key: cord-0739835-84nmd6p4 authors: Piccin, Ottavio; Albertini, Riccardo; Caliceti, Umberto; Cavicchi, Ottavio; Cioccoloni, Eleonora; Demattè, Marco; Ferri, Gian Gaetano; Macrì, Giovanni; Marrè, Pietro; Pelligra, Irene; Saggese, Domenico; Schiavon, Patrizia; Sciarretta, Vittorio; Sorrenti, Giovanni title: Early experience in tracheostomy and tracheostomy tube management in Covid-19 patients date: 2020-05-07 journal: Am J Otolaryngol DOI: 10.1016/j.amjoto.2020.102535 sha: 45300f8434e1cd683183423bf0a3590ffc7ebce6 doc_id: 739835 cord_uid: 84nmd6p4 Abstract In Italy, we have experienced Europe's first and largest coronavirus outbreak. Based on our preliminary experience, we discuss the challenges in performing tracheotomy and tracheostoma care in the setting of a new pathogen. J o u r n a l P r e -p r o o f As of 05 April, 1227943 cases and 66592 deaths have been reported in 208 countries around the world. The number of reported COVID-19 cases is rapidly increasing in most of the countries and the notification rate is increasing at similar trajectory as was observed in Hubei province in late January/early February. In Italy, we have experienced Europe's first and largest coronavirus outbreak and the trend in the number of patients requiring admission to intensive care units (ICU) for long term mechanical ventilation has relentlessly increased in the last few weeks, with the risk that critical care beds, could become rapidly saturated. Early tracheal intubation may be encouraged, as late or emergency tracheal intubation in rapidly deteriorating Covid-19 patients may be associated with greater risks, both to patients and healthcare professionals 1 . Since long-term mechanical ventilation for critically ill patients represents the most common situation for which tracheostomy is indicated, the Covid-19 pandemic is likely to significantly increase the numbers of patients requiring new tracheostomies. Moreover, there may be some benefits to perform tracheostomy in Covid-19 patients earlier than in current practice. First, considering the high risk of saturation of ICU beds, early tracheostomy allows for earlier and safer weaning attempts so increasing the availability of ICU beds (tracheostomized patients, potentially, can be managed in sub intensive care units or recovery rooms). Secondly, early tracheostomy may decrease the use of sedative drugs that actually are running low in most countries. However, since the "crisis" is evolving very quickly, the optimal timing (early or late) of tracheostomy in patients with Covid-19 is still unclear. The decision for tracheostomy will be made on a case-by-case basis after a multidisciplinary evaluation, considering the clinical situation and illness severity of patients, benefits or disadvantages of tracheostomy and hospital resources. Albeit percutaneous tracheostomy, involving more extensive airway manipulation, increases the exposure to aerosolized secretions 6 During the last 4 weeks, we performed 24 surgical tracheostomies. The median timing of tracheostomy was 10 days after intubation. Also tracheostomy tube management and decannulation process mark a significant point in-Covid-19 patients. In our Institution, a ward dedicated to the rehabilitation of tracheostomized Covid-19 patients discharged from ICU, was provided. It is an open wards containing cubicles of 3 patients and in line suction system is not available. All tracheostoma care procedures are performed at the bedside with all health care workers wearing third level PPE. In our early experience this population is characterized not only by severe cognitive disorders but also by severe swallowing impairment, presumably related to the neuroinvasive propensity of CoVs 7 and the prolonged use of sedative drugs. To minimize the risk of healthcare workers contamination, swallowing rehabilitation is not carried out by speech therapists, but by experienced staffing nurse with the supervision of an ENT consultant. Once the patient has reached a satisfactory swallowing function and a good ability to manage oral secretions, the nasogastric tube is removed and the cuff of the tube is deflated, starting some days trial of cuff deflation. A daily multidisciplinary evaluation (pneumologist, anesthesiologist, infectious disease specialist and otolaryngologist) is carried out to assess medical and respiratory status changes from baseline. Reinflation of the cuff will only occur if the patient shows signs of deterioration. Despite empirical approach, due to the lack of previous experience, all the patients are tolerating continuous cuff deflation at the first attempt. Tracheostoma tube change is limited to a single time, to reduce the size of the tube and replacing cuffed with uncuffed tube. After multidisciplinary agreement, we start with a tracheostomy tube capping trial consisting on the ability to breathe through the mouth with the tracheostomy tube closed with a cap for almost 7 days (this prolonged time is due to the significant rate of late medical decline reported in the Covid-19 cohort patients 8 ) and Unfortunately, it is not always practically feasible to adhere to guidelines and recommendations. During a new public health crisis threatening the world, each of us has to relate to local hospital resources. As in line suction system is not available in our dedicated ward , it is ineffective to maintain the cuff inflated to avoid environmental contamination. Moreover, "early" cuff deflation and tube change may facilitate the procedure of rehabilitation. It is pleonastic to emphasize that during tracheostomy care maneuvers, healthcare workers are equipped with full PPE. Currently, none of the faculty has been infected. As Covid-19 infection is a novel disease, there are a lack of specific experience. We have summarized our experience in performing tracheostomy and tracheostoma care in the setting of a new pathogen. Given the rapid evolution of the current Covid-19 pandemic this will be an early experience that is likely to change over time, so we The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice Safety Recommendations for Evaluation and Surgery of the Head and Neck During the COVID-19 Surgical Considerations for Tracheostomy During the COVID-19 Pandemic: Lessons Learned From the Severe Acute Respiratory Syndrome Outbreak COVID-19 and the otolaryngologist preliminary evidence-based review UCSF Inpatient Adult COVID-19 Interim Management Guidelines Preparing for COVID-19: early experience from an intensive care unit in Singapore The neuroinvasive potential of SARS-CoV2 may play a role in the respiratory failure of COVID-19 patients Virological assessment of hospitalized patients with COVID-2019