Outpatient Clinic Setting
Certain practices can minimize transmission of this highly contagious
virus in the outpatient setting, the most effective measure being the
deferral of all non-urgent visits and performing telemedicine visits
when a physical exam is not necessary (i.e. pathology and radiographic
imaging results). The federal government has taken steps to greatly
expand telemedicine services under Medicare and Medicaid with HIPAA
flexibilities and this was made retroactive to January 27,
2020.20
When in-office visits are absolutely necessary (e.g. postoperative
visits, tracheoesophageal prosthesis (TEP) complications, symptoms
concerning for cancer recurrence, etc.), screening prior to the visit
for symptoms of COVID-19 and self-quarantine measures may help reduce
transmission risks. An example of pre-arrival instructions for patients
are listed in Table 1. To minimize aerosolized particle spread from a
laryngectomy patient, the tracheostoma should be covered with a heat
moisture exchanger (HME), preferably with an integrated viral/bacterial
hydroscopic filter, and a physical barrier over the stoma such as a
surgical mask, scarf, or shirt, prior to their arrival to the
clinic.21,22
Two major manufacturers (Atos, InHealth) produce an HME with these
filters: Atos Provox® Micron HME™ filters virus and bacterial particles
(https://www.atosmedical.com/product/provox-micron-hme/), and the
InHealth Technologies® Blom-Singer® HME filters bacterial particles
(https://www.inhealth.com/category_s/47.htm). In addition laryngectomy
patients should, where feasible, be encouraged to use adhesive base
plates such as the Provox® StabiliBase™
(https://www.atosmedical.com/product/provox-stabilibase/) or the
Blom-Singer TruSeal Adhesive Housing
(https://www.inhealth.com/product_p/truseal_standard.htm). These
incorporate the HME and when properly applied will prevent airflow
outside of the HME, and reduce mucous contamination of clothing or other
physical barriers.
While scarves and shirts are not as effective as surgical masks in
reducing inhaled aerosol spread, they do provide some protection in
reducing aerosol projection.21,22 Attempts should be
made to minimize the time the patient spends in common areas and
check-in procedures should be expedited or performed in an examination
room when possible.
During the visit, only necessary personnel should enter the patient room
with the appropriate PPE as noted above. Defer nasopharyngoscopy and
tracheoscopy if possible. Pledgets with lidocaine and/or oxymetazoline
are preferable to atomized medications if anesthesia and decongestion
are necessary. When performing flexible tracheoscopy, attempts should be
made to minimize mucosal stimulation and resultant coughing. Following
flexible tracheoscopy, the scope should be immediately handed off and
cleaned to prevent contamination of counters and scope holders in the
exam room. If suctioning is required, having patients self-suction will
allow for providers and staff to leave the room during the time of
suctioning. However, it should be noted that viable SARS-CoV-2 has been
recovered from aerosols for up to 3 hours.23 Following
the visit, institutional protocol for room decontamination should be
followed while allowing an appropriate wait time for aerosols to settle.
For patients with moderate to high risk of COVID-19, consider
disinfecting all surfaces to reduce the risk of transmission, as
SARS-CoV-2 has been shown to be viable on some surfaces for up to 24-72
hours.24
Management of TEP Complication s
TEP complications are unique to the laryngectomy population, including
device dislodgement and leakage related to device failure in the tract.
Typically, these complications can be managed in the office using
standard PPE. However, due to the potential risk of SARS-CoV-2, the
standard management and timing to address these complications is subject
to change. Optimally, a negative pressure room and HEPA filtration can
minimize the risk of viral transmission, and should be considered in the
COVID-19 era.25 However, this is not necessarily
practical from a healthcare resource utilization and workflow
standpoint. Figure 1 presents a possible decision algorithm in managing
TEP complications including dislodgement of the prosthesis and leak
around the prosthesis.
A patient with a TEF or leak around a TEP is at an increased risk of
aspiration with potential sequelae including pneumonia, which could lead
to devastating outcomes if patients contract COVID-19. In the event of a
dislodged TEP, radiographic imaging can serve as a diagnostic tool to
replace flexible bronchoscopy or tracheoscopy in evaluating for an
airway foreign body. This can begin with standard X-rays of the chest
and abdomen but may be augmented with CT imaging.26Certainly, if the patient is in respiratory distress from an aspirated
TEP, urgent surgical intervention is indicated regardless of COVID-19
status. As noted above, these patients should be presumed to be COVID-19
positive until proven otherwise and enhanced PPE should be implemented.
Precautions to minimize aerosolization of particles while in transport
to the operating room and prior to intubation should be taken, such as
covering the stoma with an HME and surgical mask. For patients who do
not have an HME or laryngectomy tube, a tracheotomy tube with an HME can
be considered, though this may worsen their coughing.
In the stable patient, the main goal is to safely temporize and
troubleshoot any TEP complications until the risk of COVID-19
transmission is sufficiently lowered or testing is readily available.
Management at home should initially be attempted by the patient. If the
patient has a TEP plug, this can be placed to attempt to reduce any
leakage, though this will result in aphonia. Additionally, patients can
try alternative diet measures such as thickened liquids to reduce
leakage. A dislodged (non-aspirated) TEP may also be conservatively
managed at home by placing a red rubber catheter or dilator into the
TEF, if the patient is familiar with this procedure. An advantage to
this measure is that the red rubber catheter can serve as alternate
means of nutrition until TEP replacement becomes a viable option.
If in-office evaluation is necessary, ideally the patient should be
tested for COVID-19 prior to evaluation. If testing is negative and
symptoms are mild, the patient can undergo quarantine for 48 hours and
then return to the clinic at a later date for TEP insertion. Some
centers recommend a second rapid COVID-19 test is recommended following
the 48-hour quarantine prior to evaluation of intervention to mitigate
risk associated with false negative results.27However, this algorithm may remain infeasible until national testing
supplies and capacity are no longer severely limited.
In the event of a TEP complication for a known COVID-19 positive
patient, all efforts should be made by the patients to temporize
themselves at home without coming to the hospital, so long as they are
medically stable to remain at home. Once the patient is recovered from
the infection, they may then proceed with further management. For
COVID-19 positive patients, we strongly recommend the use of PAPR for
all personnel in the room during any procedures that manipulate the
airway.15 If a PAPR is not available, consider the use
of a level 4 surgical gown with helmet in addition to donning an N95
respirator and shoe covers. Involved personnel should be kept to the
bare minimum during instrumentation of the stoma in a known COVID-19
positive patient.