Technical considerations during tracheostomy
Technical considerations for performance of tracheostomy are summarized
in Table 1. For COVID-19 positive or PUI patients, tracheostomy
procedures will preferentially be performed in the ICU to allow for a
negative pressure environment and to minimize potential contamination of
additional patient care areas. The number of providers in the procedure
should be kept to a minimum. Tracheostomy may be performed either as an
open or percutaneous procedure, depending on patient factors and surgeon
preference. Coughing during the procedure can aerosolize droplets and
special modifications are employed to reduce the risk. During the time
of tracheal incision and endotracheal tube exchange, a systemic
paralytic agent should be administered to minimize coughing and
aerosolized topical anesthetic should be avoided. Meticulous hemostatic
technique should be employed prior to tracheal incision to limit the
need for additional tissue manipulation after the tracheal window is
created.
Close communication between surgical and anesthesia teams is necessary.
Ventilation should be held prior to creation of the tracheal window and
while the endotracheal tube (ETT) cuff is deflated. Application of
suction to the surgical wound may be used to create a local negative
pressure environment during exchange of the ETT for the tracheostomy
tube. Importantly, the suction circuit should include a high-efficiency
particulate arrestance (HEPA) filter to capture aerosolized viral
particles and avoid aerosolizing them into the operating theater. After
placement of the tracheostomy tube, closed circuit ventilation with
in-line HEPA filtration should be maintained and only in-line suction
should be performed.