key: cord-0790865-vw6kqo4a
authors: Lamb, Carla R.; Desai, Neeraj R.; Angel, Luis; Chaddha, Udit; Sachdeva, Ashutosh; Sethi, Sonali; Bencheqroun, Hassan; Mehta, Hiren; Akulian, Jason; Argento, A. Christine; Diaz-Mendoza, Javier; Musani, Ali; Murgu, Septimiu
title: Use of Tracheostomy During the COVID-19 Pandemic: CHEST/AABIP/AIPPD: Expert Panel Report
date: 2020-06-06
journal: Chest
DOI: 10.1016/j.chest.2020.05.571
sha: edddb2be63dda9f1aad841321aaca1d46e503ef7
doc_id: 790865
cord_uid: vw6kqo4a

Abstract Background The role of tracheostomy during the COVID-19 pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing and technique while minimizing the risk of infection to health care workers (HCW). Methods A panel comprised of intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing COVID-19 patients across a spectrum of healthcare environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidenced based consensus statement and expert panel report. Results Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19 related respiratory failure. Conclusion This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat RT- PCR testing in patients with confirmed Covid-19 evaluated for tracheostomy. To reduce the risk of infection in HCW, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment (PPE). The recommendations presented in this statement may change as more experience is gained during this pandemic.

performing tracheostomy (strong consensus) 2 4.Recommendation: We recommend that enhanced personal protective equipment 3 (PPE) be used to mitigate the risk of health care worker (HCW) related infection 4 during tracheostomy (strong consensus) 5

Remark: Tracheostomy is an aerosol generating procedure (AGP) and poses an infection 6 risk to HCW involved in the procedure (strong consensus) 7 5.Recommendation: We suggest that in patients with COVID-19 related respiratory 8 failure, tracheostomy is performed in a negative-pressure room, preferably in the 9 ICU. As an alternative, a negative-pressure room in the OR could be used, with 10 special attention to minimizing transportation-related risk of exposure (strong 11 consensus) 12

Remark: If negative pressure rooms are unavailable, the procedure could be performed 13 in a normal pressure room equipped with HEPA filters in the presence of a strict door 14 policy (strong consensus) 15 6.Recommendation: We do not recommend routine RT-PCR testing 16

(nasopharyngeal swab or lower respiratory sample) prior to performing 17 tracheostomy in patients with confirmed COVID-19 related respiratory failure 18 (strong consensus) 19

Remark: There is insufficient evidence to recommend RT-PCR testing in patients with 20

non-COVID-19 respiratory failure prior to tracheostomy. If such testing is performed, we 21

suggest that a lower respiratory sample (endotracheal aspirate) rather than a 22

nasopharyngeal swab be obtained (consensus) 23 7.Recommendation: We recommend that in patients with COVID-19 related 24 respiratory failure, tracheostomy is performed by a team consisting of the least 25 number of providers with the highest level of experience (strong consensus) 26

Remark: We suggest that prior to the initiation of tracheostomy, a multidisciplinary 27 group of providers including the primary critical care team, palliative care, infectious 28 disease, the procedural and airway team utilize respective expertise to determine the 29 goals of care, patient selection, procedural considerations, as well as workflow to 30 optimize safety of both patient and HCW (strong consensus) 31 8.Recommendation: We suggest that patients be maintained with a closed circuit 32 while on mechanical ventilation with a tracheostomy tube and with in-line suction 33 (strong consensus).

In this current viral pandemic, critically ill patients with COVID-19 account for 2 approximately 5% of all cases and are responsible for a quarter of all hospitalizations 1,2 . 3 It appears that the majority of critically ill patients require mechanical ventilation [2] [3] [4] [5] . Due 4 to the acute respiratory failure often requiring deep sedation and neuromuscular blockers, 5 these patients may need prolonged mechanical ventilation and may benefit from a 6 tracheostomy. Tracheostomy data from prior respiratory viral outbreaks are sparse, and 7 the available literature from the current outbreak is very limited 6, 7 . The decision to 8 proceed with tracheostomy in patients with COVID-19 must be patient-centric while 9

protecting the safety of health care workers (HCW). 10

Tracheostomy is considered an aerosol-generating procedure (AGP) and based on the 11

