Surgical Tracheostomy Protocol In COVID-19 Patients

BLA TRACHEOSTOMY GUIDELINE

Applies to all tracheostomies undertaken (whether known Covid-19 or not due to high-risk nature of the procedure and increasing prevalence in the community). This guideline refers mainly to open surgical tracheostomy, although in some units percutaneous procedures may be preferred. When choosing a technique, it is critical that the operator is highly experienced in whichever route is chosen to reduce time and potential complications.

Preparation

• One tracheostomy per theatre session (to be kept under review)
• Two ITU consultants to make a decision after discussion with the surgical team and senior anaesthetist. The patient should have a good expectation of achieving full recovery and an independent lifestyle.
• Unlikely to be indicated after less than 14 days of ventilation
• Consider trial of extubation – i.e. high threshold to perform tracheostomy
• The patient should be apyrexial with falling inflammatory markers (a surgical procedure undertaken during viraemia risks precipitating a clinical deterioration)
• Two Negative viral swabs (48 hrs apart) preferred, but it is accepted this may not always be possible
• The patient should be requiring PEEP ≤10cmH2O and FiO2 ≤0.4 (to promote tolerance to periods of apnoea and potential derecruitment)
• Haemodynamically stable with minimal pressor requirement
• Review CXR to ascertain starting distance of ETT tip above carina
• Patient fasted for 6 hours
• Consent form 4 completed by ITU.

OT Team

• Consultant surgeon (ENT or OMFS)
• Skilled Assistant (ENT / OMFS middle grade)
• Scrub nurse
• Consultant anaesthetist skilled in anaesthesia for surgical tracheostomy
• ODP
• Second theatre nurse as runner in theatre
• CLEAN runner in anaesthetic room with silver trolley to supply additional equipment required by anaesthetic and surgical teams
• Staff should be drawn from an agreed list. Full PPE for all theatre staff (including FFP3 mask and visor), consider powered hoods (PAPR) for operating surgeons.

Theater Preparation

• Book case with emergency theaters and liaise with theaters day prior to and on the morning of planned procedure to plan logistics –ideally schedule for afternoons using second emergency theatre team.
• Negative pressure side room on ITU (staffed by the emergency theater team) may be used for Covid-19 patients, but requires careful planning by the emergency theatre team. Consider human factors and logistics of operating in an unfamiliar environment and having to transfer all equipment. Operating outside of a theatre environment poses many technical challenges.
• A negative pressure operating theatre is preferable but few hospitals have such a facility, so most procedures will be carried out in a positive pressure environment.
• Extended team brief: The whole theatre team should be introduced to one another and meet in a quiet area to discuss the case, taking into consideration the views and ideas of all team members. The plan should be agreed and then clearly repeated, with steps in case of possible complications also agreed. This meeting should include consideration of all possible equipment needs

Airway Equipment’s

• Suction equipment with Yankauer and tracheal suction catheters (avoid use if possible). Put tape across Yankauer hole.
• Laryngoscopes: Macintosh and McGrath
• 20 ml syringe
• Tape to re-secure ETT
• Eye tapes and pads
• Drugs
• Clamp for ETT
• Long theatre ventilator tubing

Pre -Operative

• Consider reducing theatre temperature for staff comfort wearing PPE.
• Transfer onto operating table -patient head at anaesthetic machine end.
• To place on theatre ventilator, clamp ETT then turn off transport ventilator before
transferring to theatre ventilator.
• Leave ETT in-line suction in situ. Consider taping connections.
• WHO time out including tracheostomy time out (this check-list)
• Scrub team to assemble tracheostomy inline suction with clean HME filter
• A range of cuffed, non-fenestrated tracheostomy tubes should be available. Consider risks of using large tubes – aim for size 8 for males and size 6 for females.

Patient Preparation

• Tape and pad eyes
• Surgical positioning – Head ring and shoulder roll (or other as requested by consultant surgeon)
• Drape and proceed.

Anesthetic Role

• Suction oropharynx with Yankauer and trachea via in-line suction.
• Advance ETT blindly with cuff inflated observing ventilator for signs of right main bronchial intubation (increase in peak airway pressure if volume control mode, fall in tidal volume if pressure control mode)
• Increase cuff pressure and ensure patient is paralysed

Emergency Tracheostomy

Manage patient as such COVID-19 positive. Given respiratory symptoms they will fulfil criteria for suspected COVID-19 and there will not be time for testing in this situation.

