Top

European Archives of Oto-Rhino-Laryngology

Published in:

Open Access 01-08-2020 | Coronavirus | Review Article

Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic

Authors: Arunjit Takhar, Abigail Walker, Stephen Tricklebank, Duncan Wyncoll, Nicholas Hart, Tony Jacob, Asit Arora, Christopher Skilbeck, Ricard Simo, Pavol Surda

Published in: European Archives of Oto-Rhino-Laryngology | Issue 8/2020

Abstract

Purpose

The COVID-19 pandemic is placing unprecedented demand upon critical care services for invasive mechanical ventilation. There is current uncertainty regarding the role of tracheostomy for weaning ventilated patients with COVID-19 pneumonia. This is due to a number of factors including prognosis, optimal healthcare resource utilisation, and safety of healthcare workers when performing such a high-risk aerosol-generating procedure.

Methods

Literature review and proposed practical guideline based on the experience of a tertiary healthcare institution with 195 critical care admissions for COVID-19 up until 4th April 2020.

Results

A synthesis of the current international literature and reported experience is presented with respect to prognosis, viral load and staff safety, thus leading to a pragmatic recommendation that tracheostomy is not performed until at least 14 days after endotracheal intubation in COVID-19 patients. Practical steps to minimise aerosol generation in percutaneous tracheostomy are outlined and we describe the process and framework for setting up a dedicated tracheostomy team.

Conclusion

In selected COVID-19 patients, there is a role for tracheostomy to aid in weaning and optimise healthcare resource utilisation. Both percutaneous and open techniques can be performed safely with careful modifications to technique and appropriate enhanced personal protective equipment. ORL-HNS surgeons can play a valuable role in forming tracheostomy teams to support critical care teams during this global pandemic.

John Hopkins University (2020) Coronavirus Resource Centre. https://coronavirus.jhu.edu/map.html. Accessed 10 April 2020

Wu Z, McGoogan JM (2020) Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for disease control and Prevention. JAMA. https://doi.org/10.1001/jama.2020.2648 CrossRefPubMedPubMedCentral

Huang C, Wang Y, Li X et al (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China Lancet 395(10223):497–506. https://doi.org/10.1016/S0140-6736(20)30183-5 CrossRefPubMed

Wang D, Hu B, Hu C et al (2020) Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan. JAMA 323(11):1061–1069. https://doi.org/10.1001/jama.2020.1585 CrossRefPubMedPubMedCentral

Intensive Care National Audit and Research Centre (2020) ICNARC report on COVID-19 in critical care. https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports. Accessed 10 April 2020

Griffiths J et al (2005) Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 330(7502):1243. https://doi.org/10.1136/bmj.38467.485671.E0 CrossRefPubMedPubMedCentral

Adly A, Youssef TA, El-Begermy MM et al (2018) Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review. Eur Arch Otorhinolaryngol 275:679–690. https://doi.org/10.1007/s00405-017-4838-7 CrossRefPubMed

On the right Trach? (2014) A review of the care received by patients who underwent a tracheostomy. NCEPOD. https://www.ncepod.org.uk/2014report1/downloads/OnTheRightTrach_FullReport.pdf. Accessed 2 April 2020

Tian S, Hu W, Niu L, Liu H, Xu H, Xiao SY (2020) Pulmonary Pathology of Early-Phase 2019 Novel Coronavirus (COVID-19) Pneumonia in Two Patients With Lung Cancer [published online 28 Feb 2020]. J Thorac Oncol S1556–0864(20):30132–30135. https://doi.org/10.1016/j.jtho.2020.02.010 CrossRef

10.

He F, Deng Y, Li W (2020) Coronavirus disease 2019: What we know? J Med Virol. https://doi.org/10.1002/jmv.25766 CrossRefPubMedPubMedCentral

11.

Andriolo RB, Brenda NG et al (2015) Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD007271.pub3 CrossRefPubMedPubMedCentral

12.

Curry SD, Rowan PJ (2020) Laryngotracheal stenosis in early vs late tracheostomy: a systematic review. Otolaryngol Head Neck Surg 162(2):160–167. https://doi.org/10.1177/0194599819889690 CrossRefPubMed

13.

Wang R, Pan C, Wang X, Xu F, Jiang S, Li M (2019) The impact of tracheotomy timing in critically ill patients undergoing mechanical ventilation: a meta-analysis of randomized controlled clinical trials with trial sequential analysis. Heart Lung 48(1):46–54. https://doi.org/10.1016/j.hrtlng.2018.09.005 CrossRefPubMed

14.

Siempos II et al (2015) Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. Lancet 3:150–158. https://doi.org/10.1016/S2213-2600(15)00007-7 CrossRef

15.

Clec'h C et al (2007) Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med 35(1):132–138. https://doi.org/10.1097/01.CCM.0000251134.96055.A6 CrossRefPubMed

16.

Combes A et al (2007) Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med 35:802–807. https://doi.org/10.1097/01.ccm.0000256721.60517.b1 CrossRefPubMed

17.

Meng L et al (2016) Early vs late tracheostomy in critically ill patients: a systematic review and meta-analysis. Clin Respir J 10(6):684–692. https://doi.org/10.1111/crj.12286 CrossRefPubMed

18.

National Institute for Health and Care Excellence (2020). COVID-19 rapid guideline: critical care in adults. https://www.nice.org.uk/guidance/ng159. Accessed 10 April 2020

19.

