Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report

Abstract

Background: The role of tracheostomy during the coronavirus disease 2019 (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 (HCWs).

Methods: A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care 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 evidence-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 reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.

Keywords: COVID-19; SARS-CoV-2; aerosol generating procedure; open surgical tracheostomy; percutaneous dilatational tracheostomy; tracheostomy.

Figure 1

Voting results for the recommendations and remarks. AGP = aerosol generating procedure; COVID-19 = coronavirus disease 2019; HCW = health-care worker; HEPA = high-efficiency particulate air; OR = operating room; OST = open surgical tracheostomy; PDT = percutaneous dilatational tracheostomy; PPE = personal protective equipment; RT-PCR = reverse transcription polymerase chain reaction.

Figure 2

A-B, Closed circuit setup using a heat moisture exchanger with viral filter and in-line suction can be used to minimize aerosol generation. Suggested setup for patients without (A) and with (B) high oxygen requirements. Credit: Jhanvi Soni, RRT, Michelle Prickett, MD and Lisa Wolfe, MD.