key: cord-268476-3lxsh1zz
authors: Skoog, Hunter; Withrow, Kirk; Jeyarajan, Harishanker; Greene, Benjamin; Batra, Hitesh; Cox, Daniel; Pierce, Albert; Grayson, Jessica W.; Carroll, William R.
title: Tracheotomy in the SARS‐CoV‐2 pandemic
date: 2020-04-29
journal: Head Neck
DOI: 10.1002/hed.26214
sha: 
doc_id: 268476
cord_uid: 3lxsh1zz

The severe acute respiratory syndrome (SARS)‐CoV‐2 pandemic continues to produce a large number of patients with chronic respiratory failure and ventilator dependence. As such, surgeons will be called upon to perform tracheotomy for a subset of these chronically intubated patients. As seen during the SARS and the SARS‐CoV‐2 outbreaks, aerosol‐generating procedures (AGP) have been associated with higher rates of infection of medical personnel and potential acceleration of viral dissemination throughout the medical center. Therefore, a thoughtful approach to tracheotomy (and other AGPs) is imperative and maintaining traditional management norms may be unsuitable or even potentially harmful. We sought to review the existing evidence informing best practices and then develop straightforward guidelines for tracheotomy during the SARS‐CoV‐2 pandemic. This communication is the product of those efforts and is based on national and international experience with the current SARS‐CoV‐2 pandemic and the SARS epidemic of 2002/2003.

The severe acute respiratory syndrome (SARS)-CoV-2 pandemic continues to produce a large number of patients with chronic respiratory failure and ventilator dependence. Surgeons will be called upon to perform tracheotomy for a subset of these chronically intubated patients. As seen during the SARS and the SARS-CoV-2 outbreaks, aerosol-generating procedures (AGP) have been associated with higher rates of infection of medical personnel and potential acceleration of viral dissemination throughout the medical center. Therefore, a thoughtful approach to tracheotomy (and other AGPs) is imperative and maintaining traditional management norms may be unsuitable or even potentially harmful. In this backdrop, we sought to review the existing evidence informing best practices and then develop straightforward guidelines for tracheotomy during the SARS-CoV-2 pandemic. This communication is the product of those efforts and is based on national and international experience with the current SARS-CoV-2 pandemic and the SARS epidemic of 2002/2003.

Our priorities in establishing these guidelines included: optimal patient care, protection of medical personnel, minimizing further spread of the virus and preservation of important resources (ICU beds, ventilators, and PPE). These recommendations represent a consensus of stakeholders from our medical center including otolaryngologists, trauma surgeons, interventional pulmonologists, anesthesiologists, and critical care providers.

Due to the paucity of data regarding the current SARS-CoV-2 epidemic, the literature from the SARS epidemic of In Canada, 43% of cases occurred in health care workers as a result of AGPs. 1,2 One instance involved a difficult intubation of a patient who was under investigation for SARS. This intubation was linked to the infection of seven hospital staff all of whom had been wearing full PPE including N95 masks during patient contact. 2 

There are multiple reports 3,4 of safely performing tracheotomy on patients with SARS without infecting health care workers. Standard processes included strict infection control measures, seamless and regulated surgical intervention, and if possible delayed (>30 days from diagnosis) tracheotomy in patients who had been SARS positive. Infection control measures (in addition to standard airborne and contact precautions) taken during these procedures included: double gowning, PAPR suits, double gloving, a changing room after the procedure (ante room), performing the procedure in a negative pressure room. The surgical personnel were the most experienced available to minimize operating/exposure time. Patients were completely paralyzed to minimize air movement and coughing and thus viral dissemination via aerosolization. Prior to the procedure, a trial run was completed to ensure maximum efficiency of the procedure. Just prior to airway entry, the patients were pre-oxygenated, ventilation was held, and the cuff on the endotracheal tube was dropped to minimize air movement over the respiratory mucosa. While the patient was apneic, the tracheotomy incision was performed. Open suctioning of the trachea was avoided. Instead, a closed suctioning system with a viral filter was used. 3,4

