Tracheotomy in COVID-19 Positive Patients - “New Normal” Workflow of
Tracheotomy in the Era of SARS/COVID-19 Pandemic A Systematic Review
Abstract
Introduction With the COVID-19 pandemic, a “new normal” on how
surgeons and intensivists perform tracheotomy in COVID-19 patients is
essential. We aim to summarize the recommendations and present the
supporting evidence of these recommendations. Methods A search of
published works on tracheotomy, tracheostomy, COVID-19, novel
coronavirus, SARS-CoV-2 was performed on PubMed/MEDLINE/Cochrane
Library. Articles relevant to the practice of tracheotomy on patients
with COVID-19 were selected. The articles were then reviewed and divided
into 4 key categories: 1) Personal protective equipment (PPE) in
COVID-19 positive patients, 2) Adjunctive measures of airway management
before definitive intervention in COVID-19 positive patients; 3) Timing
of tracheotomy in COVID-19 positive patients; and 4) Perioperative
considerations in performing tracheotomy in COVID-19 positive patients.
Results and key points Firstly, enhanced PPE is recommended during
tracheotomy of COVID-19 positive patients. Secondly, adjunctive airway
management before definitive intervention includes the use of high flow
nasal cannulas (HFNC). Thirdly, non-invasive ventilation via continuous
positive airway pressure (CPAP) and bilevel positive airway pressure
(BiPAP) machines are not recommended. Fourth, the general consensus
suggests that timing of tracheotomy should be at least 10 days after
intubation. Finally, percutaneous dilatational tracheotomy (PDT) is
likely to be associated with a lower risk of transmission of the virus
to healthcare workers (HCW) than a surgical tracheotomy (ST). Other key
precautions would include minimizing the use of diathermy. Conclusions
The “new normal” workflow summarizes the ideal recommendations across
published societal guidelines. Enhanced PPE should be recommended
whenever possible. Adjunctive measures before definitive intervention of
COVID-19 patients should be limited to the use of HFNC, and CPAP/BiPAP
should be avoided. Tracheotomy should be performed after 10 days,
although the long term sequelae of tracheal stenosis and pulmonary
fibrosis should be ascertained with this approach.