Tracheostomy in the intensive care unit: Guidelines during COVID-19 worldwide pandemic

Abstract

Purpose COVID-19 has become a pandemic with significant consequences worldwide. About 3.2% of patients with COVID-19 will require intubation and invasive ventilation. Moreover, there will be an increase in the number of critically ill patients, hospitalized and intubated due to unrelated acute pathology, who will present underlying asymptomatic or mild forms of COVID-19. Tracheostomy is one of the procedures associated with an increased production of aerosols and higher risk of transmission of the virus to the health personnel. The aim of this paper is to describe indications and recommended technique of tracheostomy in COVID-19 patients, emphasizing the safety of the patient but also the medical team involved. Materials and methods A multidisciplinary group made up of surgeons with privileges to perform tracheostomies, intensive care physicians, infectious diseases specialists and intensive pulmonologists was created to update previous knowledge on performing a tracheostomy in critically ill adult patients (>18 years) amidst the SARS-CoV-2 pandemic in a high-volume referral center. Published evidence was collected using a systematic search and review of published studies. Results A guideline comprising indications, surgical technique, ventilator settings, personal protective equipment and timing of tracheostomy in COVID-19 patients was developed. Conclusions A safe approach to performing percutaneous dilational bedside tracheostomy with bronchoscopic guidance is feasible in COVID-19 patients of appropriate security measures are taken and a strict protocol is followed. Instruction of all the health care personnel involves is key to ensure their safety and the patient's favorable recovery.

Clinical characteristics of critically ill patients with COVID-19

“…The need for tracheostomies in critically ill COVID-19 patients ranges from 36% to 53%, according to the data found in the literature 28-30 . Prioritizing the protection of health personnel, tracheostomy was considered possible only in patients who were expected to obtain a substantial benefit. Ideally, it was performed 21 days after intubation with a negative RT-PCR test 31 . Following that criteria and up to data cutoff, none of the surgeons or intensivists who performed tracheostomies developed symptoms or tested positive for COVID-19.…”

“…Most of the patients received dexamethasone (on RECOVERY-trial dose 9 ) and empirical intravenous antibiotic therapy (143 [ Among overall patients, the median duration of hospitalization was 21 days (14-32) and the median length of stay in ICU was 13 days (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). ICU length of stay among survivors was 5 days (3)(4)(5)(6)(7)(8) for non-ventilated patients and 23 days (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31) for those patients who required invasive MV. Overall ICU mortality of this series was 25% (42).…”

Considerations about Timing to Perform Elective Tracheostomies in Patients Hospitalized in COVID-19 Units

“…A resume of these recommendations is on Table 1. Modifications of institutional protocols for performing elective tracheostomies are necessary, according to the proper realities of each assistance service, specially in developing countries [1] [2] [9].…”

“…Care of these patients has become a challenge, mostly because is necessary to understand the clinical-epidemiological characteristics of the disease. And is an urgent premise to protect the health professionals involved and not exhaust the financial re-sources available for assistance [1] [2]. Tracheostomy is a routine procedure in patients requiring mechanical ventilation due to respiratory failure.…”

An uncomplicated and safe technique for preventing endotracheal tube cuff damage during tracheostomy using pressure-controlled ventilation: the PCV method

“… 4 Herein, we describe a safe technique for tracheostomy that is applicable for patients with COVID-19, with an emphasis on the safety of both the patient and the medical team involved. 5 We have termed this technique the “pressure-controlled ventilation” (PCV) method.…”