Percutaneous tracheostomy in COVID-19 patients: a new apneic approach
Elena Moizo; Alberto Zangrillo; Sergio Colombo; Carlo Leggieri; Milena Mucci; Paolo Beccaria; Nicola Pasculli; Giovanni Borghi; Valentina Paola Plumari; Alessia La Bruna; Roberto Dossi; Martina Baiardo Redaelli; Anna Tornaghi; Gaetano Lombardi; Giovanni Landoni; Antonio Dell’Acqua; Francesca Guzzo; Giacomo Monti
Percutaneous dilation tracheostomy is an aerosol-generating procedure carrying a documented infectious risk during respiratory virus pandemics. For this reason, during the COVID-19 outbreak, surgical tracheostomy was preferred to the percutaneous one, despite the technique related complications increased risk.
We describe a new sequence for percutaneous dilation tracheostomy procedure that could be considered safe both for patients and healthcare personnel. A fiberscope was connected to a video unit to allow bronchoscopy. Guidewire positioning was performed as usual. While the established standard procedure continues with the creation of the stoma without any change in mechanical ventilation, we retracted the bronchoscope until immediately after the access valve in the mount tube, allowing normal ventilation. After 3 minutes of ventilation with 100% oxygen, mechanical ventilation was stopped without disconnecting the circuit. During apnea, the stoma was created by dilating the trachea and the tracheostomy cannula was inserted. Ventilation was then resumed. We evaluated the safeness of the procedure by recording any severe desaturation and by performing serological tests to all personnel.
Thirty-six patients (38%) of 96 underwent tracheostomy; 22 (23%) percutaneous dilation tracheostomies with the new approach were performed without any desaturation. All personnel (150 operators) were evaluated for serological testing: 9 (6%) had positive serology but none of them had participated in tracheostomy procedures.
This newly described percutaneous dilation tracheostomy technique was not related to severe desaturation events and we did not observe any positive serological test in health workers who performed the tracheostomies.
1 L. Cabrini, G. Landoni, M. Greco, et al. Single dilator vs. guide wire dilating forceps tracheostomy: a meta-analysis of randomised trials Acta Anaesth Scand, 58 (2013), pp. 135-142
2 W.-Q. Chen, W.-H. Ling, C.-Y. Lu, et al. Which preventive measures might protect health care workers from SARS? BMC Public Health, 9 (2009), p. 81
3 K. Tran, K. Cimon, M. Severn, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review PLoS One, 7 (2012), Article e35797
4 C. Chen, G. Gao, Y. Xu, et al. SARS-CoV-2-positive sputum and feces after conversion of pharyngeal samples in patients with COVID-19 Ann Intern Med, 172 (2020), pp. 832-834
5 A. Zangrillo, L. Beretta, P. Silvani, et al. Fast reshaping of intensive care unit facilities in a large metropolitan hospital in Milan, Italy: facing the COVID-19 pandemic emergency Crit Care Resusc, 22 (2020), pp. 91-94
6 L. Cabrini, G. Monti, G. Landoni, et al. Percutaneous Tracheostomy, a systematic review Acta Anaesth Scand, 56 (2012), pp. 270-281
7 F. Ciceri, A. Ruggeri, R. Lembo, et al. Decreased in-hospital mortality in patients with COVID-19 pneumonia Pathog Glob Health, 114 (2020), pp. 281-282
8 H.C. Tien, T. Chughtai, A. Jogeklar, et al. Elective and emergency surgery in patients with severe acute respiratory syndrome (SARS) Can J Surg, 48 (2005), pp. 71-74
9 V.W. Chee, M.L. Khoo, S.F. Lee, et al. Infection control measures for operative procedures in severe acute respiratory syndrome-related patients Anesthesiology, 100 (2004), pp. 1394-1398
10 P. Brass, M. Hellmich, A. Ladra, et al. A. Percutaneous techniques versus surgical techniques for tracheostomy Cochrane Database Syst Rev, 7 (2016), Article CD008045
11 Canadian Society of Otolaryngology–Head and Neck Surgery Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic J Otolaryngol Head Neck Surg, 49 (2020), p. 23
12 A. Takhar, A. Walker, S. Tricklebank, et al. Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic Eur Arch Otorhinolaryngol, 277 (2020), pp. 2173-2184
13 B.A. McGrath, M.J. Brenner, S.J. Warrilow, et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance Lancet Respir, 8 (2020), pp. 717-725
14 B.N.G. Andriolo, R.G. Andriolo, H. Saconato, et al. Early versus late tracheostomy for critically ill patients Cochrane Database Syst Rev, 1 (2015), Article CD007271
15 C. Chen, G. Gao, Y. Xu, et al. SARS-CoV-2-positive sputum and feces after conversion of pharyngeal samples in patients with COVID-19 Ann Intern Med, 172 (2020), pp. 832-834
16 J. Zhao, Q. Yuan, H. Wang, et al. Antibody responses to SARS-CoV-2 in patients of novel coronavirus disease 2019 Clin Infect Dis, 71 (2020), pp. 2027-2034
17 C. Leung Clinical features of deaths in the novel coronavirus epidemic in China Rev Med Virol, 30 (2020), p. e2103
18 G. Grasselli, A. Zangrillo, A. Zanella, et al. Baseline characteristics and outcomes of 1591 patients infected with SARSCoV-2 admitted to ICUs of the Lombardy Region, Italy JAMA, 323 (2020), pp. 1574-1581
19 Intensive Care National Audit and Research Centre ICNARC report on COVID-19 in critical care Accessed February 20, 2021 (2020)