2003 SARS outbreak it appears to pose the risk of infection to health care workers 12 (HCW) . Some experts recommend delaying tracheostomy for at least 2-3 weeks in 13 patients with COVID-19 associated respiratory failure 8, 9 . Physicians must determine the 14 role of tracheostomy in COVID-19 patients, which may depend on the predicted clinical 15

course. In some heavily affected areas, the COVID-19 pandemic is impacting healthcare 16 systems in an unprecedented manner. Tracheostomy may allow faster liberation from 17 mechanical ventilation, shorter ICU stay [10] [11] [12] [13] , and may impact availability of ICU 18

resources. There are unanswered questions regarding staff preparation and protection, 19

timing, location, technique and post-intervention care for this procedure. 20 21

This consensus statement was created to address this knowledge gap. The expert panel 22

represented CHEST, the American Association for Bronchology & Interventional 23

Pulmonology (AABIP) and the Association of Interventional Pulmonology Program 24

Directors (AIPPD). Eight key questions, corresponding to 14 decision points, were rated 25 by the panel (Table 1 ). The results were aggregated, resulting in eight main 26 recommendations and five additional remarks intended to guide health care providers in 27 the decision-making process pertinent to tracheostomy in patients with COVID-19. The 28 statement focuses on selected important issues relating to performing a tracheostomy in 29 critically ill patients with COVID-19 requiring mechanical ventilation. 30 31

Methods 32

A comprehensive literature search of Medline (PubMed interface) was executed. The 34

search strategy was comprised of both controlled vocabulary, such as the National 35

Library of Medicine's MeSH (Medical Subject Headings) and keywords employing the 36 keywords "tracheostomy" OR "percutaneous tracheostomy" OR "percutaneous 37 dilatational tracheostomy" OR "PEG" OR "percutaneous epigastric tube" AND 38 "coronavirus" OR "coronavirus 2019" OR "COVID-19" OR "2019-nCoV" OR "SARS-39

CoV-2" OR "SARS" OR "MERS" OR "COVID" OR "SARS-CoV" OR "nCoV" 40 between 2000 and present time (i.e., April 15, 2020). Additional MeSH searches were 41 performed by using the words "tracheostomy" OR "percutaneous tracheostomy" OR 42 "percutaneous dilation tracheostomy" AND "ultrasound"; "Reverse Transcription 43

Polymerase Chain Reaction" "PCR testing", "viral shedding" with no language or time 44 restrictions. Each article was assessed for relevance to the primary objective and useful 1 references and similar articles were retrieved. No language restrictions were applied. The 2 title, abstract and full text of all articles captured with these search criteria were assessed, 3

and those reporting the tracheostomy and techniques in SARS COVID-19 and non-4 COVID-19 patients were included. The reference list of all identified studies was also 5 analyzed to detect additional articles. The typical guideline methodology wasn't used for 6 this expert panel report. This manuscript is not a systematic review of the literature using 7

PICO questions, PRISMA diagrams and tables of evidence. 8 9

Consensus methodology 10 Written from multi-institutional and multi-society perspectives, this statement is intended 11

to provide context for the use of tracheostomy to direct patient management during the 12 COVID-19 pandemic. This document is structured around 8 questions. The results and recommendations  42 were presented, discussed, and refined. The panel independently and anonymously rated 43 the appropriateness of the recommendations on a five-point Likert scale (Figure 1 ). We 44 required 75% of the panel to respond to a vote for considering a specific 45 recommendation. The strength of the recommendations is based on the degree of 1 consensus resulting from the modified Delphi method. At least 70% agreement on the 2 direction of a recommendation was considered consensus. A threshold of ≥80% for 3 agreement was required for each item to reach strong consensus ( Figure 1 ). 4

We make a "suggestion" when referring to an action for clinicians to consider and a 5 "recommendation" when referring to a preferred choice of action. 6

Results: 7

Outcomes of tracheostomy 8

Recommendation 1: We suggest that tracheostomy be considered in COVID-19 9 patients when prolonged mechanical ventilation is anticipated. 10

