Though the various guidelines and protocols are available since June 2020 [3,4,5,6,7] the survey results are surprising as 72% survey responders were not confident about their knowledge. No surveys have been conducted solely to address this issue though the various tracheostomy guidelines have come up during these crises. Our study data was collected from 114 ENT surgeons from India; however, it has served the purpose of the survey. After reviewing various guidelines and recommendations, a systematic COVID TIDE approach was formed as described in Image 1.
Covering Guidelines
Ideal recommendations for tracheostomy procedure are full PPE (with FFP3/FFP2 mask, fluid repellent full covered gown, head cover, shoe cover, gloves, face shield with eye protection) [8] but despite wearing N 95 respirators during SARS pandemic some health care workers acquired the disease so the use of powered air purifying respirators(PAPR) was recommended by some clinicians [5, 8,9,10]. In spite of such recommendations, in our series PAPR user number was only 3.5%.
Operation Theatre Planning
There should be dedicated COVID theatre. The ideal recommendations are negative pressure theatre or isolation room [5]. Though in our survey we found that 78.9% surgeons were not performing this procedure in a negative pressure room. Consider a normal theatre with closed doors if the negative pressure room is not available.
Limited staff should be permitted inside the theatre. Availability of viral filters for endotracheal tube & for tracheostomy tube is recommended [10] but surprisingly in our survey only 32.5% responders were aware of filter usage.
Ventilator Precautions
Suction of endotracheal tube/ Sub glottic port is recommended prior to the shifting of the patient to operation theatre. A close communication between anaesthesia and surgical team is necessary. Ventilation precaution should be taken during the table shift of the patient too. (Image 2).
The ventilation pause is a very critical step and should be done just before giving the incision over the trachea. The ventilation can be resumed once the tube position is confirmed with EtCO2 and the cuff is inflated. (Image 3). Further the disinfection of the ventilators should be followed as per the guidelines of infection control department of the hospital.
Incision Precautions
During open tracheostomy procedure, neuromuscular blockade should be given to reduce the cough reflex and movements, which was followed only by 50% responders according to our survey report. Stay sutures should be placed for paediatric cases before giving the incision. Consider clamping of ET tube before creating the tracheal window. Ensure to create a sufficient size tracheal window for easy insertion of the tube [9]. To prevent air leak and aerosol, the cuffed non fenestrated tracheostomy tube is preferred. An empty syringe should be attached to the tracheostomy tube. Immediately inflate the cuff once the position of the tube is confirmed and then reattach the circuit [5, 7] but again this was followed by 56.1% responders only. Hold the ventilation as described previously and shown in Image 4 as well.
Doffing Protocol
Appropriate donning and doffing of PPE is the crucial step for prevention of contamination. Look for the tear or blood stains over the gown. There should be a dedicated doffing zone to prevent cross contamination. Strict adherence to the proper protocol and buddy check can avoid the risk of self-contamination while doffing [8, 10].
Tube Change Care
The usual tube care is not replaced in COVID cases too. (Image 5) The limited number of experienced staff should be involved in post tracheostomy care to avoid aerosol contamination. Regarding first tube change, majority of recommendations are in the favor of between 14 and 21 days or until patient is negative for COVID 19 testing [3, 11, 12].
While performing tracheostomy care, cuff deflation and tracheostomy dressing should be avoided unless necessary to minimise aerosol generation. Tracheostomy care should be performed with the enhanced PPE with utilisation of closed in line suction, HME filters and inflated cuff system. The frequency of tube change should be minimised to 2–3 months interval unless clinical emergency [13]. The inner cannula of the tube can be changed every 72 h [14] (Images 6, 7, 8, 9, 10, 11).
In Line Closed Suction
Always use in line closed suction catheter system regardless of mechanical ventilation requirements [13].
Decannulation
Local expertise and protocols should be followed. Droplet precautions are the minimal requirement to be followed while decannulating the patient to prevent aerosol contamination [15].
Expert Airway Team
A dedicated and experienced COVID airway team should be formed who can perform such procedures effectively with minimal risk to health care workers and the patient. Standardized COVID 19 tracheostomy simulation training might improve the health care professionals safety as well as the confidence in performing such procedures [15, 16].