Table 3.

General Risk Reduction Best Practices

General Risk Reduction Best Practices
1. Equipment and medications should be preplanned with checklist and procedure kits prior to entering the room.
2. Avoid using carts in the room to reduce the need to undergo decontamination. Consider a disposable bronchoscope.
3. Universal protocol and time out may be performed outside the room with procedure team followed by appropriate donning of enhanced PPE per institutional protocol.
4. Use of ultrasound to assess anatomy and point of entry (use standard decontamination protocol of durable equipment).
5. Deep sedation and neuromuscular blockers should be used for the procedure to minimize cough and agitation.
6. Before start, perform a trial of apnea to mimic apnea.
a. Withhold ventilation (apnea).
b. Discontinue positive end-expiratory pressure.
c. Increase the Fio2 to prevent desaturation, for a duration of 30 s to 1 min.
If apnea is not tolerated, reduce the ventilatory pressures and respiratory frequency to minimize the risk of aerosolization. Otherwise, consider deferring the procedure until ventilatory requirements are optimized.
7. Key intervals where apnea must be performed during a traditional bronchoscopic-guided percutaneous dilational tracheostomy are as follows:
• When the bronchoscope adaptor is added to the circuit.
• Prior to inserting the bronchoscope into the ETT.
• During the pullback of the ETT with cuff deflation.
• Time of insertion of the introducer needle, angiocatheter, dilation, and insertion of the tracheostomy tube, bronchoscopic confirmation of placement, until connected to closed circuit connection with ventilator.
• Removal of the ETT from oropharynx.
8. The oropharynx and the hypopharynx may be packed. A suction tip may be placed in the mouth to lessen the risk of aerosolization of oral secretions during the ETT pullback.
9. During the procedure, place a moist gauze or sponge around the guidewire, during dilation, and neck stoma as needed.
10. Ultrasound can be incorporated into PDT to avoid the need for bronchoscopic guidance. Sonography equipment will need to be decontaminated at the end of the procedure. Additionally, a modified PDT technique with placement of bronchoscope alongside the ETT while advancing the ETT below the intended stomal point of entry might reduce aerosolization.
11. During an open tracheostomy, in addition to the aforementioned steps using apnea during ETT manipulation and prior to incision into the anterior wall of the trachea, avoid or minimize the use of diathermy and suction because it carries a risk of aerosolizing particles.
12. Place a petrolatum gauze dressing at the site of the fresh stoma until it heals to prevent aerosolization or air leak.

See Table 1 and 2 legends for expansion of abbreviations.