During the current SARS-CoV-2 pandemic, reports from multiple countries suggest that Otolaryngologists and support staff are at a unique risk of SARS-CoV-2 exposure. An early case in China with devastating results involved endoscopic pituitary surgery in a patient with flu-like symptoms. 5 Contact tracing confirmed that 14 health care workers became infected with SARS-CoV-2 from this one procedure. In Wuhan, otolaryngologists and ophthalmologists were among the most commonly infected health care workers. N95 masks did not appear to completely prevent infection of health care workers. PAPR suits were more effective. 5 In Iran, over 20 Otolaryngologists have been hospitalized after testing positive for SARS-CoV-2 with at least two deaths, including a chief resident. 5 Two ENT physicians required ventilator support in the United Kingdom, with at least one ultimately succumbing to the infection. To date, over 60 physicians have died in Italy as a result of SARS-CoV-2 infection. 6 In Spain, over 12 000 health care workers have tested positive for the disease (14.4% of total reported cases). 7 In the United States, Ohio and Minnesota have reported 16%-28% of their COVID positive cases involve health care workers. 7 The American Academy of Otolaryngology: Head and Neck Surgery has recommended a multidisciplinary approach in determining indications for tracheotomy in patients with SARS-CoV-2. In addition to the necessity of donning appropriate PPE, they recommend not performing tracheotomy until 2-3 weeks postintubation and repeat SARS-CoV-2 testing is negative. The procedures should be performed under a closed circuit with a minimal number of care providers and duration of procedure. 8 Emergent tracheostomy secondary to upper airway distortion or obstruction precluding endotracheal intubation has not been reported in patients with SARS-CoV-2. Early experience suggests that patients with SARS-CoV-2 produce relatively little mucus and secretions in relation to other causes of respiratory failure. For these reasons, tracheotomy appears less critical for pulmonary toilet for patients with SARS-CoV-2. 9 5 | RECOMMENDATIONS FOR TRACHEOTOMY DURING SARS-COV-2 PANDEMIC As the number of infected patients requiring intubation and ventilator support climbs, a growing population of patients would normally qualify for tracheotomy due to failed extubation or prolonged ventilatory needs. Considering the clear evidence from both SARS and SARS-CoV-2 infection, 9 it is imperative that this patient population be managed appropriately to minimize infectious risk to the health care team.

Currently, there are no published reports on tracheotomy in patients with COVID-19. We felt there were numerous reasons to develop consensus guidelines including:

• An anticipated high volume in our center (third largest public hospital in the United States). • Known risk to intraoperative and postoperative medical staff. • Anticipated shortages of resources (ICU beds, ventilators, PPE) which could be impacted by decisions around tracheotomy. • High potential for conflict between surgeons and critical care staff over an emotionally charged issue.

To address these concerns, we assembled a task force of stakeholders in our medical center involved with tracheotomy including otolaryngology, trauma surgery, critical care medicine, and anesthesiology. The group reviewed existing literature and met virtually to draft recommendations. Ideas were refined with final recommendations approved by all Task Force members as summarized below. The availability of highly predictive testing for SARS-CoV-2 has greatly simplified the decision process in our medical center; improving the safety of medical staff, preserving resources like PPE and freeing up resources like ventilators and ICU space. severe respiratory failure should be exceedingly rare (Figure 1 ). In patients with prolonged intubation, elective tracheotomy can be delayed well beyond the usual 14-day timeline. Despite concern for airway stenosis due to prolonged intubation, recent data suggests early tracheotomy may be less crucial and the safety issues around the pandemic outweigh the risks of late airway stenosis. 10 

The SARS-CoV-2 pandemic is rapidly evolving with continuous updates in treatment and guidelines. At the time of writing, there were over 492 000 cases in the United States with almost 19 000 deaths. 12 The management algorithm recommended by our multidisciplinary team draws on experiences with the 2002-2003 SARS epidemic and the current experience of surgeons, anesthesiologists, Intensivists, and other health care workers with SARS-CoV-2. The goals of these recommendations are to provide optimal patient care, protection of medical personnel, minimizing further spread of the virus, and preservation of important resources (ICU beds, ventilators, and PPE).

The chronology of the 2002-2003 SARS mini pandemic

Cluster of severe acute respiratory syndrome cases among protected health care workers-Toronto

Tracheostomy in a patient with severe acute respiratory syndrome

Safe tracheostomy for patients with severe acute respiratory syndrome

Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic

More than 60 doctors in Italy have died in COVID-19 pandemic

How many medical workers have contracted COVID-19?

AAO position statement: tracheotomy recommendations during the COVID-19 pandemic

COVID-19 and the otolaryngologist-preliminary evidencebased review

Laryngotracheal stenosis in early vs late tracheostomy: a systematic review

Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy in high-risk patients

Tracheotomy in the SARS-CoV-2 pandemic

We thank Michel Thomas for his assistance in the graphic design of our flowchart.ORCID Hunter Skoog https://orcid.org/0000-0001-6510-9064