To the Editor,
In patients with coronavirus disease 2019 (COVID-19), tracheostomy may be required for prolonged respiratory management. However, tracheostomy is associated with an increased risk of viral transmission because of a highly aerosol-generating procedure.1 To reduce aerosolized transmission, several methods for percutaneous or surgical tracheostomy have been proposed.2-4 Of those, very effective procedures for reducing aerosolized transmission during percutaneous tracheostomy have been reported; however, these might be too skillful or acrobatic for the average critical physicians to follow.2,3 For example, Weiss et al.3 recommended that the percutaneous dilational tracheostomy (PDT) procedure should be apneically completed using a standard Seldinger technique under bronchoscopic vision. As another option, we’d like to recommend point of care supraglottic airway devices (SADs) for PDT in patients with COVID-19 to minimize aerosolized transmission and avoid a prolonged apneic period.
After appropriate analgosedation, sufficient neuromuscular blockade is achieved prior to the start of the procedure. The patient is appropriately positioned supine with a transverse rolled towel beneath the scapulae to augment neck extension. To avoid using a bronchoscope, which may increase the risk of intra-procedural hypoxemia and transmission of COVID-19,5 we apply the mini-surgical PDT, which allows tracheal puncturing to occur upon the appearance of tracheal rings after vertical and horizontal retraction of overlaying tissues a helps us to prevent a posterior wall laceration.6 We use a Neo Perc™ (Covidien Japan, Tokyo), which is a commercially available percutaneous tracheostomy kit. The reason why we use this kit is that this kit includes a blunt introducer needle to reduce the risk to penetrate or injure the posterior wall of the trachea. Just prior to the punctuation of the tracheal wall between the tracheal rings, the anesthesiologist places the ventilator in standby mode, removes the tracheal tube, and inserts a SAD, where an appropriate size of i-gel™ (Nihon Koden, Tokyo) is usually used. This procedure is done underneath the transparent plastic drape with creating negative pressure by a suction tube to prevent the spread of aerosolized particles. Basically, the remaining procedure of PDT is apneically completed using a standard Seldinger technique. However, small manual ventilation with 100% oxygen is applied using the SAD underneath the clear drape when the anesthesiologist determines the high possibility of desaturation. In such cases, wet gauze is used to cover the tracheostomy incision to prevent pollution. Immediately following cuff inflation after tracheostomy tube insertion, the ventilator tubing is connected to resume ventilation.
It would be the most favorable that the main parts of mini-surgical PDT from punctuation of the tracheal wall to tracheostomy tube cuff inflation can be done apneically. However, it has been reported that personal protective equipment may inhibit our optimal surgical performance.7 Therefore, it may not work out as we hoped. In such cases, the back-up secured airway by the SAD, which does not hamper the procedure of tracheostomy, should give a temporal margin to the surgeons and contribute to high-quality safety management. It is true that there is a concern that malposition can lead to significant leaks,8 causing inadequate aerosol generation. However, we think that the drape with negative pressure over the SAD can effectively secure healthcare personnel safety during the very short surgical procedure. It would be very appreciated that this method can be considered as an alternative option for conversion from tracheal intubation to tracheostomy in COVID-19 patients.
Acknowledgments
Not applicable.
Author Contributions
Taichi Kotani, Satoki Inoue, and Keiko Uemura were major contributors in writing the manuscript. Masahiko Kawaguchi reviewed and edited the manuscript. All authors read and approved the final manuscript.
Availability of Data and Material
Not applicable.
Conflict of Interest
The authors declare having no conflicts of interest.
Consent for Publication
Not applicable.
Declarations Ethics Approval and Consent to Participate
Not applicable.
Funding
This study was supported only by departmental funding from our institution.
References
1 |
Pichi B, Mazzola F, Bonsembiante A, et al.
CORONA-
steps for tracheotomy in COVID-19 patients: a
staff-safe method for airway management.
Oral Oncol.
2020;105:104682.
|
2 |
Angel L, Kon ZN, Chang SH, et al.
Novel percutaneous
tracheostomy for critically ill patients with COVID-19.
Ann Thorac Surg. 2020;110(3):1006-1011.
|
3 |
Weiss KD, Coppolino A 3rd, Wiener DC, et al.
Controlled
apneic tracheostomy in patients with coronavirus
disease 2019 (COVID-19).
JTCVS Tech. 2021;6:172-177.
|
4 |
Foster P, Cheung T, Craft P, et al.
Novel approach to reduce
transmission of COVID-19 during tracheostomy.
J
Am Coll Surg. 2020;230(6):1102-1104.
|
5 |
Hashemian SM, Digaleh H, Massih Daneshvari Hospital
Group.
A prospective randomized study comparing
mini-surgical percutaneous dilatational tracheostomy
with surgical and classical percutaneous tracheostomy:
a new method beyond contraindications.
Medicine
(Baltimore). 2015;94(47):e2015.
|
6 |
Rahmanzade R, Hashemian SM.
Mini-surgical percutaneous
dilatational tracheostomy (msPDT): our experience
during the COVID-19 pandemic.
Br J Surg.
2020;107(10):e363.
|
7 |
Yánez Benítez C, Güemes A, Aranda J, et al.
Impact
of personal protective equipment on surgical performance
during the COVID-19 pandemic.
World J Surg.
2020;44(9):2842-2847.
|
8 |
Van Zundert AAJ, Kumar CM, Van Zundert TCRV.
Malpositioning
of supraglottic airway devices: preventive and
corrective strategies.
Br J Anaesth. 2016;116(5):579-582.
|