Indications and care during intubation and tracheostomy
Head and neck surgeons, otolaryngologists, maxillofacial surgeons and
anesthetists are at high risk of contamination and infection by
SARS-CoV-2 when assisting patients with tracheostomy or performing a
rhinoscopy or a laryngoscopy because of the generation of aerosols.
Fortunately, tracheostomy is unlikely to be required for the majority of
patients. All patients must be examined by a physician wearing PPE such
as N95 or FFP2 mask or PAPR, gown, cap, eye protection and
gloves.8, 28 For
a tracheostomy, all staff must keep PPE with a powered air-purifying
respirator (PAPR) throughout the
procedure.11
The Royal College of Surgeons has posted guidance for surgical
tracheostomy during the COVID-19 pandemic
(https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic),
with advice as to decreasing the risk of aerosolization: stop
ventilation while the tracheostomy window is being performed, and only
resume ventilation when the cuff of the tracheostomy tube has been
inflated.
Zuo and co-workers presented the Chinese Society of Anesthesiology Task
Force on Airway Management recommendations for proper practice of
tracheal intubation by frontline anesthesiologists and critical care
physicians in critically ill patients with COVID-19
disease.36 Intubation
is considered a high-risk procedure due to the physician exposure to
secretions, blood, droplets and aerosols and should be indicated only
for patients with severe respiratory distress or hypoxemia after
standard oxygen therapy. It should be undertaken in an airborne
isolation room and enhanced droplet/airborne PPE should be applied to
all the healthcare workers, including N95 masks, hair cover,
protective coverall, gown, gloves, face shields and goggles (prepared
for anti-fog) and shoe covers. If available, a protective head hood or
PAPR should be used. Whenever possible, it should be performed by an
experienced anesthesiologist with assistance of another physician.
Airway assessment before intervention is regarded as crucial. All airway
management tools must be disposable and available including
a videolaryngoscope with disposable blades, and devices for needle or
scalpel cricothyroidotomy. According to Aminnejad et
al.37 and
Yang et
al.38 the
administration of intravenous lidocaine prior to tracheal extubation can
reduce coughing without side-effects, and it can be recommended also for
intubation aiming to reduce the risk for the physician who is doing the
procedure. Several specific recommendations are also afforded for an
anticipated difficult airway. The endotracheal tube must be secure and
then the patient is put in mechanical ventilation. All devices must be
collected in double-sealed bags and proper disinfection implemented
during disposal. All equipment and environment surfaces must be cleaned
and
disinfected.36
Akin to the physicians at high risk, allied health and nursing
professionals who care for patients with head and neck diseases continue
to be at high risk. Problematic settings include postoperative
tracheostomy care and valve changes for laryngectomees. These personnel
should adhere to the same PPE recommendations as for other professional
groups involved in airway interventions.