Technical considerations during tracheostomy
Technical considerations for performance of tracheostomy are summarized in Table 1. For COVID-19 positive or PUI patients, tracheostomy procedures will preferentially be performed in the ICU to allow for a negative pressure environment and to minimize potential contamination of additional patient care areas. The number of providers in the procedure should be kept to a minimum. Tracheostomy may be performed either as an open or percutaneous procedure, depending on patient factors and surgeon preference. Coughing during the procedure can aerosolize droplets and special modifications are employed to reduce the risk. During the time of tracheal incision and endotracheal tube exchange, a systemic paralytic agent should be administered to minimize coughing and aerosolized topical anesthetic should be avoided. Meticulous hemostatic technique should be employed prior to tracheal incision to limit the need for additional tissue manipulation after the tracheal window is created.
Close communication between surgical and anesthesia teams is necessary. Ventilation should be held prior to creation of the tracheal window and while the endotracheal tube (ETT) cuff is deflated. Application of suction to the surgical wound may be used to create a local negative pressure environment during exchange of the ETT for the tracheostomy tube. Importantly, the suction circuit should include a high-efficiency particulate arrestance (HEPA) filter to capture aerosolized viral particles and avoid aerosolizing them into the operating theater. After placement of the tracheostomy tube, closed circuit ventilation with in-line HEPA filtration should be maintained and only in-line suction should be performed.