Discussion
The COVID-19 pandemic has presented healthcare systems with the unprecedented task of managing large volumes of patients with critical respiratory illness. Tracheostomy has emerged as a downstream component of care with heightened risk of viral transmission to healthcare providers and requires careful consideration in this context. Our multi-specialty work group was created during the early spread of COVID-19 cases in the United States and we evaluated and modified our current institutional tracheostomy guidelines in preparation for a surge of COVID-19 positive patients with the potential to overwhelm our healthcare system. These guidelines were created with the intent of preserving quality of patient care and reducing clinician exposure in order to maintain a capable healthcare workforce. Factors relevant to our review included optimal timing of tracheostomy, duration of viral shedding in patients with COVID-19, risk to procedural teams from aerosol generation during tracheostomy, ICU capacity, and availability of PPE. A summary of risk mitigation strategies is presented in Table 2.
There is limited evidence available during this evolving stage of the COVID-19 pandemic. As such, modifications to our existing protocols were made by consensus and were based upon published reports from countries with earlier COVID-19 experience and data available from the 2003 SARS epidemic. The policies that were developed at UCSF are aligned with the position statement on tracheostomy recently published by the Airway and Swallowing Committee of the American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS).6