoid emergent tracheostomy in SARS-CoV-2 patients due to
the high risk of unsafe conditions and health care worker
contaminations.[48] Similarly, intubation techniques (i.e. rapid
sequence intubation) which avoid mask ventilation, prolonged open airway
manipulation are recommended when appropriate. When life threatening
airway obstruction occurs in a setting in which intubation is not
possible, healthcare workers should perform the tracheostomy with the
above noted PPE keeping in mind that PAPR respirator use is often not
feasible or available in emergent situations. In situations where CPR is
being performed, chest compressions should be held at the time the
airway is entered, until the airway is secured and the cuff inflated on
the device, to minimize health care worker exposure.
6. Appropriate post tracheostomy management.
The post-tracheostomy management should also be mentioned, as in
addition to routine tracheostomy care, there are some considerations for
SARS-CoV-2 patient. Securing circuits properly and avoiding unnecessary
humidification systems may reduce the risk of unexpected circuit
disconnection and aerosolization leading to exposure. The circuit should
remain closed as much as possible, and closed line suctioning should be
used. Heat moister exchangers with viral filters and HEPA filtration
should be used when possible. Tracheostomy tube changes should be
avoided, and only performed in cases of cuff failure, or emergent
situations.
7. Organize an appropriate team.
While the members of the health care team performing tracheostomy vary
across institutions, team members may include surgeons,
medicine/intensivists, anesthesiologists, respiratory therapists,
nurses, and other ancillary staff required during these procedures. The
importance of appropriate PPE/PAPR training and usage cannot be
overstated in the setting of active SARS-CoV-2 infection. Teams who
perform the procedure regularly will be more efficient and less likely
to be unfamiliar with the procedure or appropriate health care
protective measures and infection control. The inclusion of trainees
such as residents and fellows during these procedures requires careful
consideration and will vary based on institutional policies.
Currently there is limited data on the host innate immune status of
SARS-CoV-2 infected patients.[51] Consideration of the inclusion of
health care workers who have previously been exposed and subsequently
recovered from documented SARS-CoV-2 infection may be warranted. While
the exact timing of immunity and subsequent safety for the return of
health care providers infected with SARS-CoV-2 remains unknown,
sufficient antibody responses have been documented to occur between days
15-20, or approximately two weeks after the onset of
symptoms.(Figure 3)[23] Inclusion of these individuals on
these teams may allow for high risk procedures to be performed by health
care workers who have mounted an immune response to the virus, depending
on institutional quarantine policies. Similarly, these individuals
should not be involved in tracheostomy procedures or other airway
procedures in non-infected patients due to the risk of iatrogenic
infection with SARS-CoV-2 due to limited available data about the
risks.[52]