key: cord-0978286-77kedzec authors: De Seta, Daniele; Carta, Filippo; Puxeddu, Roberto title: Management of Tracheostomy during COVID-19 Outbreak: Heat and Moisture Exchanger Filter and Closed Suctioning System date: 2020-05-07 journal: Oral Oncol DOI: 10.1016/j.oraloncology.2020.104777 sha: 30cdb160cc9a1e4945db729c3e5ee20fed3b5ba5 doc_id: 978286 cord_uid: 77kedzec • Precautions for safer management of tracheostomy should be taken for all patients. • HMEFs and closed endotracheal suctioning systems protect patients and healthcare professionals. • Precaution for reduce the COVID-19 diffusion should be taken until the epidemic is controlled. We carefully read and appreciate the recent published editorial by Pichi et al. [1] highlighting the risks of infection during tracheostomy for the healthcare professionals that represent more than 10% of the total infected population in Italy, according to the latest report from the Italian Superior Institute of Health [2]. The paper proposes a step-by-step method for a safer tracheostomy for those patients affected by COVID-19 requiring a mechanical ventilation. The CORONA procedure proposed in the above mentioned work should be followed, in our opinion, not only for those patients affected by COVID-19 but for all the patients needing a temporary or permanent tracheostomy also in future. The guidelines of the Italian Society of Otolaryngology for the surgical management of ENT procedures during the COVID-19 outbreak (www.sioechcf.it) include the execution of two swabs for the SARS-CoV-2 testing (4 days and 48 h before surgery) for all patients. If the test cannot be performed, the patient has to be considered as positive. Given the possibility to have false SARS-CoV-2 negative results attributable to the low viral load especially in asymptomatic or mildly symptomatic patients [3] , since the beginning of the COVID-19 pandemic our policy has been to act like every patient was positive, in order to avoid any unrecognized infection. Moreover, tracheostomy may be necessary as life treating procedure for upper respiratory airway dyspnea giving not the time for testing the patient. Since the beginning of march 2020 we performed in our Unit, that is not in a COVID-19 dedicated Hospital, 15 procedures requiring tracheostomy (including 2 total laryngectomy, 3 OPHL, 1 transoral laser pharyngectomy, 6 advanced stage tumors excision requiring a free flap reconstruction and 3 emergency tracheostomy), none of these patients was positive for SARS-CoV-2 at nasopharyngeal swab, but 3 of them cannot be tested preoperatively and were tested only after surgery. The closed endotracheal suctioning systems are recommended for the prevention of the ventilator associated pneumonia, but its role is debated [5] , despite that it is a fact that these systems allow the aspiration of endotracheal secretion without risk of spread the aerosol in the room. The two systems in our patients were connected to the cannula with a T-connector in order to have a closed circuit that allows the aspiration of endotracheal secretions and the safe breathing with the HMFE (Fig. 1) . The use of these two devices is recommended for all patients underwent permanent or temporary tracheostomy during the time of hospitalization or at least until two negative swabs were obtained. For a correct management of the HMFE the continuous measurement of arterial oxygen saturation using pulse oximetry (SpO2) and the filter change after 24 h are recommended for reduce the risk of filter obstruction by condensation [6] . In this period no one is aware of the duration of this epidemic, but several experts warn of another outbreak in the autumn 2020. Furthermore, we do not know if and how this event will change the management standards of operating rooms and hospital wards in the future. In our opinion, a prudent attitude should be used for all patients; the CORONA tracheostomy procedure [1] together with the use of HMEF and Closed Suctioning System could be useful to reduce the risks of intra-hospital spread of viral infections preserving the patients and healthcare professionals after tracheostomy. CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway management Potential preanalytical and analytical vulnerabilities in the laboratory diagnosis of coronavirus disease 2019 (COVID-19) The bacterial and viral filtration performance of breathing system filters VAP Guidelines Committee and the Canadian Critical Care Trials Group. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: prevention Hidden hazards and dangers associated with the use of HME/filters in breathing circuits. Their effect on toxic metabolite production, pulse oximetry and airway resistance Figure Legend Figure 1. Patient at postoperative day 2 after a left mandibular resection, bilateral neck dissection and fibula free flap reconstruction. The bacterial/viral filter is provided with the heat and moisture exchanger (HMEF6/I The authors declare that they have no conflict of interest.