| Planning (Week of Surgery) |
Team education: prepare the PPE and learn how to wear and use them Choose the operating room, preferably one with negative-pressure or, if that’s not available, a well-ventilated room with closed doors during the procedure Review the indication for tracheostomy, for the timing and for the prognosis Choose cuffed and non-fenestrated tracheostomy tubes Choose the COVID team and perform some simulation |
| Day of Surgery |
Check the availability of PPEs for all staff, tracheostomy grab bag and tubes of various size with functioning cuff, closed in-line suction Check the indication and the appropriateness of the tracheostomy, and whether the patient is relatively stable for tolerating lying flat with periods of apnea A full paralysis of the patient reduces the risk of coughing |
| During Surgery |
Stop ventilation and turn off flows after exposition of the trachea, allowing time for passive expiration Advance the cuff beyond the proposed tracheal window, hyperinflate the cuff, and re-establish oxygenation with PEEP Before opening the trachea, stop ventilation Create a tracheal window, taking and inserting the cuffed non-fenestrated tracheal tube Inflate the cuff immediately and confirm the position with end-tidal CO2 Take off PPE correctly, in the appropriate area |
| After Surgery |
Pay attention during patient transfer and to holding the tracheostomy tube while in movement Use only in-line closed suction circuits Perform a periodic check of cuff pressure Do not change dressing unless there’s clear sign of infection The first tube change should be delayed by 7-10 days and staff must use all personal protections; perform a pause in ventilation, with flows off before deflating the cuff and inserting the new tube, after that follows immediate cuff re-inflation Use the cuffed non-fenestrated tube until the patient is confirmed negative to infection |
