key: cord-0684144-ytbj4l0h authors: Tenório, Lucas Ribeiro; Nakai, Marianne Yumi; Artese Araújo, Giancarlo; Menezes, Marcelo Benedito; Bertelli, Antônio Augusto Tupinambá; Romeo, Dominic; Rajasekaran, Karthik; Gonçalves, Antonio José title: Safely performing percutaneous dilatational tracheostomies on COVID‐19 patients in the intensive care unit: A standardized approach date: 2021-09-23 journal: Laryngoscope Investig Otolaryngol DOI: 10.1002/lio2.658 sha: 7fcd4eb616135d40e7abf09eddf31cf4b795c6b9 doc_id: 684144 cord_uid: ytbj4l0h BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and the resulting coronavirus disease 2019 (COVID‐19) have afflicted hundreds of millions of people in a worldwide pandemic. During this pandemic, otolaryngologists have sought to better understand risk factors associated with COVID‐19 contamination during surgical procedures involving the airways such as tracheostomies. OBJECTIVE: This study provides a standardized technique of performing an ultrasound (US)‐guided percutaneous dilatational tracheostomy (PDT) on COVID‐19 patients in the intensive care unit (ICU). It also outlines safety strategies for health care providers that includes proper use of personal protective equipment (PPE) and regular testing of otolaryngologists for COVID‐19 contamination. METHODS: This study analyzed data from 44 PDT procedures performed on COVID‐19 patients in the ICU of hospitals in Sao Paulo and Santos, Brazil. The PDT procedures were conducted between April 2020 and August 2020, which coincided with a peak of the COVID‐19 pandemic in São Paulo, Brazil. Surgeons were tested for COVID‐19 using a two‐stage serological enzyme‐linked immunosorbent assay specific for SARS‐CoV‐2 antigens. CONCLUSION: This study describes a safe standardized technique of US‐guided PDT for COVID‐19 patients in the ICU using a method that also decreases the risk of surgeon contamination. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (COVID- 19) have afflicted hundreds of millions of people in a worldwide pandemic. 1, 2 During this pandemic, otolaryngologists and head and neck surgeons have sought to better understand risk factors associated with COVID-19 contamination during surgical procedures involving the airways such as tracheostomies. [2] [3] [4] However, given that COVID-19 is readily spread via aerosolization, it is essential to establish safe practices for performing tracheostomies. 2, 5 The literature currently offers some recommendations for safely performing tracheostomies on COVID-19 patients in the intensive care unit (ICU), but there is no consensus on the best practice. 2, 3, 6 Several authors argue in favor of performing the procedure using the open surgical technique under general anesthesia in a negative pressure room. [6] [7] [8] However, ICUs often lack both the infrastructure necessary to conduct an open tracheostomy as well as negative pressure rooms. Others suggest performing tracheostomies in the operating room (OR). 9 However, transporting COVID-19 patients to the OR exposes both the medical team and hospital facility to potential contamination. This study argues that using a standardized ultrasound (US)guided percutaneous dilatational tracheostomy (PDT) procedure is the most effective way to perform tracheostomy on COVID-19 patients in the ICU. It also outlines effective safety strategies for health care providers that includes proper use of personal protective equipment (PPE) and regular testing of otolaryngologists and head and neck surgeons for COVID-19 contamination. This study analyzed data from 44 PDT procedures performed on COVID-19 patients in the ICU of hospitals in Sao Paulo and Santos, Brazil. The PDT procedures were performed between April 2020 and August 2020, which coincided with a peak of COVID-19 pandemic in São Paulo, Brazil. Each PDT was conducted by a team of two surgeons operating in the ICU using a standardized US-guided technique. All the surgeons had expertise in both US and PDTs. Surgeons were tested for COVID-19 using a two-stage serological enzyme-linked immunosorbent assay (ELISA) specific for SARS-CoV-2 antigens. Additionally, they were followed for signs and symptoms This study was carried out over a period of 140 days between April 7 and August 25, 2020. The sample included 44 patients, all diagnosed with COVID-19 by positive reverse transcriptase polymerase chain reaction tests. The indication for tracheostomy was prolonged orotracheal intubation. The minimum number of days in mechanical ventilation was 8 days, the maximum was 29 days, the mean number was 17.5 days, and the median number was 18.0 days ( Figure 1 ). The medical team studied consisted of five surgeons. Four were males and one was a female. The males were 32, 35, 39, and 42 years old and the female was 37 years old. One of the males was a former smoker with a history of high blood pressure, another was a smoker, and the two others did not have any notable comorbidities. The female had asthma. Three of the males and the female had O+ blood type and one of males had AÀ blood type. Each time that a surgeon was involved in a PDT procedure was counted as one exposure. In total, there were 68 exposures distributed among the five surgeons in the following way: 27 (39.7%), 16 (23.5%), 13 (19.1%), 9 (13.2%), and 3 (4.4%). The mean number of exposures was 13.6 and median number was 13. For each surgeon, the results of their SARS-COV-2 ELISA tests for each of the 15 days after their final PDT were negative. Further, at the time that this article was submitted for publication, no medical team members who assisted with the PDTs or any of the close contacts of the surgeons presented with COVID-19 symptoms. After obtaining informed consent, each PDT was conducted using the following standardized method (Figures 2 and 3 ). 