Data are lacking on the subject of clinical utility of tracheostomy versus prolonged 11 intubation and mechanical ventilation in patients with COVID-19 respiratory failure. In 12 the medical and surgical literature reviewed by our team, prolonged intubation and late 13 tracheostomy were grouped together and were defined as 10-15 days after initiation of 14 mechanical ventilation. One study from New York University (NYU) Langone Health 15

showed that 33% of patients who underwent percutaneous dilatational tracheotomy 16

(PDT)at a mean of 10 days were liberated from mechanical ventilation 7 .The follow up of 17 18 days is too short to comment on how tracheostomy impacts long term outcomes in this 18 patient population, especially in the absence of a control group. 19 We ventilator support is anticipated. The data from COVID pandemic are limited but the 45 procedure was performed safely for patients and operators 7 . Most data reviewed pre-46 1 ARDS. The information from publications suggests that tracheostomy could potentially 2 offer better outcomes including ventilator-free days, shorter stay in the ICU, shorter stay 3 in the hospital and perhaps reduced incidence of hospital-acquired pneumonia when 4 compared with prolonged mechanical ventilation. Therefore, we suggest that 5 tracheostomy be considered in COVID-19 patients when mechanical ventilation is 6 anticipated to be longer than 10-15 days. 7 8 9

Timing of tracheostomy 10 Recommendation 2:There is insufficient evidence for recommending a specific 11 timing for tracheostomy in COVID-19 related respiratory failure. 12

Conventionally, in the medical ICUs, tracheostomy has been performed in patients with 13 ongoing mechanical ventilatory needs, 2-3 weeks after endotracheal intubation. shedding, as detected in upper respiratory specimens, was 20 days in survivors, with the 1 virus being detectable until death in non-survivors 28 . In another study on critically ill 2 patients, viral RNA was detectable in lower respiratory tract specimens in 69% of 3 patients beyond 28 days from symptom onset 3 . These data argue against waiting 3 weeks 4

for performing the tracheostomy. 5 6

However, recent published reports from China, Italy and the United States demonstrate 7 that COVID-19 has a high ICU mortality 4,5,28-32 . ICU mortality in studies with longer 8 follow-up rates is 42% and 78% 28,29 . In addition, 12-58% of patients remain in the ICU at 9

the end of their respective follow-up periods 4,5,30-32 . Institutions now face the decision of 10 pursuing a tracheostomy in many COVID patients, most of whom may require prolonged 11 mechanical ventilation 5 . In a study on 1,591 critically ill patients with COVID-19 from 12

Italy 58% of patients were still in the ICU at the end of their follow-up (minimum of 7 13 days) 5 . The median ICU length of stay in those who survived and those who died in the 14 ICU was 8 and 7 days, respectively. These data suggest that waiting until at least the 15 second week to assess a patient's ICU course may be prudent, as many patients would 16

have by then declared their disease trajectory. 17 18

The existing evidence regarding early versus late tracheostomy in critically ill patients in 19

medical ICUs does not favor one approach. There is no generalizable best timing to 20 perform tracheostomy in patients with COVID-19 related respiratory failure requiring 21 mechanical ventilation. There is insufficient evidence to suggest performing a 22 tracheostomy in the second week of mechanical ventilation or later, and this decision 23

should be individualized based on clinician's best estimate regarding prognosis and 24 factoring in institutional critical care resource constraints. The lack of COVID-19 25 tracheostomy-related evidence, the conflicting published data on early versus late 26 tracheostomy in general, and the unique COVID-specific scenarios of HCW exposure 27 and resource utilization in stretched systems, make it impossible to provide specific 28 guidance on timing of tracheostomy. 29 30

Tracheostomy Technique 31

Recommendation 3: We suggest that in patients with COVID-19 related respiratory 32

failure, either open surgical (OST) or percutaneous dilatational tracheostomy (PDT) 33

can be performed in patients expected to require prolonged mechanical ventilation. 34

Remark: Utilization of techniques which minimize aerosolization is recommended when 35 performing tracheostomy. 36

