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.