8. Lidocaine was applied as local anesthetic before a skin incision was made. 9. Subcutaneous tissue was mildly dissected. 10. An US-guided puncture using an introducer needle was performed, entering the tracheal lumen below the second tracheal ring. 11. The J-tipped flexible guide wire was then introduced into the surgical site. 18. Respiratory cycling is resumed. 19 . The ETT, which is still clamped, is then removed. 1. PPE is removed. 2. Surgeons "buddy check" to ensure that safety precautions were followed. Throughout the COVID-19 pandemic, the number of critically ill patients requiring tracheostomies has increased. 2, 4 Prior to this Before the pandemic, PDT was the standard procedure for tracheostomies in the ICU. 10 Our study has found that PDTs still can be safely performed at the bedside of COVID-19 patients in ICU. Performing PDTs in the ICU is safe for two reasons. First, it reduces the risk of exposing the hospital staff since does not require transporting patients to the OR. Second, PDT is a quick procedure lasting approximately 5 to 10 minutes that reduces the time the surgeon is exposed to a contaminated environment. Several authors have also discussed the importance of performing airway procedures inside negative pressure rooms. 11, 12 However, most ICUs in Brazil and many throughout the world either lack negative pressure rooms altogether or have limited access to it. In our study, no PDT was performed in negative pressure rooms. To minimize surgeon exposure to air exhaled from COVID-19 patients receiving PDTs, we introduced minor changes to standard PDT protocol. First, PPE was incorporated into the PDT procedure. Second, the "buddy check" method was used when surgeons dress in and disposed of PPE. Third, bronchoscopy guidance was switched for the quicker US-guidance. Fourth, a step-by-step of ventilation standby was carried out. Fifth, mechanical ventilation was temporarily interrupted. Sixth, neuromuscular blockage was used to prevent the cough reflex. The combination of these modifications appears to have contributed to the safety of our procedure on COVID-19 patients. We believe that temporary interruption of mechanical ventilation is an essential measure to minimize exposure to COVID-19 aerosol particles during both tracheal puncture and the dilatational procedure. When ventilation is temporarily interrupted, airflow through the needle and dilatation instruments decrease. Additionally, the minimal exposure of the tracheal surface characteristic in PDT limits the leakage of peri-instrumental air, which is an advantage over open tracheostomies where the tracheal surface often is exposed for prolonged periods. An alternative explanation for our positive outcomes could relate to the timeframe of tracheostomy indications. In general, the viral load in COVID-19 patients eventually decreases over time. [13] [14] [15] However, our PDT's were often performed on patients who had been intubated for between 10 and 20 days and thus likely had a decreased viral load that was less likely to contaminate the care team. 16, 17 Despite our positive results, we cannot prove that the PDT technique and our protocol are effective at reducing the risk of contamination of surgeons performing PDTs on ICU patients. This is an observational study with a limited number of cases. Further, our study did not show direct evidence of aerosol reduction using our procedures. Still, as the number of COVID-19 cases reamins high, observational studies like this are important contributions to understand the best clinical practice as well as to inform future studies. Research with more robust evidence that examine larger cohorts and randomized controlled trials are necessary but take longer and are not as feasible during the pandemic. It should also be highlighted that four of the five surgeons had O+ blood type, which may be a protective factor against COVID-19 contamination. [18] [19] [20] [21] [22] [23] Notably, prior experience performing PDT's is essential to ensure positive results, especially when operating on COVID-19 patients in the ICU. Surgeons are not used to performing tracheostomies with full PPE. Wearing a mask, goggles, and a face shield can be obstructive. Further, the additional psychological stress associated with performing an airway procedure with the high risk of contamination makes performing PDT's on COVID-19 patients particularly challenging. 24 In conclusion, we have described a safe standardized technique of conducing US-guided PDT in COVID-19 patients that minimizes the risk of surgeon contamination. 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Lucas Ribeiro Ten orio https://orcid.org/0000-0002-7987-3079Karthik Rajasekaran https://orcid.org/0000-0003-2148-1643 BIBLIOGRAPHY