Tracheostomy is considered an AGP and in COVID-19 related respiratory failure, it can 37 potentially increase the risk of transmission to HCWs. The optimal technique in these 38 patients remains unknown as both procedures have pros and cons, summarized in Table  39 2. A meta-analysis and a systematic review of the pre-COVID literature suggest that [36] [37] [38] [39] . Due to its performance at the bedside and safety profile, 2 bronchoscopy-guided PDT has become the preferred practice in many institutions 33,40 . 3 PDT has been demonstrated to be at least as safe as the conventional surgical approach in 4 most critically ill patients. There is also emerging evidence from this pandemic that a 5 novel modified technique of PDT in which the ETT cuff remains inflated and in the distal 6 trachea and the bronchoscope inserted next to the ETT 7 can be safely performed with no 7 major immediate complications for patients and no documented infection to HCWs. This 8 modified technique may be more feasible with earlier tracheostomies before the 9 development of laryngeal edema that may preclude scope insertion alongside the ETT. 10

To date, it is unclear however, which technique is safer for COVID-19 patients while 11

reducing transmission to HCW. 12

In our literature search, we identified case series from the 2003 SARS outbreak and 13 statements from professional societies or institutions regarding tracheostomy in COVID-14 19 pandemic 9,41 . Most of these articles comment on the aerosolization potential of each 15 procedure to HCW and the various techniques described to minimize such risk. (Table 3 ) 16

In these position or perspective papers, PDT is considered a procedure that involves more 17 extensive airway manipulation as it uses bronchoscopy and dilation of the tracheal inter-18 cartilaginous space. These factors may indeed result in an increased aerosolization risk 19

and exposure to the operators and ancillary personnel 6 . On the other hand, PDT is a 20 procedure that offers the ease of performing it in the ICU in a negative pressure room, 21

minimizing the risk associated with transporting a COVID-19 patient to the operating 22

room. PDT generally results in less bleeding and therefore less need for cautery 23 equipment with cautery (often needed with OST) which itself carries a risk of 24 aerosolizing particles 42 . PDT typically may require fewer HCW involved in the procedure 25 when compared to OST. Lastly, the role of ultrasonography has been highlighted as a tool 26

during PDT in COVID-19 patients, thereby reducing the need for bronchoscopic 27 guidance with its potential risk of aerosolization. In fact, three pre-COVID-19 studies 28 demonstrated shorter procedure duration and lower hemorrhage using ultrasound 29 compared to bronchoscopic guidance during PDT 36-39 . 30 With OST, the use of bronchoscopy is avoided and therefore aerosolization risks may be 31

diminished. There is the added possible risk of aerosolization with cautery and use of 32 suction. Logistical considerations, such as space and personnel, should be carefully 33 considered when this procedure is performed at the bedside, as some operating rooms do 34 not have negative pressure capabilities. In these circumstances, meticulous planning with 35 institutional specific infection control teams and simulated rehearsing should be 36 considered by the operating team. Performing OST at the bedside may be preferred to 37 avoid aerosolization due to inadvertent disconnection of the ventilator circuit during 38 patient transport. 39

Regardless of technique, the portions of the tracheostomy procedure with the highest risk 40 of aerosolization to personnel are during endotracheal tube repositioning with cuff 41 deflation, the incision portion of the tracheotomy into the anterior tracheal wall, dilation 42 of the trachea and the tracheostomy cannula insertion. The operators should strive to 43 implement techniques that are considered best practices to minimize aerosolization. 44

These include ensuring complete neuromuscular blockade, packing the oropharynx, 45

performing apnea at times when aerosolization risk is highest or when manipulating the 46 1 sponge at the stoma site. All techniques should ideally be performed at the patient's 2 bedside to avoid unnecessary transfers to the operating room where the risk of ventilator 3 circuit interruption and exposure to other areas of the hospital may occur. 4

Our recommendation highlights the fact that the optimal technique, OST or PDT, is 5 unknown since there are pros and cons to both procedures. Therefore, the technique 6 utilized should be based on individual institutional expertise and defined protocols. Not 7 every institution has the ability to perform PDT or bedside OST. Importantly, this 8 recommendation outlines that OST is not absolutely necessary, as once thought during 9

the SARS outbreak. We recognize that institutions may change their practice, as more 10 evidence is emerging during or after this pandemic. In summary, the data on the risk of HCW infection during tracheostomy are mixed. The 20

available data suggest that the rate of infection, when enhanced PPE measures are 21 employed, is considerably lower than when they are not used or are used improperly 52,53 . 22

