COVID-19 patients for tracheostomy: Anesthetic and team considerations

The need for extended invasive mechanical ventilation in patients infected with COVID-19 will expectedly lead to the increase in the number of tracheostomies performed. Data from China revealed that 3.2% (2583 of 79,824) of all confirmed COVID-19 cases required intubation and invasive ventilation [1]. A case series from Washington State showed that 12.5% of the 24 critically ill patients continued to receive mechanical ventilation at day 14 of their ICU admission [2]. One preliminary study from Italy showed that among 1300 patients, 88% of those hospitalized required mechanical ventilation and 58% of their patients still resided in the ICU 5 weeks after admission [3]. Similarly, in an article recently published in the New England Journal of Medicine describing hospitals in NYC, 33% of the patients required invasive mechanical ventilation during the course of 4 to 5 weeks. Of those 130 patients that required intubation, only 33.1% were extubated at the time of publication. [4].

Prolonged intubation can lead to complications including tracheomalacia, tracheal stenosis, fistulas and superimposed ventilator associated pneumonias. During the ICU course, the need for a tracheostomy in a COVID-19 patient will need to be entertained to avoid sequela from long-term intubation, simplification of care, ease of ventilator weaning, and improved patient mobility. However, performing a tracheostomy on a patient infected with coronavirus places healthcare workers in an environment of high exposure to aerosolized airway secretions. There is a dearth of publications describing tracheostomy procedures performed in high risk patients infected with virulent respiratory pathogens such as SARS. Wei et al. reported his team's experience with 3 tracheostomy cases during the SARS epidemic in Hong Kong [5]. Our current COVID-19 pandemic has far outpaced the 2003 SARS epidemic in terms of the number of patients that are requiring mechanical ventilation [[1], [2], [3], [4]]. When approached to assist in a tracheostomy for a COVID-19 positive patient, a multi-disciplinary pre-procedure meeting should be called to assess the absolute need to perform the surgery. Meticulous and vigilant forethought and planning to mitigate the risk of infection must be made prior to initiating these procedures.

Team communication is critical throughout high intensity procedures such as a tracheostomy in COVID positive patients. Distracting alarms in the ICU and noise dampening personal protective equipment (PPE) can hinder hearing and effective communication during procedure. Under normal conditions, other personnel may be readily available to provide assistance when necessary. Due to the enormous risk of this type of procedure to healthcare workers, only the most experienced and minimal number of providers should be present in the procedure room. Vigilant communication between these individuals is crucial to coordinate pauses in ventilation prior to surgical airway entry as well as interruptions in circuit connections. Pausing ventilation prior to tracheal dilation minimizes the risk for aerosolization [5]. Furthermore, eliminating unnecessary circuit disconnects preserve PEEP and oxygenation for these patients with severe pulmonary impairments [5].

The solidary team approach to tracheostomy has been emphasized in previous published case reports during the SARS epidemic almost two decades ago [5]. Even though surgical techniques have improved since SARS, contemporary teams have to adapt to the constant PPE and ventilator shortages and modifications on a national level. Consequently, minute details such as donning and doffing PPE equipment that is unfamiliar to us or operating an alien ventilator become paramount safety issues. Our goal is to contribute our team and anesthetic considerations (see Table 1 for summary) to our collective knowledge and experience on managing this unprecedented humanitarian crisis.

Table 1.

COVID-19 tracheostomy checklist.

Outside procedure room (ideally negative pressure rooms with anterooms) 1.Full team huddle and timeout to discuss step by step procedure. If transporting to operating room for anatomical (high BMI) or equipment (surgical instruments or open tracheostomy) concerns, discuss rationale with the team. If proceeding to the OR, consider taking ICU ventilator with the patient to minimize circuit disconnects. 2.Personal protective equipment: Respirator (N95 or powered air-purifying respirators [PAPR]), eye protection, gown/coveralls, leg/shoe covers or boots, cap, double gloves. 3.Verify location and function of intravenous (IV) access. 4.Verify suction (with viral filters) but minimize or avoid use. 5.Verify bag valve mask with attached viral filter and that it is connected to oxygen source. 6.Review clinical and hemodynamic trends and prepare paralysis, sedative, hypnotics, and/or resuscitation medications. 7.Huddle with respiratory therapist to FAMILIARIZE ON KNOBS AND SETTINGS ON VENTILATOR. Know how to raise alarm volume. 8.Consolidate all essential surgical and anesthetic equipment to simplify and minimize entry and exit out of the room. 9.Support team remains outside: Anesthesiology personnel, nurse, and respiratory therapist.

Inside procedure room 1.Team: Anesthesiologist, surgeon, procedure nurse. 2.Administer hypnotic/sedation and paralysis to prevent coughing or movement throughout the entire procedure. 3.Mildly overinflate ETT cuff to ensure no leak is present. 4.Inspect circuit connections and location of the HME filter, viral filter, capnography. 5.Place a clear drape over the patient's face being careful not to contaminate the surgical field. 6.Position at the head of the bed. Ensure that the IV is easily accessible and the ventilator is within reach and operational. Make sure you are familiar with placing ventilator on standby, putting FIO2 to 100%, and resuming ventilation. 7.Check hemodynamics and capnography. 8.Release ETT from the ETT holder or tape. 9.After the needle insertion and subsequent guidewire placement, PAUSE VENTILATION. 10.Once the tracheostomy tube has been inserted and the cuff has been inflated, attach the circuit. 11.Restart the ventilator and check for chest movement, expired end tidal CO2, and appropriate inspired/expired tidal volumes. 12.Remove the ETT and wrap it with the plastic drape that was placed over the patient's face. Dispose of the wrapped ETT carefully to minimize contamination of environment. 13.Exit the room once the tracheostomy is securely sutured to skin and vital signs are stable. Exit one by one with vigilant monitoring of the doffing process by infection control teams. Debrief with full team in a clean area.