Keeping an Open Mind: Tracheostomy for Patients With Coronavirus Disease 2019

To the Editor In their article for The Open Mind, Dr Bassi et al1 ask whether surgical tracheostomy is better than percutaneous tracheostomy in patients with coronavirus disease 2019 (COVID-19), gravitating toward surgical tracheostomy to promote staff safety. Several other recommendations similarly aim to improve safety for the health care team; relatively less emphasis is placed on identifying measures to improve safety and benefit for patients. We explore this flip side of the coin. As frontline health care workers are called on once again to don their personal protective equipment (PPE) and perform and manage tracheostomy, it is a critical juncture to pause and reflect on what we have learned. Having established safe practices for clinicians, how can we make tracheostomy safer for patients? From this perspective, we expand on Bassi et al’s1 recommendations, considering technique, neuromuscular blockade, airway manipulation during apneic tracheostomy, preprocedural apnea trials, and protective barriers. With respect to technique, Bassi et al1 suggest that performing a surgical tracheostomy in the controlled environment of the operating room may be safer for staff than a percutaneous tracheostomy. This notion is traced back to the SARS outbreak in Singapore, Hong Kong, and Canada, where staff performed these procedures using FFP3/N95 facemasks and enhanced PPE, ranging from face shields to powered air-purifying respirators (PAPRs).2 While enhanced PPE remains standard during tracheostomy, surgical and percutaneous techniques have progressed significantly during the past 20 years. There is no evidence of superior safety with either technique, nor is there unequivocal difference in outcomes, although there may be cost advantages and fewer complications associated with a percutaneous procedure.3 Curtailing use of percutaneous techniques may reduce availability of tracheostomy during surges, thereby prolonging ventilator dependence, exacerbating resource scarcity, or delaying rehabilitation. The recommendation for use of neuromuscular blocking drugs during tracheostomy insertion in patients with COVID-19 is appropriate, as avoiding patient movement and coughing reduces aerosol generation. However, critically ill patients are at risk of tachyphylaxis to neuromuscular blocking drugs, and therefore neuromuscular monitoring is recommended by international consensus guidance to ensure deep paralysis during tracheostomy.2 This precaution is particularly relevant to COVID-19 tracheostomy candidates who often have prolonged periods of paralysis. Recalibrating approaches with an eye toward patient safety can ensure that COVID-inspired practices do not endanger patients. Pausing ventilation at key steps to minimize aerosol spread is an important evolution in percutaneous and surgical technique, but such pauses should not be longer than necessary, given the limited pulmonary reserve of patients with COVID-19 acute respiratory distress syndrome (ARDS). Placing the inflated endotracheal tube cuff distal to the tracheostomy site can help minimize apnea duration.2 Although Bassi et al1 allude to pushing the tube toward the carina when discussing anesthetic management, their third point for surgical tracheostomy states, “Before tracheotomy, the tracheal tube is withdrawn and the ventilation is stopped.” To be precise: during a surgical procedure, advancing the endotracheal tube distal to the operative site without cuff deflation and without suspending ventilation allows the surgeon to expose and even open the trachea without pausing ventilation. To insert the new tracheostomy tube, ventilation is suspended, the endotracheal tube cuff is deflated and withdrawn proximal to the tracheotomy, the new tracheostomy tube inserted and ventilation recommenced when the closed circuit is attached. Airway management during percutaneous tracheostomy requires that the endotracheal tube be carefully manipulated proximally such that the cuff lies at (or even above) the vocal cords. Owing to the risk of inadvertent proximal displacement of the cuff, we recommend that ventilation of the lungs be suspended before tube repositioning for percutaneous tracheostomy. Videolaryngoscopy improves the precision of airway manipulations, especially considering the risk of a difficult airway owing to the additive effects of critical illness, prolonged intubation, and laryngeal edema associated with severe acute respiratory syndrome coronavirus 2.4 We also recommend that a dedicated assistant be responsible for turning the ventilator or anesthetic machine on or off during these critical maneuvers. Because apnea may cause rapid and critical hypoxia in the ventilator-dependent, critically ill patient, we recommend preoxygenation, followed by a trial of apnea in the intensive care unit, with a fractional inspired oxygen concentration of 1.0 and a positive-end expiratory pressure (PEEP) of 5 cm H2O in the supine patient, before tracheostomy.2 If rapid desaturation occurs during this apnea test, the patient has insufficient reserve to tolerate a pause in ventilation, and tracheostomy should be deferred. Finally, we commend the authors for their resourcefulness in developing a novel barrier that resides between operators and the patient. While the device illustrated is less restrictive than some other boxes developed for this purpose, we nonetheless have reservations about the use of Perspex, Plexiglas, or other acrylic/plastic barriers. We acknowledge that not all institutions have negative pressure environments and specialized equipment to protect staff during tracheostomy, but the foremost consideration is nonetheless standardized protocols and adequate PPE. Our own experience with simulated airway management behind barrier enclosures is similar to that of reports in the literature—the risk of the barrier impeding emergency airway management outweighs protective benefit.5 If such devices are used, the extent of barricade should be minimized, and all staff should have ample experience, including instruction on how to manage emergencies and circumvent the barrier if needed. In summary, Bassi et al’s1 approach to tracheostomy during the COVID-19 pandemic is an excellent framework for tracheostomy, which is most efficacious when viewed through the lens of patient safety. Tracheotomy techniques that are adapted to minimize risk of viral transmission can inadvertently introduce perils for patients. Through proactively recognizing and addressing such unintended consequences, safety of clinicians and patients can be assured. Time-honored precepts of critical care still apply—even in the midst of pandemic—and measures to minimize risk of derecruitment during apneic episodes are essential. Multidisciplinary teamwork is indispensable in assuring safe outcomes. We will learn more from robust data collection initiatives, such as the Global Tracheostomy Collaborative.6 Perhaps the most striking lesson of the pandemic is that we needn’t choose between our safety and welfare of our patients; with careful foresight we can have both. Brendan A. McGrath, MB, ChB, FRCP, FRCA, EDIC, DICM, AHEA, FFICM, MAcadMEd, PhDDepartment of Anaesthesia & Intensive Care MedicineManchester University NHS Foundation TrustManchester Academic Critical CareDivision of Infection, Immunity and Respiratory MedicineSchool of Biological SciencesFaculty of Biology, Medicine and HealthManchester Academic Health Science CentreThe University of Manchester Manchester, UK[email protected] Paolo Pelosi, MD, FERSDepartment of Surgical Sciences and Integrated DiagnosticsUniversity of GenoaGenoa, ItalyDepartment of Anesthesiology and Intensive CareSan Martino Policlinico HospitalInstituto di Ricovero e Cura a Carattere Scientifico for Oncology and NeurosciencesGenoa, Italy Michael J. Brenner, MD, FACSGlobal Tracheostomy CollaborativeRaleigh, North CarolinaAmerican Academy of Otolaryngology – Head & Neck SurgeryAlexandria, VirginiaDepartment of Otolaryngology – Head & Neck SurgeryUniversity of Michigan Medical SchoolAnn Arbor, Michigan

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