Although the specific risk associated with tracheostomy during COVID-19 is not known, 23

tracheostomy is one of the high-risk AGP, and prior SARS experience suggests that 24 adequate protection is essential to prevent HCW from contacting the infection. In 25 addition to PPE, other ways of mitigating the risks for HCW involved in the 26 tracheostomy procedure include location and technique. 27 28

Location of tracheostomy procedure 29

Recommendation 5: We suggest that in patients with COVID-19 related respiratory 30 failure, tracheostomy is performed in a negative-pressure room, preferably in the 31 ICU. As an alternative, a negative-pressure room in the OR could be used, with 32 special attention to minimizing transportation-related risk of exposure. PPE. In addition, the use of negative-pressure canopies is currently under investigation. 42

The review of existing studies from prior viral outbreaks and the front-line experience 1 from the COVID-19 pandemic are the basis of these recommendations. Tracheostomy 2 should ideally be performed at the bedside in the ICU, with patients being located in 3 negative pressure rooms or normal pressure rooms with strict door policy with the use of 4 HEPA filters. 5 6

The role of pre-procedure COVID-19 testing 7

Recommendation 6: We do not recommend routine RT-PCR testing 8

(nasopharyngeal swab or lower respiratory sample) prior to performing 9 tracheostomy in patients with confirmed COVID-19 related respiratory failure. techniques for minimizing aerosolization. We believe that in the context of an ongoing 45 pandemic, however, it is prudent to perform all AGP with enhanced PPE. This is 46 especially important given the variability in the sensitivity of test results due to timing of 1 testing and type of testing kits. Pre-tracheostomy re-testing in COVID-19 and testing in 2 non-COVID-19 patients, may facilitate decisions regarding duration and type of isolation 3 precautions and must follow local guidelines for infection control practices. 4 5

We based the remark to this recommendation on the limited published evidence 6 suggesting greater number of positive RT-PCR tests and a higher viral respiratory load in 7

LRT samples compared to NP swab 3,71,72 . Additionally, data from a well-conducted study 8 suggest a higher viral load and a slower decline in RNA concentration in LRT samples 9

compared to the NP swabs 63 . We recognize that the test results depend upon wide variety 10 of factors including sample collection technique, transportation, processing, and method 11 used for RT-PCR testing. Therefore, when obtained, a lower respiratory sample should be 12 processed using validated tests available at individual institutions. 13 14

The role of a multidisciplinary team 15

Recommendation 7 nurses, respiratory therapists, and speech and language pathologists. These teams have 28 reported improved outcomes, including the incidence of airway bleeding, physiologic 29 disturbances and efficiency of care delivery 73,74 . Implementation of a multidisciplinary 30

PDT service was shown to result in a marked decrease in major complications (25.4% 31 pre-implementation and 4.9% post-implementation) and a reduction in wait time for the 32 performance of tracheostomy (2.6 days pre-implementation and 1.3 days post-33 implementation) 74 . Several other reports of tracheostomy-centered multidisciplinary 34

teams have been published and support these findings 75-78 . 35 Review of the literature revealed several articles supporting the use of a multidisciplinary 36 team, however there are limited or no data specifically evaluating this paradigm in the 37 setting of pandemic illness. We found two case series 42,55 and four editorials/technical 38 communications/systematic reviews of the literature 34,79-81 . Both case series discussed 39 tracheostomy during the SARS-CoV epidemic of 2003. The systematic reviews included 40 one from the SAR-CoV epidemic and three pertaining to the current COVID-19 41 pandemic. All the manuscripts discussed the need to minimize the number of procedural 42 team members due to concerns for pathogen exposure and conservation of PPE with the 43 number of personnel ranging between three and five. Four of the six manuscripts 44 recommended a three-person team consisting of 1-2 surgeons, one person to manage the 45 ventilator/ETT and if there was only one surgeon performing the procedure one 46 additional staff member (bronchoscopist, nurse or respiratory therapist). In addition, there 1 are pre-COVID-19 data that performing tracheostomy and gastrostomy procedures using 2 gastroscope and/or bronchoscope in the same sitting by a single specialty has a good 3 safety profile with possible advantages of shorter ICU and hospital LOS 82-85 . This could 4 be considered in institutions with such expertise but there might be concerns for the 5 additional time required to perform PEG placement leading to extended exposure time. 6

