A Safe Approach to Percutaneous Tracheostomy for COVID-19 Patients in Intensive Care

Abstract

The novel coronavirus disease 2019 (COVID-19) has placed a burden on critical care facilities worldwide. Patients who remain critically unwell with COVID-19 require prolonged periods of ventilation, and the burden of both the resources during a pandemic and the slow respiratory wean must be managed. Percutaneous tracheostomies are commonplace in long-term intensive care patients, yet little is known about their role in COVID-19, particularly how operator safety is maintained during the procedure. Here, we describe an approach designed to minimize cross-infection of the operators undertaking percutaneous tracheostomies within this subset of patients. Focus should be on non-technical skills, prolonged periods of pre-oxygenation, and minimal ventilation during the procedure to minimize the risk of aerosolization generated from an open breathing system. Our modified technique demonstrates successful early experiences with no operators testing positive for COVID-19 or developing symptoms following any performed procedure.

Keywords: covid-19; difficult airway management; ent procedures; healthcare worker safety; percutaneous tracheostomy; pulmonary critical care.

Figure 1. Endotracheal tube visualized by video laryngoscopy and withdrawn just distal to the vocal cords.

Figure 2. Swivel adaptor valve.

Figure 3. Tracheal puncture using cannulation needle.

Note the bronchoscopy scope remains in situ, and the airway handler forms a tight seal around the swivel connector to minimize airway leakage.

Figure 4. The guidewire should be clearly visualized with the bronchoscope.

Figure 5. Manual covering of stoma site.

If manual ventilation is required, the tracheal opening should be manually covered while maintaining sterility.

Figure 6. Connection to the ventilator circuit together with in-line suction.