Dear Editor,At 29th of February the World Health Organization (WHO) reported 85403 confirmed globally confirmed case of COVID-19 . COVID-19 is dramatically increasing in Italy, the last report from the ministry of health on the 9th of march reported the presence of 9172 confirmed cases and 733 patients in intensive care unit (ICU) . We agree with Chan et al that physicians managing airway procedures are at particularly high risk to contract the COVID-19 infection . We support the authors that claimed for a full protective wearing including N95 respirator, gown, cap, eye protection, and gloves, during aerosol generating procedures (AGP) . However, we’d like to focus the attention on the tracheostomy procedures in COVID-19 patients since otolaryngologists, anesthesiologists and intensive care physicians are at high risk of contracting the infection during tracheostomy . Tracheostomy is required in case of prolonged mechanical ventilation and intensive care unit (ICU) stay . Surgical tracheostomy is an AGP associated with an increased risk severe acute respiratory distress (SARS) infection . Strict adherence to infection control guidelines in SARS is mandatory in performing tracheostomy in ICU or operating room .Few years ago, we proposed the double lumen endotracheal tube (DLET) for percutaneous tracheostomy in critically ill patients . DLET was equipped with an upper channel that allows passage of a bronchoscope during the percutaneous tracheostomy and with a lower channel exclusively dedicated to patient ventilation . The lower channel is equipped with a distal cuff positioned just above the carina that may allow a safe mechanical ventilation by keeping stable gas-exchange and limiting the spread of aerosol during the procedure . During the percutaneous procedure, the puncture of the anterior tracheal wall, Seldinger insertion, dilatation, and cannula positioning were all performed with the DLET correctly placed in the trachea. The DLET was removed at the end of the tracheostomy when the cannula is inserted and correctly positioned with the FFB .Surgical tracheostomy in COVID-19 patients should be done with a close collaboration between otolaryngologists, preforming the surgical procedure, and anesthesiologists or intensive care physicians managing the general anesthesia and the airway.When a surgical tracheostomy is done under general anesthesia, just before the surgeon makes the tracheal stoma, the endotracheal tube is withdrawn, so that the cuff of the tube is not in the surgical field . But when the surgeon makes the tracheal incision, ventilation is lost and the surgeon has to be quick enough to create the soma and insert the tracheostomy tube in a short time . During this procedure a large spread of aerosol may occur. To avoid the aerosol, we suggest to push down the endotracheal tube beyond the site chosen for the tracheal stoma at the beginning of the procedure. The endotracheal tube should reach the tracheal carina so the cuff is surely distal to the tracheostomy site. By checking the airway pressure and the end-tidal CO2, on the mechanical ventilator we can realize if the endotracheal tube is still in the lower tract of the trachea or in the endobronchial tract. Our previous experience with the DLET demonstrated that the endotracheal tube and the tracheal cannula can be simultaneously inserted inside the trachea . According to this, pushing down the endotracheal tube and cuffed it at the level of the carina may avoid the spread of aerosol and, then, may add an extra security for the medical staff during a procedure at high risk of generating aerosol.ReferencesCoronavirus disease 2019 (COVID-19) Situation Report – 40.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200229-sitrep-40-covid-19.pdfItalian Minister of Health. COVID-19 Italian cases.http://www.salute.gov.it/portale/nuovocoronavirus/dettaglioContenutiNuovoCoronavirus.jsp?lingua=italiano&id=5351&area=nuovoCoronavirus&menu=vuotoChan YJK, Wong EWY, Lam W. Practical Aspects of Otolaryngologic Clinical Services During the 2019 Novel Coronavirus EpidemicAn Experience in Hong Kong. JAMA Otolaryngol Head Neck Surg. Published online March 20, 2020. doi:10.1001/jamaoto.2020.0488Vargas M, Sutherasan Y, Antonelli M, Brunetti I, Corcione A, Laffey JG, et al. Tracheostomy procedures in the intensive care unit: an international survey. Critical Care 2015;19:291-301Tran K, Cimon K, Severn M et al. Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review. . PLoS ONE 2012; 7(4): e35797. doi:10.1371/journal.pone.0035797Chun-Wing A, Yin -Chun L, Kit-Ying L. Management of Critically Ill Patients with Severe Acute Respiratory Syndrome (SARS). Int. J. Med. Sci. 2004 1(1): 1-10Vargas M, Servillo G, Tessitore G, Aloj F, Brunetti I, Arditi E, et al. Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube. A Comparison of Feasibility, Gas Exchange, and Airway Pressures. Chest 2015; 147:1267-74Walts PA, Sudish CM, DeCamp MM. Techniques of surgical tracheostomy. Clin Chest Med 24 (2003) 413 – 422
Background: The Coronavirus disease – 2019 (COVID-19) pandemic is a global health crisis and Otolaryngologists are at increased occupational risk of contracting COVID-19. There are currently no uniform best-practice recommendations for Otolaryngologic surgery in the setting of COVID-19.Methods: We reviewed relevant publications and position statements regarding the management of Otolaryngology patients in the setting of COVID-19. Recommendations regarding clinical practice during the Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks were also reviewed.Results: Enhanced personal protective equipment (N95 respirator and face shield or powered air-purifying respirator, disposable cap and gown, gloves) is required for any Otolaryngology patient with unknown, suspected, or positive COVID-19 status. Elective procedures should be postponed indefinitely, and clinical practice should be limited to patients with urgent or emergent needs. Conclusion: We summarize current best-practice recommendations for Otolaryngologists to ensure safety for themselves, their clinical staff, and their patients.
