key: cord-1002468-3c1fdph3 authors: Favier, Valentin; Kimmoun, Antoine; Gatin, Amélie; Gallet, Patrice title: Percutaneous tracheostomy simulation training for ENT physicians in the treatment of COVID-19-positive patients date: 2020-06-10 journal: Eur Ann Otorhinolaryngol Head Neck Dis DOI: 10.1016/j.anorl.2020.06.002 sha: 9180b0de3e7954e940dca2f1113c63db097c6878 doc_id: 1002468 cord_uid: 3c1fdph3 Abstract Tracheostomy in COVID-19-related severe acute respiratory syndrome is at high risk of viral dissemination. The percutaneous dilatation technique could reduce this risk, being performed at the bedside and minimizing airway opening. In the COVID-19 context, however, with precarious respiratory status, it requires specific preparation. We designed a 3-hour training module, and here provide a step-by-step schedule, including video analysis, a demonstration of the kit, the recommended precautions related to COVID-19, and several simulation scenarios of increasing difficulty, using a high-tech mannequin. A low-tech procedural simulator was also developed for practicing the steps of the procedure. Our experience (3 sessions with 14 participants) highlighted the difficult points of the procedure in the COVID-19 context, and defined a check-list for clinical practice and an assessment grid. This type of simulation helps to prepare teams for a potentially delicate technical act. The COVID-19 pandemic requires current practice to be adapted to emerging needs and enhanced protection of patients and care-givers [1] . Patients in intensive care usually need prolonged respiratory assistance [2] , blocking access for new cases when the saturation point is reached. Tracheostomy could hasten termination of respiratory assistance and reduce ICU stay [3] . However, it incurs a high risk of SARS-CoV-2 viral dissemination as it involves ventilation circuit disconnection and aerosolization. Based on experience from Asia in 2004 [4] and 2020 [5] , the American Academy (https://www.entnet.org/content/tracheostomy-recommendations-during-covid-19-pandemic) and the ENT-UK National Tracheostomy Safety Project (https://www.entuk.org/tracheostomy-guidanceduring-covid-19-pandemic) drew up guidelines for surgical tracheostomy; intensive care physicians, however, seem to favor the percutaneous technique, which is quicker and does not require transfer to theater, without more immediate complications [6] [7] . Likewise, according to the recent guidelines from the French ENT Society (SFORL) on tracheostomy under the COVID-19 pandemic (https://www.sforl.org/wp-content/uploads/2020/04/SFCCF-SFORL-COVID-19-2i%C3%A8mearticle.pdf), the percutaneous technique is to be preferred, to limit aerosolization-related viral contamination of care staff and avoid theater transfer. The procedure has been well described and is used in intensive care [8] [9] , but usually requires 2 operators (1 at the patient's head for flexible endoscopic control, and 1 for the tracheostomy) and an anesthesiologist to deal with the respirator and the drugs. To free up time for intensive care specialists, ENT physicians may be called upon to perform percutaneous tracheostomy, having the requisite anatomic knowledge and experience in dealing with the upper airway. This has been the case in the Nancy University Hospital and the Metz Military Hospital. However, the technique requires training, especially in the COVID-219 context. To minimize error, simulation can be of great help, and the present technical note describes a training schedule for ENTY physicians in percutaneous tracheostomy in COVID-19+ patients. Page 4 of 18 J o u r n a l P r e -p r o o f 4 A 3-hour half-day session can include 4-6 participants working in 2-3 pairs in a simulation room equipped with a video camera and microphones. The scenario requires 1 facilitator (anesthetist), and can be supervised by 1 or 2 session leaders. Session procedure is shown in figure 1 . A 15-min video introduction presents the kit, step-by-step breakdown of the manual procedure and error screening in a sample procedure; technical pitfalls and clinical risks are highlighted. Trainees are then given a percutaneous tracheostomy kit (Ultraperc kit Portex TM , Smiths Medical, Minneapolis, Minnesota, USA) to handle ahead of simulation. The second phase involves a home-made low-tech procedure simulator, costing less than €20 ( Figure 2 ), for practice ahead of full-scale simulation. Trainees wear a full protective outfit: surgical clothing, FFP2 mask, protective glasses, hood, overshoes and 2 pairs of sterile gloves. An "observer" is useful, to oversee donning and doffing, as recommended in the French health authority's methodology guide (https://solidarites-sante.gouv.fr/IMG/pdf/guidecovid-19-phase-epidemique-v15-16032020.pdf). A dedicated checklist forming an acrostic from A to M enables trainees to prepare fully before entering the room, so as not to have to go out during the procedure. Percutaneous tracheostomy is fairly easy to learn, but, in the context of a highly contagious lung disease such as COVID-19, with severely impaired respiratory capacity, it has to be performed especially efficiently and safely, adapting the steps of Ciaglia's procedure [8] (Table 1) . We therefore thought it essential to formalize training in a safe environment by means of a simulation workshop. Having conducted this training module 3 times, we are able to draw some lessons and lay out the best debriefing approach. The detailed results are presented in Annexes 2 and 3. Page 6 of 18 J o u r n a l P r e -p r o o f 6 Although, with experience, surgeons' self-assessments seem well-correlated with their real skill [10] , trainees are prone to overestimate their skills, especially in non-technical areas [11] . We therefore advise associating self-assessment to