Guidance for tracheostomy use during COVID-19 pandemic
Three medical societies released an expert panel report on the use of tracheostomy during the COVID-19 pandemic while minimizing the risk for infection to health care workers.
Critically ill patients with COVID-19 account for 5% of all cases and one-quarter of all hospitalizations. Many of these patients require prolonged mechanical ventilation. Performing tracheostomies on these patients may allow for faster removal from ventilation, shorter hospitalization and thus greater ICU resource availability, but there are currently unanswered questions regarding preparation, timing, technique and protection for health care workers.
Because COVID-19 is transmitted via droplets, open airway procedures like tracheostomy may pose a significant risk to health care workers performing these procedures, according to a press release from the American College of Chest Physicians.
“We believe we addressed the most common questions being faced by physicians during this pandemic pertinent to the practice of tracheostomy,” Carla R. Lamb, MD, FCCP, interventional pulmonologist at Lahey Hospital and Medical Center in Burlington, Massachusetts, and colleagues wrote. “One of the strengths of this expert panel report is that it represents the opinions and perspectives of intensive care and interventional pulmonary experts from 10 states with the highest burden of COVID-19 in the U.S.”
Recommendations
The expert panel report was issued by CHEST, the American Association for Bronchology and Interventional Pulmonology, and the Association of Interventional Pulmonology Program Directors to address concerns and knowledge gaps in tracheostomy use during the COVID-19 pandemic. The panel comprised intensivists and interventional pulmonologists from the three professional societies, representing 13 institutions with experience in managing patients with COVID-19 infection.
The panel conducted a systematic review of existing literature and devised eight important recommendations to guide for health care workers on the use of tracheostomy in patients with COVID-19 respiratory failure. The recommendations are as follows:
- Tracheostomy should be considered in patients with COVID-19 when prolonged mechanical ventilation is anticipated.
- Optimal timing of tracheostomy in patients with COVID-19 remains debatable, as there is insufficient evidence to recommend specific timing. Decisions on timing should be individualized and based on prognosis and institutional critical care resource constraints, according to the panel.
- Patients with COVID-19 respiratory failure expected to require prolonged mechanical ventilation can undergo open surgical or percutaneous dilatational tracheostomy.
- Enhanced personal protective equipment should be used to lower risk for COVID-19 transmission to health care workers during tracheostomy.
- Tracheostomy should be performed in a negative-pressure room, preferably in an ICU, or in the OR, to minimize COVID-19 transmission. The panel also recommends special attention to minimize transportation-related exposure risk.
- Reverse transcription polymerase chain reaction testing is not recommended prior to tracheostomy in patients with confirmed COVID-19 respiratory failure.
- Tracheostomy should be performed by a team comprising the least number of providers with highest level of expertise.
- Patients should be maintained with a closed circuit while on mechanical ventilation with a tracheostomy tube and with in-line suction.
The full recommendations and details are included in the expert panel report.
Questions remain
The panel notes that there are still unanswered questions about evolving staff preparation and protection, timing, technique and postintervention care for patients with COVID-19-related respiratory failure undergoing tracheostomy. The panel recommends performing the procedure using techniques that minimize aerosolization.
“Tracheostomy is an essential clinical strategy for managing patients with COVID-19, but as this report emphasizes, the use of appropriate personal protective equipment is critical to reducing the risk to health care workers and best practices to minimize aerosolization should be used,” Steven Q. Simpson, MD, FCCP, president-elect of CHEST, said in the release.
The panel also noted that the recommendations in this report “may change as more experience and data are collected during the COVID-19 pandemic.
“Due to the urgency of this situation, information needs to be made available to provide clinicians general recommendations based on limited published data and panel’s expertise,” the researchers wrote. “This statement should be considered a living document that could be updated in the future in a timely manner as new evidence becomes available.”