Discussion
COVID positive patients may remain infective for periods greater than 20
days (1). Delaying a tracheostomy might not reduce
infectivity of such patients whereas a timely tracheostomy may allow for
patients to be weaned off sedation faster and moved to intermediate care
wards, freeing up ICU resources. False-negative PCR test results are an
additional concern and therefore reasonable measures to protect staff
and the patients should be continuously practiced (2).
The tracheotomies of such patients in the ICU should be meticulously
planned and be performed in a negative pressure room facility wherever
available. The space restraints of an ICU room and suboptimal or
improper positioning in the ICU setting versus the risks involved in
transferring such patients from the ICU to Operation Theatre are factors
to be taken under consideration. We preferred PCDT over surgical
tracheostomy as PCDT potentially reduces the risk of surgical site
infection and rarely requires transfer to the theatre(3).
We established guidelines in advance for peri-tracheostomy care of such
patients with the multi-disciplinary involvement of Anaesthesiologists,
ENT surgeons, tracheostomy nurses, Speech and Language Therapists &
Physiotherapists.
A multi-disciplinary team tracheostomy plan proforma was developed and
each patient had a careful clinical review with tracheostomy and post
tracheostomy care plan established in advance.
On the day of surgery all necessary equipment was pre-arranged into
sterile packs in an anteroom of the negative pressure ICU suite.
We avoided the modified technique wherein the bronchoscope is passed by
the side of the endotracheal tube (4,) as in our
opinion this technique carries an increased risk of aerosolization.
The tracheostomy after-care of COVID-19 patients differs from routine
care tracheostomy because of a high risk of transmission of infection
due to Aerosolisation. Routine tracheostomy specific Aerosol Generating
Procedures (AGPs) include tracheal open suctioning, tracheostomy changes
and sputum induction(5,7) but other interventions like
chest physiotherapy, inner cannula changes and nebulisation may also
increase the likelihood of coughing and sputum
production(5).
We recommend that all Tracheostomy Care related interventions in
COVID-19 patients (positive, suspected or recovering) should be treated
as AGPs and staff should don full PPE at all such times.
There are 7 crucial steps involved(6) and the
frequency of each of these interventions should be reviewed and
re-evaluated as needed to reduce clinical risk to the patient as well as
to protect staff (Table 1).
Positive pressure ventilation also increases the potential for aerosol
risks to staff (7) and staff taking care of patients
receiving positive pressure ventilation should don appropriate PPE. A
cuff inflated, closed system is most likely to prevent
cross-contamination of staff, equipment and other patients and therefore
closed in-line suction is recommended (8).
In the wards a regular Multi-disciplinary tracheostomy ward round should
be done. A daily record of all tracheostomy related
care/intervention/events should be maintained. All tracheostomy care
interventions should be treated as AGPs. A simple face mask should be
applied over the face of the patient once the cuff is deflated to
minimize droplet spread.
Any tracheostomy tube change should be discussed by the clinical team to
outline the potential risks versus the benefits of this AGP. The
procedure should be performed with full PPEs, and preferably in a single
room with negative pressure facility. Ensure availability of all
emergency equipment and drugs before the start of a procedure.
All patients should be trialled on dry oxygen via HME filter as first
line intervention (5). For routine tracheal suctioning
a closed, inline suction with HME filter should be preferred to reduce
the risk of aerosolization (9).
Initially we proposed a simple system, for spontaneously breathing
patients with tracheostomy in –situ, which had a Closed Suction Unit,
HME Filter and Swedish nose for oxygen supply (fig 2). Although simple,
this circuit is ‘heavy’ and can cause drag on the tracheostomy tube.
We eventually used a novel circuit called Kelley Circuit (fig1).The
Kelley Circuit combines the ProTrach® XtraCare™ HME with an
electrostatic filter with a closed-circuit suction
system(10). In our experience this circuit is more
compact and light-weight and therefore will cause less drag.
Conclusion:
A surge of COVID-19 patients can overwhelm hospitals with a possibility
of many requiring mechanical ventilation and possible tracheostomy. The
decision of surgical or percutaneous tracheostomy should be dependent on
the experience of the tracheostomy performer, health-care worker safety,
resource availability, and patient-centred care. Proper and acceptable
guidance for performance and post tracheostomy care is crucial and
should be established in advance. We believe our modified strategic
approach for PCDT offers an extra level of safety to healthcare workers.