Reversible cause for airway obstruction

• Intubation rather than tracheostomy would be preferable, follow difficult airway guidance
• Avoid use of high flow oxygen/AIRVO
• Most skilled airway manager (anaesthetist) present should manage airway to maximise first pass success 
• Most skilled airway manager (ENT) for tracheostomy if required
• Reduce unnecessary team members to essential staff
• See Standard Operative Procedure for tracheostomy below

Irreversible cause for airway obstruction i.e. (Laryngeal mass)

• Irreversible cause for airway obstruction where intubation is not appropriate, tracheostomy as per standard operative procedure below
• At this time, it may not be advisable for laryngeal debulking in those where COVID-19 status is unknown 

Elective Tracheostomy

• COVID-19 testing to be performed in all patients prior to elective tracheostomy
• Tracheostomy is a high-risk procedure because of aerosol-generation, it may be prudent to delay tracheostomy until active COVID-19 disease has passed (icmanaesthesiacovi-19.org)
• ENT and ITU consultant to discuss appropriateness of tracheostomy in COVID-19 positive patient
• If COVID negative following testing proceed as per standard operating procedure (fluid resistant surgical mask, surgical gown, gloves and eye protection.

Standard operative procedure for tracheostomy

• Most skilled anaesthetic and ENT clinician performing anaesthetic and procedure, to ensure that the procedure is safe, accurate and swift
• Reduce unnecessary team members to essential staff
• Preparation and Gowning:

1. Use FFP3 mask.
2. Eye/face protection should be worn for performing tracheostomy or changing a tracheostomy tube due to the risk of respiratory secretions or body fluids. One of the following options are suitable:
   1. surgical mask with integrated visor
   2. full face shield/visor
3. Fluid resistant disposable gown should be worn. If non-fluid resistant gown is used a disposable plastic apron must be worn underneath. A sterile disposable gown must be used for surgical tracheostomy.
4. Gloves must be appropriate to allow palpation, use of stitches and surgical instruments. Consider using Eclipse system or “double-gloving”.

• Cuffed non-fenestrated tracheostomy should be used to avoid aerosolizing the virus
• Every effort should be made not to pierce the cuff of the endotracheal tube when performing tracheotomy
• Initial advancement of the endotracheal tube should be performed prior to tracheostomy window being made
• If possible, cease ventilation whilst window in the trachea is being performed and check the cuff is still inflated before recommencing ventilation
• Ventilation to cease prior to tracheostomy tube insertion and ensure swift and accurate placement of tracheostomy tube with prompt inflation of the cuff.
• Confirm placement with end tidal CO2.
• Ensure there is no leak from the cuff and the tube is secured in position
• HME (Heat and moisture exchanger) should be placed on the tracheostomy to reduce shedding of the virus should the anaesthetic tubing be disconnected
• Avoid disconnecting HME but if necessary, disconnect distal to HME.

Post tracheostomy care

• RCoA suggests avoiding humidified wet circuits as theoretically it will reduce the risks of contamination of the room if there is an unexpected circuit disconnection
• Avoid changing the tracheostomy tube until COVID-19 has passed, will have to review with infectious diseases
• Cuff to remain inflated and check for leaks
• Make every effort not to disconnect the circuit.
• Only closed in line suctioning should be used.

Tracheostomy and Tracheostomy Tube Changes in confirmed negative or not suspected COVID 19

Equipment and Gowning:

1. Use fluid resistant surgical mask.
2. Eye/face protection should be worn for performing tracheostomy or changing a tracheostomy tube due to the risk of respiratory secretions or body fluids. One of the following options are suitable:
   1. surgical mask with integrated visor
   2. full face shield/visor
3. Usual surgical gown for tracheostomy and single use disposable apron for tube change.
4. Gloves must be appropriate to allow palpation, use of stitches and surgical instruments. Consider using Eclipse system or “double-gloving”.

Important information

Personal protective equipment (PPE) is only part of a system to prevent contamination and infection of healthcare workers. In addition to PPE, procedures such as decontamination of surfaces and equipment, minimising unnecessary patient and surface contact and careful waste management are essential for risk reduction. The virus can remain viable in the air for a prolonged period and on non-absorbent surfaces for many hours and even days (van Doremalen N et al, 2020). Where an aerosol-generating procedure has been performed the room should be deep cleaned after 20 minutes (Public health England).

Reliable use of PPE significantly reduced the risk of infection in healthcare workers during the SARS epidemic.

A 2012 systematic review of infection risk to healthcare workers Van Doremalen et al, 2020, based on limited literature, ranked airway procedures in descending order of risk as

1. Tracheal intubation
2. Tracheostomy (and presumed for emergency front-of-neck airway (eFONA))
3. Non-invasive ventilation (NIV)
4. Mask ventilation

References

• icmanaesthesiacovi-19.org
• ENT UK Guidance for ENT during the COVID-19 pandemic
• van Doremalen N, Bushmaker T, Morris DH et al. Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1. NEJM in press doi: https://doi.org/10.1101/2020.03.09.20033217.
• https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic-l-harrison-et-al
• https://www.entuk.org/bla-tracheostomy-guideline-external

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