The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities.There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists and otolaryngologists. Health workers represent between 3.8% to 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter).All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55-65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Healthcare facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for cancer patients.For those who are working with COVID-19 infected patients’ isolation is compulsory in the following settings: a) unprotected close contact with COVID-19 pneumonia patients: b) onset of fever, cough, shortness of breath and other symptoms (gastrointestinal complaints, anosmia and dysgeusia have been reported in a minority of cases).For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (e.g.; rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia) it is strongly recommended that all healthcare personnel wear personal protective equipment (PPE) such as N95, gown, cap, eye protection and gloves.The procedures described are essential in trying to maintain safety of healthcare workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances.
Lung ultrasound (LU) has rapidly become a tool for assessment of patients stricken by the novel coronavirus 2019 (COVID-19). Over the past two and a half months (January, February and first half of March 2020) we have used this modality for identification of lung involvement along with pulmonary severity in patients with suspected or documented COVID-19 infection. Use of LU has helped us in clinical decision making and reduced the use of both chest x-rays and computed tomography (CT).
Orleans Parish in Louisiana is in the midst of an exponentially increasing number of patient admissions with COVID-19 and respiratory symptoms. Patients have been described having CT findings most consistent with an Early stage (< 7 days from symptoms onset) or an Advanced stage (8-14 days from symptoms onset).We describe and illustrate those Early and Advanced stage CT findings from patients with documented COVID-19 who have been admitted to University Medical Center in New Orleans, Louisiana.
A 57-year-old man was diagnosed with acute aortic dissection (AAD), but had marked infiltration shadows in his right lung. Intraoperative findings showed that large subadventitial hematomas had spread from the ascending aorta to the right pulmonary artery, which may have caused the infiltration of the lung. Subadventitial hematoma must be considered in rare cases of AAD with pulmonary infiltration.
Purpose : Pulmonary ultrasound can rapidly identify the etiology of acute respiratory failure (ARF) and assess treatment response. The often-subjective classification of abnormalities makes it difficult to document change over time and communicate findings across providers. The study goal was to develop a simple, scoring system that would allow for standardized documentation, have high inter-provider agreement, and correlate with clinical metrics.Methods : rospective of adults intubated for ARF performed at intubation, 48-hours, and extubation. A total lung score (TLS) was calculated. Clinical metrics and final diagnosis were extracted from the medical record.Results : TLS correlated positively with mortality (p=0.0), ventilator hours (p0.00), intensive care unit and hospital length of stay (p=0.00, p=0.0), and decreasing PaO2/FiO2 (p0.00). Agreement of findings was very good (kappa=0.83). Baseline TLS differed significantly between ARF categories (non-pulmonary, obstructive, and parenchymal disease).Conclusions : A quick, was associated with clinical metrics including mortality among a diverse population of patients intubated for ARF. In addition to diagnostic and prognostic information at the bedside, a standardized and quantifiable approach to PU provides objectivity in serial assessment and may enhance communication of findings between providers.
El objetivo del presente informe fue medir el tiempo de reacción de un operador ante distintos estímulos, y así poder hallar, por medio del análisis estadístico, el tiempo de reacción promedio, como así también la incertidumbre de lo medido (desviación estándar). Para ello fue utilizado un cronómetro, el cual era encendido y apagado a máxima velocidad, y en otro caso medir el periodo de dos intermitencias del faro. Mediante los datos obtenidos, se construyeron histogramas con el fin de analizarlos. Obteniendo el tiempo de reacción del operador y el error del mismo. Además, visualizando en la comparación de los histogramas de la segunda experiencia que la incertidumbre no es influida por el número de mediciones, sino de los resultados variables de la misma, mientras que el error absoluto disminuye cuanto mayor es el número de mediciones.