assessment by the supervisor or supervisors (Table 2 and The simulations and the discussions between trainees and supervisors notably highlighted the question of managing the intubation catheter, which is the most delicate point in the procedure. The recommendation was to have the more experienced ENT physician at the patient's head (endoscope), as this position requires good experience of intubation and flexible endoscopy to secure optimal positioning in the airway. It also makes the leader free to synchronize ventilation with the anesthetist and guide the trainee performing the percutaneous tracheostomy as such, which was generally agreed to be more technically straightforward. The intubation catheter should be freed from its attachments and positioned in the axis of the incisors to optimize endoscopy. When the catheter has to be moved, the movement should be slow and careful; the hand holding the catheter should lean on the patient's face to limit the risk of unintentional extubation on exposing the inferior edge of the cricoid. It is recommended to verbally call out the mark on the catheter (which respect to the dental arcades) before the catheter is raised and once it has been positioned below the glottis. In case of accidental extubation, the flexible endoscope is the best guide for reintubation, but an Eschmann stylet and a laryngoscope should also be readily available. To minimize leakage, a finger is placed on the trocar at cervical level as soon as possible, and the physician handling the endoscope also attempts to minimize leakage at the endoscope entry point. The respirator is put on prolonged expiratory pause when leakage is most likely, if the patient can tolerate this. A further precaution against aerosolization would be to have a portable air purifier in the room throughout the procedure, to filter out airborne viral particles before, during and after tracheostomy. In the present case, all the scenarios were played out on the "high-tech" SimMan 3G simulator, which allows real-time adjustment of physiological constants transmitted to an intensive care screen, modeling complications (pneumothorax), modifying neck conformation (to simulate goiter, laryngeal deviation, etc.) and simulating difficult intubation (Figure 4) . A less sophisticated simulator could be used, but such full-scale simulation allows consensus to be reached on difficulties, however rare, that Table 2 ). The fact that the other trainees were able to watch a given pair's simulation in real time and take part in the debriefing ironed out some difficulties for the subsequent scenarios, so that procedure time constantly decreased despite the increasing difficulty (Annex 2). The present check-list, with its "A-to-M" mnemonic form, can be of great importance as, in the context of intensive care for COVID-19 patients, the room must be closed and the team needs to be completely self-sufficient, which requires having all necessary equipment to hand in sufficient quantity to ensure the safety of both patient and staff. Supervised doffing revealed some errors: hands too close to the collar in removing the cap, the need to put all the clothing in the trash can without having to push it in, so as to avoid aerosolization, and errors in removing the mask (need to pull the elastic bands from behind to in front of the skull to remove the mask from the face without raising it to the hairline). In conclusion, simulation of percutaneous tracheostomy with a training module covering theory with video support, technical practice on the low-tech simulator, then clinical practice on the full-scale hightech simulator seems suited for training ENT physicians. The module is also an opportunity to stress the specificities of protection against COVID-19 in the ICU setting. We consider the format reproducible in most simulation centers equipped with high-tech simulators, and that the low-tech simulator is easy and cheap to produce for the purely technical aspect of the training. The authors have no conflicts of interest to disclose in relation to the present article Elsewhere, Valentin Favier received funding from the French College of ENT and Head and Neck Surgery for a 1- year research project on simulation in head and neck surgery. 12 Table 1 : Percutaneous tracheostomy steps under flexible endoscopy, adapted from the description by Ciaglia [8] . Kit contents and tracheostomy cannula balloon status should be checked in advance. The patient is sedated and curarized under 100% FiO2. Respirator settings and alerts are adjusted to accept the extra pressure induced by the flexible endoscope within the intubation catheter. So far as possible, steps 7-8, 10-11 and 13-15 should be conducted under expiratory pause. Steps 17-20 should be conducted in <30 sec (ideally, <15 sec). Step Expiratory pause Detailed description 1 Skin disinfection, wide cervicotomy-type surgical draping (4 drapes) Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Clinical progression of patients with COVID-19 in Shanghai Tracheostomy in the intensive care unit: guidelines from a French expert panel. Ann Intensive Care Severe acute respiratory syndrome (SARS): lessons learnt in Hong Kong Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev Network Comparative Meta-analysis of Percutaneous Dilatational Tracheostomies Using Anatomic Landmarks, Bronchoscopic, and Ultrasound Guidance Versus Open Surgical Tracheostomy Elective Percutaneous Dilatational Tracheostomy: A New Simple Bedside Procedure Are general surgeons able to accurately selfassess their level of technical skills? Clinical skills in junior medical officers: a comparison of selfreported confidence and observed competence Withdrawal of intubation catheter (ideally clamped) and endoscope 23 Safety cord/suture and usual protection measures