In summary, published data suggest an improvement in patient outcomes when utilizing a 7 multidisciplinary approach in PDT. Thus, we recommend that a multidisciplinary team be 8 formed at each institution, to optimize expertise in the support and performance of 9 tracheostomies to minimize risk and limit size of procedure team. Palliative care and 10

Infectious Disease teams could offer meaningful insights into patients' overall goals of 11 care, chance of meaningful recovery, duration of viral shedding, factors that could affect 12 the decision or the timing of tracheostomy. This multidisciplinary team paradigm is vital 13 in the setting of pandemic illness crisis when critical care needs exceed standard capacity 14 resulting in "surge" level in which non-ICU providers definitively benefit from expert 15 multi-disciplinary team for collaborative decision making in all aspects of tracheostomy 16

care. 17

Post-tracheostomy care of COVID-19 patients 18

Recommendation 8: We suggest that patients be maintained with a closed circuit 19

while on mechanical ventilation with a tracheostomy tube and with in-line suction. 20

The inner cannula and tracheostomy tube changes as well as airway clearance are all 21 considered to be AGPs. The optimal techniques for post-tracheostomy care as well as 22

timing of inner cannula and tracheostomy tube changes is not known in COVID-19, 23 SARS or MERS. The best guidance comes from societal statements 41,86,87 that balance an 24 emphasis on safety both for patients and HCW in the setting of viral pandemics 54,58,80,88 25 (Table 4 ) 26

The recommendations include use of enhanced PPE when performing tracheostomy care 27 in the COVID-19 positive patient with the least number of HCW present. If available, 28

single-use disposable equipment should be utilized. Whenever possible, the patient 29 should maintain a closed circuit at all times regardless of mechanical ventilation 30 requirements. If the patient no longer requires mechanical ventilation but is not ready for 31 capping trials, a closed circuit can be fashioned using a heat moisture exchanger (HME) 32

with viral filter and in-line suction can be utilized to minimize aerosol generation ( Figure  33 2). Of note, HME filters on patients with trach masks increase the resistance of the flow 34 and may get clogged due to secretions. Inner cannulas should be changed on an as-35

needed basis rather than a scheduled routine. initial tracheostomy tube with the cuff deflated and either a speaking valve or a capping 46 trial, then minimizing tracheostomy tube changes is advised. If a larger tracheostomy 1 tube has been placed, HCW could try to limit the number of tracheostomy tube changes 2 and expedite a decannulation protocol as able. 3

These recommendations are designed to minimize risk for HCW performing necessary 4

AGPs on patients who have undergone placement of a tracheostomy tube. Some 5 questions that are not addressed in the literature include how to provide appropriate 6 nutrition and swallow evaluations for patients with tracheostomy as well as when airway 7 clearance can begin for these patients. The disposition of post tracheostomy patients with 8

COVID-19 has not been addressed in the published literature. Typically, these patients 9

are discharged to a long-term acute care facility (LTAC), however some LTACs may not 10 accept a patient with a tracheostomy tube prior to the first tracheostomy tube change and 11 may require conversion to negative COVID-19 testing. 12 13

Summary 14

This consensus statement on tracheostomy is intended to offer guidance in the decision 15 making, preparation, timing, techniques and post procedure care of patients with COVID-16 19 related respiratory failure. We believe we addressed the most common questions being 17 faced by physicians during this pandemic pertinent to the practice of tracheostomy. One 18 of the strengths of this expert panel report is that it represents the opinions and 19

perspectives of intensive care and interventional pulmonary experts from 10 states with 20 the highest burden of COVID-19 in the US. May require transport to the OR through hallways with theoretical risk of accidental disconnection from the ventilator and contamination The stoma in an OST might be larger when compared to PDT and it may take longer time to close after decannulation thus leading to longer aerosolization New modified techniques described with bronchoscopy alongside the ETT which may reduce aerosolization and reduce number of personnel at bedside or use with ultrasound alone to reduce need for bronchoscopy General Risk Reduction Best Practices 1. Equipment and medications should be pre-planned with checklist and procedure kits prior to entering the room. 2. Avoid using carts in the room to reduce the need to undergo decontamination. Consider a disposable bronchoscope 3. Universal protocol and time out may be performed outside the room with procedure team followed by appropriate donning of enhanced PPE per institutional protocol. 4. Use of ultrasound to assess anatomy and point of entry (utilize standard decontamination protocol of durable equipment) 5. Deep sedation and neuromuscular blockers should be used for the procedure to minimize cough and agitation.

