Safety and Feasibility of a Novel Protocol for Percutaneous Dilatational Tracheostomy in Patients with Respiratory Failure due to COVID-19 Infection: A Single Center Experience

Abstract

Introduction. The rapidly spreading Novel Coronavirus 2019 (COVID-19) appeared to be a highly transmissible pathogen in healthcare environments and had resulted in a significant number of patients with respiratory failure requiring tracheostomy, an aerosol-generating procedure that places healthcare workers at high risk of contracting the infection. Instead of deferring or delaying the procedure, we developed and implemented a novel percutaneous dilatational tracheostomy (PDT) protocol aimed at minimizing the risk of transmission while maintaining favorable procedural outcome. Patients and Methods. All patients who underwent PDT per novel protocol were included in the study. The key element of the protocol was the use of apnea during the critical part of the insertion and upon any opening of the ventilator circuit. This was coupled with the use of enhanced personnel protection equipment (PPE) with a powered air-purifying respirator (PAPR). The operators underwent antibody serology testing and were evaluated for COVID-19 symptoms two weeks from the last procedure included in the study. Results. Between March 12th and June 30th, 2020, a total of 32 patients underwent PDT per novel protocol. The majority (80%) were positive for COVID-19 at the time of the procedure. The success rate was 94%. Only one patient developed minor self-limited bleeding. None of the proceduralists developed positive serology or any symptoms compatible with COVID-19 infection. Conclusion. A novel protocol that uses periods of apnea during opening of the ventilator circuit along with PAPR-enhanced PPE for PDT on COVID-19 patients appears to be effective and safe for patients and healthcare providers.

Therapeutic and Interventional Bronchoscopy Performed in Critically ill COVID-19 patients: A Systematic Review

“…Use of positive pressure hood, bronchoscopy under negative pressure ventilation, regular body temperature checks for HCWs, and weekly RT-PCR. Compliance with reprocessing of bronchoscopes reduced the rate of transmission and co-infection in patients (3, 68, 86, 75, 29). The HCWs performing high risk maneuvers during 2020-2021 pandemic were comparatively safer than those performed tracheal intubations in SARS-CoV-1 epidemic (90).…”

“…Disposable bronchoscopes were found to have least number of complications caused by it (86,25), compared to standard bronchoscopes which were responsible for few mild-moderate events (14,74,21,11,51,45,76,56). Cheap and affordable re-useable bronchoscopes would be beneficial for reducing infections lower or middle income countries, presently are less utilized.…”

“…Major bleeding, hemoptysis, and delayed bleeding was rare after therapeutic bronchoscopy and was found in patients undergoing bronchoscopy guided PDT (49,77). Bronchoscopy guided tracheostomy caused majority of adverse events in COVID-19 patients compared to other interventional bronchoscopy or therapeutic bronchoscopic procedures (61,86,3,82,81,56,87). Bronchoscopes were not responsible for occurrence of any major events in severely ill patients undergone PDT (Refer Supplementary figure 2-3).…”

Measurement of airborne particle emission during surgical and percutaneous dilatational tracheostomy COVID-19 adapted procedures in a swine model: Experimental report and review of literature

“…PEEP was adjusted on i/plateau and ii/driving pressure [ 36 ]. When circuit disconnection was required, manual expiratory pauses were performed to prevent from excessive aerosol generation [ 23 ]. The expiratory pauses were used each time a potential leak in the ventilation circuit had to be managed.…”

“…Tracheostomies, as well as endotracheal intubation, are classified as aerosol-generating procedures [ 1 – 3 ], exposing healthcare workers (HCWs) to a risk of viral infection [ 4 ]. Based on previous experiences (i.e., SARS-Cov-1 [ 5 , 6 ]), simulation studies and expert consensus, various adaptations have been proposed for both surgical [ 7 – 13 ] and percutaneous [ 7 , 14 – 23 ] tracheostomies, including suggestions of protective equipment [ 13 , 24 ] ( Table 1 ). Despite many recommendations quickly issued to ensure the safety of HCWs performing tracheostomies [ 25 , 26 ], the safety differences between surgical tracheostomies (ST) and percutaneous dilatational tracheostomies (PDT) techniques are unknown [ 27 ].…”