National Tracheostomy Safety Project (2020). NTSP Considerations for tracheostomy in the COVID-19 outbreak. https://www.tracheostomy.org.uk/storage/files/NTSP%20Advice%20for%20patients%20with%20a%20tracheostomy%20in%20the%20Coronavirus%20pandemic.pdf Accessed 2 April 2020

20.

Kress JP, Pohlman AS, O'Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342(20):1471–1477. https://doi.org/10.1056/NEJM200005183422002 CrossRefPubMed

21.

Leung C (2020) Clinical features of deaths in the novel coronavirus epidemic in China. Rev Med Virol. https://doi.org/10.1002/rmv.2103 CrossRefPubMedPubMedCentral

22.

Grasselli G, Zangrillo A, Zanella A et al (2020) Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy. JAMA. https://doi.org/10.1001/jama.2020.5394 CrossRefPubMedPubMedCentral

23.

American Academy of Otolaryngology and Head and Neck Surgery (2020) AAO position statement: tracheotomy recommendations during the COVID-19 pandemic. https://www.entnet.org/content/aao-position-statement-tracheotomy-recommendations-during-covid-19-pandemic. Accessed 2 April 2020

24.

Cereda D, Tirani M, Rovida F et al (2020) The early phase of the COVID-19 outbreak in Lombardy, Italy. (submitted 20 March 2020) https://arxiv.org/abs/2003.09320. Accessed 4 April 2020

25.

Zou L, Ruan F, Huang M, Liang L et al (2020) SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 382(12):1177–1179. https://doi.org/10.1056/NEJMc2001737 CrossRefPubMedPubMedCentral

26.

Lescure F, Bouadma L, Nguyen D et al (2020) Clinical and virological data of the first cases of COVID-19 in Europe: a case series. Lancet Infect Dis. https://doi.org/10.1016/S1473-3099(20)30200-0 CrossRefPubMedPubMedCentral

27.

Zhou F, Yu T, Du R, Fan G et al (2020) Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 395:1054–1062. https://doi.org/10.1016/S0140-6736(20)30566-3 CrossRefPubMedPubMedCentral

28.

Canadian Society of Otolaryngology-Head and Neck Surgery (2020) Recommendations from the CSO-HNS Taskforce on Performance of Tracheotomy During the COVID-19 Pandemic. https://www.entcanada.org/wp-content/uploads/COVID-19-Guidelines-CSOHNS-Task-Force-Mar-23-2020.pdf Accessed 2 April 2020

29.

Fang Y, Zhang H, Xie J et al (2020) Sensitivity of chest CT for COVID-19: Comparison to RT-PCR. Radiology. https://doi.org/10.1148/radiol.2020200432 CrossRefPubMed

30.

Public Health England (2020) COVID-19: Guidance for infection prevention and control in healthcare settings. Version 1.1,27/3/20 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/876577/Infection_prevention_and_control_guidance_for_pandemic_coronavirus.pdf#page=27 Accessed 2 April 2020

31.

Givi B, Schiff BA, Chinn SB et al (2020) Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg. https://doi.org/10.1001/jamaoto.2020.0780 CrossRefPubMed

32.

Tay JK, Khoo ML, Loh WS (2020) Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak. JAMA Otolaryngol Head Neck Surg. https://doi.org/10.1001/jamaoto.2020.0764 CrossRefPubMed

33.

Chow T et al (2006) Conversion of operating theatre from positive to negative pressure environment. J Hosp Infect 64(4):371–378. https://doi.org/10.1016/j.jhin.2006.07.020 CrossRefPubMedPubMedCentral

34.

Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A (2016) Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD008045.pub2 CrossRefPubMedPubMedCentral

35.

Krishnan K, Elliot SC, Mallick A (2005) The current practice of tracheostomy in the United Kingdom: a postal survey. Anaesthesia 60:360–364. https://doi.org/10.1111/j.1365-2044.2004.04106.x CrossRefPubMed

36.

ENT-UK (2020) COVID-19 Tracheostomy guidance. https://www.entuk.org/sites/default/files/files/COVID%20tracheostomy%20guidance_compressed.pdf Accessed 2 April 2020

37.

Loeb M, McGeer A, Henry B, Ofner M et al (2004) SARS among Critical Care Nurses. Toronto Emerg Infect Dis 10(2):251–255. https://doi.org/10.3201/eid1002.030838 CrossRefPubMed

Title: Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic
Authors: Arunjit Takhar
Abigail Walker
Stephen Tricklebank
Duncan Wyncoll
Nicholas Hart
Tony Jacob
Asit Arora
Christopher Skilbeck
Ricard Simo
Pavol Surda
Publication date: 01-08-2020
Publisher: Springer Berlin Heidelberg
Keywords: Coronavirus
SARS-CoV-2
Care
COVID-19
Tracheostomy
Published in: European Archives of Oto-Rhino-Laryngology / Issue 8/2020
Print ISSN: 0937-4477
Electronic ISSN: 1434-4726
DOI: https://doi.org/10.1007/s00405-020-05993-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 8/2020

The author’s reply regarding "Intratympanic gentamycine for Ménière’s disease: is there a selective vestibulotoxic effect?”

Patient-Reported Outcome Questionnaires for the evaluation of olfactory and gustatory dysfunctions in COVID-19

Intratemporal facial nerve schwannomas: multicenter experience of 80 cases

Gustatory dysfunctions in COVID-19

Chondrolaryngoplasty for transgender patients: feasibility of a scar-free approach

Hippocrates and cholesteatoma