key: cord-0899591-d8qe8bux
authors: Bartter, Thaddeus C.; Mathew, Roshen; Meena, Nikhil K.
title: Traditional technique in lieu of novel percutaneous tracheostomy technique during COVID-19
date: 2020-06-11
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.06.002
sha: b94994c0947663d4166be2c6c62e97e2835abff7
doc_id: 899591
cord_uid: d8qe8bux

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To the Editor:

We read with interest the novel percutaneous tracheostomy (PT) technique (1) described by Angel et al. While we found their technique to be clever and thoughtful, it was not clear that it represents an advance which will truly mitigate aerosolization of secretions from Covid-19 patients undergoing PT.

With "traditional" PT using the blue rhino dilator technique, (2) the system is initially opened for the in-line insertion of a swivel adaptor and then a bronchoscope. The next broach of the system comes as the blue rhino dilator is removed and the tracheostomy placed. Each of these can be accomplished with brief (5-30 seconds) intervals with patient in apnea, and the ventilator in standby mode. Each time, before the system is broached, a surgical hemostat briefly clamps the endotracheal tube (ETT) to reduce aerosolization.

With the novel technique, the ETT is advanced and the initial steps are conducted with the balloon inflated distal to the site of neck penetration. During the transition to tracheostomy, the ETT must be pulled back above the insertion site and the bronchoscope passed beyond the balloon. This has the potential of causing an upper airway leak that persists until the tracheostomy has been inserted at the neck. The duration of that leak may vary on a case-by-case basis. The broach at the neck during removal of the dilator and placement of the trach would not differ significantly.

With the traditional technique, (2) the stage is set with visual guidance for the entire procedure. With the novel technique, the procedure is interrupted midway for readjustment of ETT and bronchoscope. There is a small risk that passing the bronchoscope beyond the end of the ETT for the final steps will be problematic. For the traditional approach the bronchoscope could be held by almost any ancillary provider or trainees. For the novel approach some level of bronchoscopy skill is essential.

With procedures, any introduction of complexity can increase risk. We laud Angel et al. for their ingenuity. A modification of traditional PT insertion in which the closed system is broached briefly with apnea, in a conscious and controlled manner still represents the simplest approach.

Novel Percutaneous Tracheostomy for Critically Ill Patients with COVID-19

Performing Tracheostomy during the Covid-19 Pandemic: Guidance and Recommendations from the Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma