UMMC Elective Tracheostomy Protocol during COVID-19 Pandemic

Last update: April 10, 2020

Institutional practice guidelines for the indications and performance of tracheostomy during COVID-19 crisis help achieve a reasonable balance between need to protect health care staff during these high-risk procedures and the utilization of limited institutional resources.

Guiding principles

• Risk stratify cases in which no/minimal harm would come to the patient if the surgery is delayed
• Approach to cases in which surgery cannot be delayed
• Minimize health care worker exposure
• Minimize travel within the hospital
• Minimize the length of the procedure
• Minimize the need for repeat procedure
• Maximize a system resource allocation
• Establish COVID-19 testing protocol

Indication for elective tracheostomy

• Length of mechanical ventilation is not an indication for tracheostomy
• Recovery phase of respiratory failure with PEEP ≤ 8, FiO2≤ 50%, tolerating 1-minute apnea without significant O2 desaturation
• Favorable clinical prognosis, with tracheostomy to expedite vent weaning and transition out of the ICU and into the wards or post hospital care facility

Approach to the non-COVID-19 patient

• If patient has symptoms concerning for COVID-19, call Medcom (601-984-4367) to assess the need for isolation and testing for COVID-19.
• Bedside vs open/OR procedure based on the consultant discretion
• Recommend disposable bronchoscope during bronchoscopic guidance
• Personal Protective Equipment (PPE) - applies to all personnel present in the room
  • Limit personnel in the room
  • Surgical mask/N95, eye protection, gown, and gloves
  • Currently, CDC guidance does not recommend hairnet/bonnet or shoe covers while performing procedures on COVID positive/suspect, but these can be used based on provider preference
  • Follow N95 re-use policy to conserve PPE
• Post-tracheostomy care
  • Aggressive vent wean, PT and OT to facilitate early transfer from ICU
  • Change tracheostomy per standard care with standard PPE
  • Wearing a surgical mask during tracheostomy manipulation is recommended

Approach to COVID-19 positive/COVID-19 PUI

General principles

• Prefer bedside procedure to minimize transport
• If procedure needs to be done in OR, negative pressure room is required
• Reduce amount of staff needed for the procedure (should equal 4 for either approach)
• Most experienced surgeon/proceduralist trained in donning and doffing of PPE to perform procedure without trainees involvement
• Pre-procedural administration of glycopyrrolate 0.4 mg to reduce secretions
• Neuromuscular blockage throughout the case
• Confirm placement endoscopically and by end-tidal CO2 rather than CXR
• Cuffed non-fenestrated tracheostomy tube should be used
• Attempt to complete the procedure within 25 minutes time frame
• Viral filter should remain on a ventilatory circuit
• Personal Protective Equipment – PAPR or N95 + full face shield, water resistant gown, and double gloves. Currently, CDC guidance does not recommend hairnet/bonnet or shoe covers while performing procedures on COVID positive/suspect, but these can be used based on provider preference.
• Use a clear plastic sheet or another protective device over the surgical site
• Place all necessary equipment in the room, no one enters or exits while a case is in progress unless emergency
• Upon completion of the case, staffs need to remain in the room until full air circulation occurs (5 minutes)

Procedural principles - percutaneous approach

• • Clamp ET tube, put ventilator on hold and insert a bronchoscopy adapter
• • Don’t deflate ET cuff when positioning an ET tube prior a needle insertion
• • Once wire is in place, pre-oxygenate, put ventilator on hold to perform dilation and insertion of a tracheostomy tube during apneic pause if possible
• Cover stoma with gauze between the steps
• Inflate tracheostomy cuff, connect the circuit to tracheostomy tube, resume ventilation, and then remove ET tube
• Notify members when disconnecting from the vent or removing ET tube

Procedural principles - open approach

• Anesthesia informed of imminent tracheal incision; all team members are prepared
• Preoxygenation  100% for 3min then apnea
• Cuff deflated just before incision down to trachea or pushed distal to avoid accidently popping balloon of the ETT balloon
• ETT pulled back 3 cm and visualization of tip of ETT at tracheotomy
• Avoid cautery use and minimize tracheal suctioning to avoid aerosolization
• Resume mechanical ventilation only after the tracheostomy tube balloon is inflated and a closed circuit re-established

Post-tracheostomy care

• If tracheostomy manipulation is required N95 and full face mask are required. Currently, CDC guidance does not recommend hairnet/bonnet or shoe covers while performing procedures on COVID positive/suspect, but these can be used based on provider preference.
• Cuff to remain inflated and check for leaks frequently
• Only closed in-line suctioning should be performed
• Decannulation should be done as soon as medically safe, and site covered with an occlusive dressing. Providers should be aware this site can take up to 2 weeks to close and in 1-3% of patients will not close (for which outpatient follow up is recommended).

References

• Group of Interventional Respiratory Medicine, Chinese Thoracic Society. Expert consensus for bronchoscopy during epidemic of 2019 Novel Coronavirus infection (Trial version). Chin J Tuberc Respir Dis, 2020, 43: Epub ahead of print
• Wahidi et al. American association for bronchology and interventional pulmonology (AABIP) statement on the use of bronchoscopy and respiratory specimen collection in patients with suspected for confirmed COVID-19 infection. Update March 19, 2020
• Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One 2012; 7: e35797
• Chan et al. Practical Aspects of Otolaryngologic Clinical Services During 2019 Novel Coronavirus Epidemic, JAMA Otolaryngology-Head&Neck Surgery, March 2020
• Wei et al. Safe Tracheostomy With Severe Acute Respiratory Syndrome, Laryngoscope, 113:1777-1779, 2003
• WHO Interim Guidance 19 March 2020 – Rational ise of personal protective equipment (PPE) for coronavirus disease (COVID-19)
• Tracheostomy Guidance during COVID-19 Pandemic

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.