Introduction
Tracheostomy has been termed an aerosol-generating procedure in the COVID-19 pandemic. As a result, concerns have been raised regarding the safe performance of the tracheostomy procedure. During the first wave in 2020 there were some who advised deferral of the procedure as it was thought that healthcare workers (HCWs) would be exposed and therefore likely contract the viral infection.
It was thought that by deferring the procedure the patient would enter a phase where they would be less infectious and so posed less of a danger of transmitting the disease to those who were performing the procedure.
Some authors have pointed out that such a course is from the perspective of the healthcare deliverers. How did such decisions affect patients on whom such procedures were to be conducted? These were pertinent and relevant questions which needed to be answered.
Tracheostomy in COVID-19 Situations
Many papers have been published subsequently on this subject. Many questions have been answered. However, the long-term effects of these decisions will only be answered by careful follow-up of these survivors.
Early experience with SARS CoV-2 in China showed that HCWs involved in the tracheostomy were at greater risk (odds ratio 4.15) than those who were not. This led to guidelines of donning a fully enhanced personnel protection equipment (PPE). This included protective surgical gown, N95 mask, helmet/face shields, gloves, and boots.
At the beginning of the COVID-19 pandemic, many treating physicians were pessimistic about tracheostomy and whether it would make any difference to the course of the disease. Since they held such an opinion, they considered deferral as a means to protect the HCWs who would have been involved in the performance of the tracheostomy.
They also postulated that during proning the tracheostomy tube would likely get obstructed.
Early on in the pandemic in 2020, there was a rush to place patients on invasive mechanical ventilation (IMV).1 After some time it became apparent that most patients could be managed with noninvasive oxygenation (NIMV) and the numbers requiring IMV dropped significantly. This in turn caused the numbers requiring tracheostomy to also decline.
Some reports point out that the N95 mask was the single most important piece of equipment needed when performing the tracheostomy procedure.
The N95 masks are effective at filtering 99.5% of particles >0.75 µm which travels within aerosol particles which are >1 µm. Thus, the N95 mask protects the wearer from the virus.
Timing
Some studies have clearly shown that early tracheostomy leads to better outcomes in terms of survivorship as well as being weaned off IMV.2
Conversely delayed tracheostomy was associated with poorer survivorship and lengthy and costly delay in weaning off the ventilator.
Early tracheostomy was labeled as tracheostomy performed by day 10 of being placed on IMV.
Timing of tracheostomy was significantly associated with the length of stay,3 40 days for early tracheostomy (tracheostomy done within 10 d of being intubated) versus 49 days for late/deferred tracheostomy. Competing risks models with death as the competing risk demonstrated that late tracheostomy was 16% less likely to get off the ventilator.
Early tracheostomy led to early discharge from hospital.4 Enhanced PPEs for the operating surgeons was associated with low rates of transmission.5 More importantly, early tracheostomy was associated with diminished risk of mortality.
Many papers4,6,7 concede that there was no way of accurately determining the degree of infectivity and the viral load. It was thought that since the viral loads were thought to reduce substantially by day 8 the viral particles would also be less. So performance of tracheostomy by day 10 was thought not to pose as serious a possibility of disease transmission as previously thought.8,9
However, all personnel involved in the procedure had as a protocol to don a full and complete PPE when performing the tracheostomy.10,11
Recent data clearly demonstrates12 that even after upper respiratory tract samples become negative, lower respiratory tract samples can remain positive for up to 39 days. The correlation between positive results by quantitative PCR viral testing and infectivity is currently being investigated.13
Data also demonstrates that patients with the severe form of the disease present with a much higher viral load that decreases slowly.14
Another factor that should influence decision making is the presence of comorbidities. Patients with no comorbidities do much better than those with health issues.
Many studies during the second wave demonstrated that very few HCWs developed COVID-19 following tracheostomy.15–17
These studies focused on the following factors18: (1) safety for surgeons, (2) appropriate timing of tracheostomy, (3) whether outcomes were pulmonary or influenced by tracheostomy.
Recommended protocols for tracheostomy in COVID-19 are currently as follows19–21:
Mandatory adequate PPE for the operating personnel. This includes surgical gown, N95 mask, helmet/face shield, cap, gloves, boots/appropriate footwear.
Site to perform tracheostomy. Most prefer to do it by the bedside. Transporting the patient to the operating room runs the risk of dissemination of disease.
Precautions to reduce time of exposure to infected elements. Speed of performing tracheostomy is important especially once the trachea is about to be opened. At that time the ventilator should be placed on standby. Once the trachea is opened the tracheostomy tube should be inserted correctly and swiftly.
To avoid complications, delays, and confusion, a well-established tracheostomy team should be in place. Everyone in the team is expected to know their role and exactly how the procedure is to be conducted safely and efficiently.
Open versus percutaneous tracheostomy is the team’s choice and they should be familiar with both.
Our Protocol
Tracheostomy to be conducted at the earliest when it is apparent that the patient will need prolonged IMV support.
We have an established team of personnel familiar with open and percutaneous tracheostomies. At times we conducted hybrid procedures especially if the patient was obese. An incision was taken in the neck until the trachea was distinctly visible and palpable.
All tracheostomies were conducted by the bedside.
We favored the percutaneous tracheostomy procedure because it was quick and safe and as time went by expertise and confidence of performing it reliably, safely, and efficiently grew exponentially.
We record our technique which is simple, efficient, and safe and is replicable. These guidelines can help even inexperienced surgeons to conduct a safe tracheostomy procedure using the percutaneous technique.
Procedure with Percutaneous Tracheostomy
Patient positioning: The neck should be extended and the area prepped.
The endotracheal tube withdrawn to 17 cm to the incisor teeth.
Infiltration with anesthetic solution.
Two-centimeter horizontal incision (Fig. 16.1).
Injection into the trachea: The syringe should have its plunger withdrawn and if bubbles are seen it indicates that the trachea has been entered correctly (Fig. 16.2). If not, then the endotracheal tube needs to be withdrawn further. Resistance can be felt when injecting into the trachea if the endotracheal tube has not been withdrawn enough. Withdrawing the ET will help the surgeon to correctly identify the trachea.
The syringe is withdrawn and the J-wire is inserted through the needle. The surgeon will be able to feel the wire enter the trachea.
The red spigot is threaded through the J-wire and the trachea is dilated (Figs. 16.3–16.5).
This is removed and the bigger white dilator is then threaded into the J-wire and the tracheal opening is further dilated (Figs. 16.6and16.7).
The ventilator is now put on standby in order to prevent aerosolization of infected fluids.
Insertion of the dilator is a very important step as it provides an opening large enough for the tracheostomy tube to be inserted. The tracheal dilator should be inserted into the trachea and then the jaws of the forceps opened sufficiently enough to allow the passage of the tracheostomy tube to allow it to enter smoothly. The trachea is dilated horizontally as well as vertically (Figs. 16.8and16.9).
The dilator is removed, and the tracheostomy is then threaded and inserted. Once inserted into the trachea, the cuff is inflated and secured (Fig. 16.10).
