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.