Airway Management for Endoscopic Laryngotracheal Stenosis Surgery During COVID‐19

Abstract

<jats:p> The novel coronavirus disease 2019 (COVID-19) pandemic presents unique challenges for surgical management of laryngotracheal stenosis. High viral concentrations in the upper aerodigestive tract, the ability of the virus to be transmitted by asymptomatic carriers and through aerosols, and the need for open airway access during laryngotracheal surgery create a high-risk situation for airway surgeons, anesthesiologists, and operating room personnel. While some surgical cases of laryngotracheal stenosis may be deferred, patients with significant airway obstruction or progressing symptoms often require urgent surgical intervention. We present best practices from our institutional experience for surgical management of laryngotracheal stenosis during this pandemic, including preoperative triage, intraoperative airway management, and personal protective measures. </jats:p>

Laryngotracheal resection for a post-tracheotomy stenosis in a patient with coronavirus disease 2019 (COVID-19)

“… 11 While some surgical cases of laryngotracheal stenosis may be deferred, patients with significant airway obstruction or progressing symptoms often require urgent surgical intervention. 11 Consequently, appropriate measures should be taken to prevent them and a discussion about their appropriate treatment and timing would be recommended.…”

Multidisciplinary Safety Recommendations After Tracheostomy During COVID‐19 Pandemic: State of the Art Review

“…Early endoscopic intervention improves the outcome of postintubation airway stenosis. 9,75 Such interventions include inhaled steroids and antibiotics with anti-inflammatory effects, such as macrolides and trimethoprim/sulfamethoxazole, to promote mucosal healing and target local bacteria. 76,77 Early operative assessment with debridement of necrotic mucosa complements medical therapy to limit mature scar formation.…”

“…[1][2][3][4][5][6][7] Multidisciplinary team members (otolaryngologists, anesthesiologists, emergency physicians, intensivists, nurses, respiratory therapists, and speech-language pathologists) treating patients with tracheostomy are at elevated risk of COVID-19 infection (odds ratio, 4.2; 95% CI, 1.5-11.5), and previously unrecognized risks for patients are becoming apparent. [8][9][10][11][12][13][14][15][16][17][18][19] Efforts to devise safety standards and protocols for intubation and tracheostomy have been initiated across institutions. [20][21][22][23] Amid this intense focus on the tracheotomy procedure, including indications, timing, and technique, far less attention has been afforded to several high-stakes postprocedural considerations.…”

Optimizing Airway Surgery in COVID 19 Era

“…Tracheotomy/Tracheostomy [5,15,16,27,29] -Under General Anaesthesia with complete paralysis in elective cases where orotracheal intubation is possible -Metallic tracheostomy tubes are to be avoided to prevent mucosal injury -A cuffed silicon (Bivona) tracheostomy set is considered to be the best of its kind during tracheotomy; subsequently the tube can be deflated and can be left unchanged for 1 month unless indicated [8] The semi-urgent airway cases, which can be planned electively Example: repeat or staged airway procedure like second dilatation of tracheotomised case of subglottic tracheal stenosis, Benign vocal fold lesion like polyp, Early vocal fold malignancy -A relatively larger sized tube is used, to avoid frequent changing due to blockage -Adequate pre-oxygenation prior to tracheostomy -The skin incision should be generous to avoid unnecessary delay in the procedure -Procedure should be as fast as possible, performed by well-trained hands -There should be limited use of suction and electrocautery -Holding the ventilation just before making the tracheal incision will prevent the sudden burst of aerosols -The tracheostomy hub should be connected immediately to ventilator, preferably with a closed suction system -Connection with Viral filter or a heat and moisture exchanger (HME) is always recommended -Training and optimising tracheostomy tube self care at home and video-teleconsultation -In cases where orotracheal intubation is unfavourable, TIVA or IV deep sedation with HFNC can be preferred [7] Foreign Body Airway Removal [2,11,17] -Use of video-endoscopy for maintaining distance -Use of optical forceps for an expeditious procedure -Use of glass slide for blocking the vents of the bronchoscope -Side endoscope port oxygenation -Good communication with anaesthesiology team for avoiding unnecessary delay and minimisation of PPV -Swift execution of the procedure when intermittent apnea technique with complete neuromuscular blockade was used as anesthesia -TIVA or deep IV sedation is a good alternative to PPV -Plastic drape barrier [26] Subglottic Tracheal Stenosis [12,19,24,25] -Preference of repeated Coblation excision and dilatation -Intralesional steroid instillation -Relook procedure with balloon dilatation, wherever applicable -Aerosol minimalisation by closed ventilation via cuffed tracheostomy tube -CTR and anastomosis is another surgical option, but as…”