Tracheostomy in suspected or confirmed cases of COVID-19

Tracheostomy in patients admitted to the ICU who are under orotracheal intubation and mechanical ventilation is usually indicated between the fourth and the twenty-first intubation day. Most of the times it is done between 10 and 14 days. This indication may vary according to the severity of the disease and critical status of the patient. In critical ill patient, where the mechanical ventilation expectation is for more than 14 days, the tendency is to perform the tracheostomy earlier.^[ 4 ^]

Several reports show that the health condition of COVID-19 patients admitted to the ICU, under mechanical ventilation, is extremely severe and the mean time of intubation is of about two weeks.^[ 2 7 8 ^] The indication of tracheostomy must be carefully discussed case-by-case between ICU physicians and head and neck surgeons because this procedure is a high risk one, due to aerosol-generation. In general, there is a trend to avoid tracheostomy. However, for a small proportion of cases, it may be necessary to provide adequate respiratory care. Generally after 21 days. In preparation and during the procedure, all safety measures must be undertaken to mitigate occupational risk for physicians and other healthcare workers. As it is not an emergency indication, it is necessary to ensure that family understand the indication and the risks, and then sign an informed consent.

A tracheostomy in intubated patients is usually performed in the ICU. The ideal team consists of a surgeon and assistant with experience in tracheostomy in the ICU environment (head and neck surgeon, thoracic surgeon, or general surgeon). An intensivist must be present monitoring and acting on the infusion or suspension of drugs, decrease or increase gases, as well as helping to extubate the patient. It is necessary also have a scrub nurse, a physical therapist, a nurse and a nurse technician to deliver the necessary materials.^[ 4 ^]

The ideal environment to perform a tracheostomy in a COVID-19, like other patients with infection and acute respiratory syndrome, is a room with negative pressure or an isolated room.^[ 9 10 ^] However, it is not available in most Brazilian hospitals, except in the operating room. Whenever these conditions are not available, consider performing the procedure at the bedside, with closed doors, turning off the laminar flow (if present). Many surgeons prefer to perform the tracheostomy in the operating room. The decision depends on each hospital infrastructure and must be carefully discussed among all the team. A special consideration is the safety of the patients' transportation to the operating room. There are situations that the procedure must be performed at an operating room: morbid obese patients, large thyroid goiter or other neck mass or other anticipated technically difficult cases. Aiming to protect human resources, the team must be reduced to the essential staff (surgeon, assistant, anesthesiologist and a nurse technician).

Personal protective equipment (PPE) is essential to prevent contamination of all healthcare workers before, during and after a tracheostomy. All team must use surgical cap, masks type N95 or PPF2 (PPF3, if available); goggles or face shield; disposable longsleeved waterproof apron, two pairs of disposable gloves; and shoe covers.^[ 6 10 ^]

The choice of the technique to be used (percutaneous or open traditional) depends on the team's experience. There is no scientific evidence that percutaneous tracheostomy is safer and generates less aerosols. The current recommendation for percutaneous tracheostomy is to perform an ultrasound-guided procedure because it is prudent to avoid bronchoscopy. Ultrasound is a safe method to assist positioning the tracheostomy cannula inside the trachea.^[ 11 ^]

Regarding surgical equipment and surgical technique, the tracheostomy cannula must be cuffed and not fenestrated. Reserve at least 2 other cannulas of different sizes. The most experienced surgeon must perform the procedure. Reduce the use of electrocautery as much as possible. Before opening the trachea, ask the intensivist/anesthesiologist to administrate intravenous lidocaine to reduce the risk of coughing. The endotracheal tube must be pushed beyond the chosen site for tracheotomy to avoid aerosol spread. Pre-oxygenate and be sure that the patient endures a period of apnea required for cannula replacement. Ask the intensivist/ anesthesiologist to hold mechanical ventilation (if possible), made the tracheostomy window, ask the intensivist/anesthesiologist to pull the tracheal tube and then quickly introduce the cannula, secure it in position, place a heat and moisture exchanger (HME) device with viral filter aiming to reduce virus shedding, hyperinflate the cuff, ensure that there is no leak and finally connect the patient to ventilator. The orotracheal tube must be removed and a mask must be placed on patient to reduce dispersion if the patient cough. Seal as much as possible with the space between the skin incision and the tracheostomy tube. Suture the tracheostomy cannula to the skin.^[ 4 ^] All surgical instruments and disposables must be collected in sealed bags. All equipment and environment surfaces must be properly disinfected.

It is rare, but in some cases, an experienced intensivist or anesthesiologist will not be able to perform orotracheal intubation. Therefore, cricothyroidotomy may be indicated. However, the surgical team that will perform the procedure should not perform it as an extreme emergency surgical act. The patient must be oxygenated; the intensivist or anesthesiologist can use a laryngeal mask. The protection measures must be the same described before. The cricothyroidotomy is performed according to the established technique and the incision must be sutured tightly so that no aerosols will escape.^[ 4 ^] After performing the cricothyroidotomy, it must be replaced immediately by a tracheostomy following all the safety protocols described above.

The healthcare workers that deal with the patient must wear complete PPE. The cannula cuff must remain inflated and it is mandatory to check for leaks periodically. The circuit must not be disconnected and only closed in line suctioning should be used. The change of cannula must not be done until COVID-19 is cured.