6. Before start, perform a trial of apnea to mimic apnea. a. withhold ventilation (apnea) b. discontinue positive end-expiratory pressure (PEEP) c. increase the inspired fraction of oxygen (FiO2) to prevent desaturation, for a duration of 30 seconds to a minute.

If apnea is not tolerated, reduce the ventilatory pressures and respiratory frequency to minimize the risk of aerosolization. Otherwise, consider deferring the procedure until ventilatory requirements are optimized.

7. Key intervals where apnea must be performed during a traditional bronchoscopic guided percutaneous dilational tracheostomy are • When the bronchoscope adaptor is added to the circuit • Prior to inserting the bronchoscope into the endotracheal tube (ETT)

• During the pull-back of the ETT with cuff deflation • Time of insertion of the introducer needle, angiocatheter, dilation,and insertion of the tracheostomy tube, bronchoscopic confirmation of placement, until connected to closed circuit connection with ventilator • Removal of the ETT from oropharynx 8. The oropharynx and the hypopharynx may be packed. A suction tip may be placed in the mouth to lessen the risk of aerosolization of oral secretions during the ETT pullback.

9. During the procedure, place a moist gauze or sponge around the guidewire, during dilation, and neck stoma as needed.

10. Ultrasound can be incorporated into PDT to avoid the need for bronchoscopic guidance. Sonography equipment will need to be decontaminated at the end of the procedure. Additionally, a modified PDT technique with placement of bronchoscope alongside the ETT while advancing the ETT below the intended stomal point of entry might reduce aerosolization 11. During an open tracheostomy, in addition to the above steps using apnea during ETT tube manipulation and prior to incision into the anterior wall of the trachea, avoid or minimize the use of diathermy and suction as it carries a risk of aerosolizing particles.

12. Place a petrolatum gauze dressing at the site of the fresh stoma until it heals to prevent aerosolization or air leak. 1 2 3 4 Table 4 : Summary of post-tracheostomy care of COVID-19 patients 5

• Avoid changing the tracheostomy tube until COVID-19 has passed • Cuff to remain inflated and check for leaks • Make every effort not to disconnect the circuit • Only closed in line suctioning should be used

• AGPs should be performed on patients suspected or confirmed with infection only if medically necessary • Strategies to reduce aerosol generation should be applied • The number of HCWs present during AGPs should be limited to those essential for patient care and support American Academy of Otolaryngology-Head and Neck Surgery

• Limit the number of providers participating in tracheotomy procedure and post-procedure management • Avoid circuit disconnections and suction via closed circuit • Place a heat moister exchanger (HME) with viral filter or a ventilator filter once the tracheotomy tube is disconnected from mechanical ventilation • Delay routine post-operative tracheotomy tube changes until COVID-19 testing is negative Canadian Society of Otolaryngology-

• Avoid open suction and instead use closed, inline suction whenever possible • Avoid repeated suctioning and disconnection of the ventilator circuit • Use an HME with HEPA level filter (preferred), to provide humidity, reduce secretions with minimal increase in perceived respiratory resistance in the ventilator circuit or on the ventilator exhaust portion. ○ Monitor filter for obstruction risk • Minimize nebulization, instillation of fluids • Avoid all unnecessary examinations or procedures including decannulation until the patient is considered COVID-19 negative • For mature at-home tracheotomy patients, defer all routine tracheotomy changes during pandemic

• Identify the minimum number of people required to safely conduct a session • Consider bundling care with other healthcare professionals • Carefully consider equipment use and discuss with infection control services to ensure it can be properly decontaminated • Avoid moving equipment between infectious and non-infectious areas • Wherever possible, single patient use, disposable equipment is preferred 1 2 3 

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