Tracheostomy During COVID-19: CHEST/AABIP/AIPPD Recommendations

An expert panel represented by CHEST, the American Association for Bronchology & Interventional Pulmonology (AABIP), and the Association of Interventional Pulmonology Program Directors (AIPPD) has released 8 recommendations on the use of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic. These recommendations were published in the journal CHEST.

The CHEST/AABIP/AIPPD expert panel consisted of 13 pulmonary and critical care physicians from 10 of the 20 US states with the highest COVID-19 burden. The panel performed a comprehensive literature review of papers that discussed tracheostomy and coronavirus. Panel members structured their recommendations to answer 8 pertinent questions related to tracheostomy procedures in patients with COVID-19-related respiratory failure.

Recommendations

Based on a strong consensus, the expert panel recommends the consideration of tracheostomy in patients with COVID-19 if clinicians anticipate mechanical ventilation will be required. Despite the limited data available, the panel added that the literature appears to support the clinical usefulness of tracheostomy in patients with COVID-19 when prolonged ventilator support is needed. The current literature suggests the tracheostomy procedure may confer better outcomes, such as ventilator-free days, shorter hospital stays, shorter stays in the intensive care unit (ICU), and reduced hospital-acquired pneumonia incidence compared with prolonged mechanical ventilation.

Currently, little evidence is available to recommend a specific timeframe for tracheostomy in patients with COVID-19-related respiratory failure. Traditionally, tracheostomy is performed 2 to 3 weeks following endotracheal intubation in patients with ongoing mechanical ventilation needs. The panel suggests that early tracheostomy may offer some benefits, such as lower sedation requirements and better patient comfort. They added that early tracheostomy in selected patients with COVID-19 may optimize ICU resources, particularly for healthcare systems that experience rising cases of critically ill patients. However, there is currently insufficient evidence to recommend early vs late tracheostomy in patients with COVID-19.

A strong consensus by the expert panel was made in the recommendation of either open surgical tracheostomy (OST) or percutaneous dilatational tracheostomy (PDT) in patients with COVID-19-related respiratory failure who require prolonged mechanical ventilation. This recommendation was made in part because of evidence from a meta-analysis that reported that PDT could lead to lower wound infection and bleeding rates compared with OST. Conversely, other evidence during the outbreak of severe acute respiratory syndrome (SARS) suggested that performance of OST was associated with no infections to the healthcare worker if enhanced personal protective equipment (PPE) was used.

To reduce the healthcare worker’s risk of infection during tracheostomy, an aerosol-generating procedure, a strong consensus-based recommendation was made for the use of enhanced PPE. Additionally, the panel recommended the use of techniques that would minimize aerosolization during the tracheostomy procedure (strong consensus).

For patients with COVID-19-related respiratory failure, the expert panel recommends that the tracheostomy be performed in a negative-pressure room. The ICU is the preferable location for the procedure. Alternatively, the panel suggests that a negative-pressure room in the operating room (OR) may be feasible, but healthcare workers should be aware of and take active steps to reduce transportation-related risk of exposure (strong consensus). In a case where a negative-pressure room is unavailable, the panel recommends that the tracheostomy could be performed in a normal pressure room that is equipped with HEPA filters. In addition, the normal pressure room should include a strict door policy.

Routine reverse transcription polymerase chain reaction (RT-PCR) testing with a nasopharyngeal swab or lower respiratory sample prior to tracheostomy was not encouraged by the panel, especially in patients with confirmed COVID-19-related respiratory failure (strong consensus). This statement was made because little evidence exists to recommend this testing in patients with non-COVID-19 respiratory failure before tracheostomy. According to a consensus statement made by the panel, a lower respiratory sample with endotracheal aspirate rather than a nasopharyngeal swab be obtained if RT-PCR testing is performed.

The panel also recommends that a team comprising the fewest number of providers with the highest level of experience be involved in performing a tracheostomy in a patient with COVID-19-related respiratory failure (strong consensus). They recommend that a multidisciplinary care team consisting of the primary critical care team, palliative care, infectious disease, as well as the procedural and airway team work together to identify the care goals, patient selection, procedural considerations, and appropriate workflow to optimize patient and healthcare worker safety (strong consensus).

Finally, the expert panel recommends that patients should be maintained with a closed circuit during mechanical ventilation with a tracheostomy tube and in-line suction (strong consensus). They noted that a closed circuit can be created using a heat moisture exchanger with viral filter and an in-line suction to reduce aerosol generation if the patient no longer needs mechanical ventilation but is not prepared for capping trials.

The panel concluded that this statement should be considered a “living document” to be updated in the future as new evidence becomes available during the COVID-19 pandemic.

Reference

Lamb CR, Desai NR, Angel L, et al. Use of tracheostomy during the COVID-19 pandemic: CHEST/AABIP/AIPPD: expert panel report [published online June 5, 2020]. CHEST. doi:10.1016/j.chest.2020.05.571