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