Performing Ultrasound-Guided Percutaneous Tracheostomy in COVID-19 Patients

We read with great interest the article by Foster and colleagues¹ about tracheostomy in patients with COVID-19. Although the literature on tracheostomy in such patients is scarce and based largely on experience with the severe acute respiratory syndrome epidemic, their recommendations are well supported by the available literature. However, we believe that there is room for discussion about the use of percutaneous tracheostomy specifically.

Our institution is now one of the largest public medical facilities dedicated to patients with COVID-19 in South America. Based on the current evidence about the procedure and contamination precautions, we developed a dedicated tracheostomy team for COVID-19. Our institutional protocol resembles the one described by Foster and colleagues,¹ except for the absence of a negative pressure room and the use of percutaneous tracheostomy, which is being done using ultrasound.

Ultrasound-guided percutaneous tracheostomy (UGPT) has not yet experienced widespread use. The risk of complications, especially injury to the posterior wall of the trachea, still haunts surgeons. Although severe, this complication is rare and not exclusive to the UGPT technique,² and studies have shown that UGPT is as safe as the bronchoscopy-guided percutaneous tracheostomy.^{3 , 4} At a time when contamination risks are highlighted, it seems that the UGPT might preserve the benefits of the percutaneous technique^{5 , 6} without the associated risk of bronchoscopic airway manipulation.

Several potential benefits of the UGPT should be underscored. First, the procedure can be carried out by a single surgeon, keeping the assistant prepared to join only if conversion is needed, minimizing personnel exposure. Second, there is no need for smoke evacuators because no cautery is used. Third, UGPT can be performed easily at the bedside, precluding transport to the operating room and its contamination risks and potential complications. However, unfavorable anatomic conditions, the impossibility of neck extension, and the presence of large vessels on the puncture trajectory might preclude UGPT.

We developed small modifications of the usual dilational technique to reduce the risk of aerosolization during UGPT. Before ultrasound-guided endotracheal tube positioning, ensure the mechanical ventilation has stopped and full expiration has been achieved. Then, deflate the cuff, pull the endotracheal tube proximally, reinflate the cuff, and secure the tube in its new position with ventilation halted. Re-establish ventilation and wait for adequate pre-oxygenation before proceeding. Immediately after tracheal puncture, stop the ventilation. Perform the next steps (ie guidewire passage and surgical tract dilation), protecting the tracheostomy site with a surgical towel. Ventilation is re-established after successful placement of the tracheostomy tube, which is confirmed by lung ultrasound, or capnography when available, avoiding the use of stethoscopes. If oxygenation is necessary before that final step, the surgeon must block the tracheostomy site, reassuming the procedure after adequate oxygenation and another ventilation halt. All staff involved must shower after doffing their personal protective equipment.

We have performed more than 10 UGPTs in patients with COVID-19 using the modification mentioned. Such a technique is feasible with adequate but short training of the team, and the apnea time is short and well tolerated, evidenced by only a mild decrease in oxygen saturation in a few patients during the procedure (unpublished data). In addition, the whole procedure can be carried out with the endotracheal tube cuff inflated proximally to the puncture site, potentially preventing additional viral spreading towards the physician responsible for the airway manipulation.

Surgeons should choose the technique they are most familiar with to perform tracheostomy. We believe that by standardizing the relevant steps of the procedure, surgeons who are more familiar with the percutaneous technique might still use it during the COVID-19 pandemic.