Methods and materials
Fourteen confirmed COVID-19 patients treated with tracheostomy before April 3, 2020 in [removed for blind peer review] were retrospectively analyzed. All patients except case 7 underwent standard open tracheostomy (OT). Case 7 underwent an open revision tracheostomy because of thyroid bleeding and incorrect intubation position after percutaneous tracheostomy (PT). The clinical characteristics of patients were detailed in Table 1. The median age of all patients was 69 years, ranging from 45 to 80 years old. Seven 7 (50%) patients were male. Eleven (78.5%) patients had at least one underlying comorbidity, the most common of which were hypertension (64.2%), diabetes (50%), malignancy (14.3%) and cerebrovascular disease (14.3%). The median duration from illness onset to tracheostomy was 50 (ranging from 33~90) days. The intubation period was ranged from 9~36 days with a median of 25.5 days. Case 14 had experienced reintubation for ventilatory assistance after an unsuccessful extubation. All patients were given anticoagulant therapy due to increased coagulation activity while this therapy was suspended for the four cases after the occurrence of cerebral hemorrhage or gastrointestinal bleeding. Common coexisting disorders before tracheostomy included cerebrovascular disease (64.2%), acute kidney injury (42.8%), acute liver injury (28.7%), acute cardiac injury (21.4%). Case 2, case 3 and case 5 had experienced endotracheal cannula obstruction and replacement. Follow-up was to continue through at least 14 days after tracheostomy until April 17, 2020 or death.
Patients were placed in a single intensive care unit (ICU) room with a portable operating lamp and frequent air exchange. A tracheostomy set of instruments and a closed suction device connected to a virus filter membrane was prepared. The medical staff includes two skilled surgeons, an ICU specialist responsible for anesthesia and monitoring, and a standby nurse. Protective equipment included waterproof medical cap, medical protective mask (N95), goggles with an anti-fog screen, protective garment, anti-penetration isolation gown, surgical gloves, and plastic shoe covers and powered air-purifying respirators (PAPRs).
The patients were given preoxygenation (100% oxygen for 5 min) and then fully paralyzed. Following routine tracheostomy, mechanical ventilation was stopped when the surgeon was going to incise the trachea. The endotracheal tube was slowly pulled out to just above the tracheotomy site under direct vision. No tracheal or wound suctioning was attempted to avoid possible aerosol generation. The tracheostomy tube was inserted, followed by inflation of the balloon. We immediately connected the tracheostomy tube to the ventilator and performed suction with a closed system. The endotracheal tube was removed when adequate ventilation was confirmed.