Tracheostomy During the COVID‐19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries

Abstract

Objective The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. Data Sources Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. Review Methods The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. Conclusions Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. Implications for Practice Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

COVID-19 survivorship: How otolaryngologist-head and neck surgeons can restore quality of life after critical illness

“…For some post-ICU impairments, a longer duration of critical illness is associated with greater impairment [ 4 ]. Timing of tracheostomy is therefore a key consideration [ 5 ]. Over 80% of patients requiring mechanical ventilation manifest residual impairments ( Fig.…”

“…Intubation can be more challenging due to reduced visualization or personal protective equipment that impedes communication. Otolaryngologist input into optimal tracheostomy timing and multidisciplinary care may decrease laryngeal injuries and expedite both early diagnosis and intervention [ 5 ].…”

Emergency surgical tracheotomy in the era of COVID-19 pandemic

“…On the other hand, many authors emphasized that the risk of viral aerosolization is significantly reduced when tracheotomy is performed in negative pressure rooms [43,46,52,57,60,62]. Certainly, this point along with the creation of dedicated routes for the transport of COVID-19 patients represents a considerable logistic and economic burden for many hospitals.…”

“…The use of several types of facial filters has been reported by the studies exploring the management of CICO scenario in COVID-19 patients. Some authors suggest that, in the case of aerosol-producing procedures like OST, operators should use powered air-purifying respirators (PAPRs) [33,52,62]. However, some uncertainties with this indication arise because of their limited availability, the long time required to wear them -not always compatible with emergencies -and the generation of noise that could interfere with communications between the members of the emergency team [33,61].…”

Björk Flap Tracheotomy for COVID-19 Pneumonia With Massive Thyroid Struma: A Stable Airway to Expedite Ventilator Weaning

“…Given clinical deterioration and the need for ventilatory support to improve oxygen saturation, the patient underwent endotracheal intubation, which was maintained for 10 days. The patients demonstrated no progress with weaning, and therefore, a tracheostomy was performed in the operating room in accordance with international guidelines, 7 with all members of the team wearing appropriate personal protective equipment (PPE).…”