Since the beginning of the pandemic caused by the new Coronavirus (SARS- CoV-2), critically ill patients care has been challenging. It is necessary to perform the best available practice and protect the health team, preserving human resources and rationalizing costs. Changes in tracheostomies institutional protocols are necessary according to each health care services reality. This is particular important in developing countries. The aim of this study is to establish a practical and sucint guideline to minimize controversies regarding the proper timing to perform elective tracheostomies in critically ill coronavirus infected patients.
Since the announcement of the first cases of pneumonia due to an unknown cause in December 2019, with the establishment of a disease caused by the new Coronavirus (SARS-CoV-2), a pandemic has been installed with more than 3,000,000 cases reported worldwide. Of these cases, about 17% develop the Acute Respiratory Distress Syndrome in different degrees of intensity. Care of these patients has become a challenge, mostly because is necessary to understand the clinical-epidemiological characteristics of the disease. And is an urgent premise to protect the health professionals involved and not exhaust the financial resources available for assistance [
An integrative review was done regarding the studies published during the Covid-19 pandemic. PubMed, Lilacs, Google Scholar and Scielo databases were used to search relacted articles. Only texts in english and portuguese were used. The terms used in the bibliographic search were “tracheostomy” and “coronavirus”. The inclusion criteria were studies that discussed the safety procedures and timing to perform elective tracheostomies.
During the pandemic, the following considerations must be reinforced. Tracheostomy plays an important role in the weaning process of mechanical ventilation. There is a need to adapt the usual procedures during a COVID-19 Pandemic. The reality and availability of local staff and material resources are always taken into account when making decisions. Tracheostomy and post-procedure care expose the health team at risk of contamination. The decision to perform the tracheostomy must consider the best existing practice. A tracheostomy in patient COVID-19 may not always be beneficial [
The majority of studies reviewed agreed that a multidisciplinary approach is mandatory to decide indications and ideal time to perform elective tracheostomies. A resume of these recommendations is on
Due to the increased risk to contaminate the health care team working in COVID-19 units, several steps and check points must be observed during the tracheostomies. These essential check points are summaryzed in
It is considered that patients affected by the critically stages of this disease need mechanical ventilation for a long time. The performance of elective tracheostomies in patients undergoing prolonged mechanical ventilation has benefits in terms of airway management, injury prevention and facilitating the weaning of the ventilator [
| Time to perform tracheostomy |
|---|
| Tracheostomy should only be considered in patients who have shown a good evolution Patients with ventilatory instability or need for high FiO2 are not candidates for tracheostomy Patients who demonstrate poor prognosis are not candidates for tracheostomy Patients who require a prone position for ventilation are not candidates for tracheostomy Extubation attempts should be conservative, given the team’s exposure and risk of contamination in new intubation Tracheostomy should be considered after at least three attempts at weaning from mechanical ventilation, with the patient still intubated in an unsuccessful T tube ventilation in a period of 7 consecutive days In cases of extubation failure requiring re-intubation, the reasons for the failure should be discussed and the tracheostomy considered The ideal time for tracheostomy indication is between the 14th and 21st days of intubation Obtaining the consent form for the procedure, from the in charge family member, remains mandatory It is desirable that candidates for tracheostomy have a new PCR negative for Covid-19 |
FiO2—Inspired fraction of oxygen, PCR—Polymerase Chain Reaction.
| Essential check points |
|---|
| There is no emergency response or any procedure without proper staff protection Availability of complete personal protective equipment for all professionals involved in contact with the patient: masks type PFF2 or N95, face shield; long sleeve waterproof and disposable gown The team must be composed of at least: surgeon, surgical assistant, nursing technician and anesthetist or intensive care physician (who will be responsible for the control of ventilation and management of the orotracheal tube) Working and tested auxiliary surgical light Working and tested electrocautery Working and tested suction Instruments for tracheostomy, tracheostomy cannulas with probable numbers (at least two cannulas of sequential numbers) 100% FiO2 and 5 cm H2O PEEP ventilation prior to procedure Checking the complete sealing of the orotracheal cannula cuff and positioning it distally to the tracheostomy site Complete patient sedation using hypnotic agent, opioid and neuromuscular blocker (in charge of the anesthetist or intensive care physician) No use of electrocautery on the trachea Mechanical ventilation in PAUSE mode and clamped orotracheal tube for extubation Tracheostomy cannula preferably already connected to the closed suction system and with a filter installed when introduced into the trachea |
FiO2—Inspired fraction of oxygen, PCR—Polymerase Chain Reaction.
Modifications of institutional protocols for performing elective tracheostomies are necessary, according to the proper realities of each assistance service, specially in developing countries [
Tracheostomies must be a safer procedure during the pandemic. Delay in indications protect pacients from unnecessary procedures and expose the team to a lesser risk of contamination due to a decreased virus count on patient airway [
In order to preserve health care team and give chance of survival to patients able to recovery, it is mandatory to accomplish the best available practice to performing elective tracheostomies during the COVID-19 pandemic.
J.M.S. thanks to Fhilipe de Oliveira Prybicz and Allan Augusto Ferrari Ramos de Oliveira.
All authors have read and approved the final version of the manuscript.
The authors declare no conflicts of interest regarding the publication of this paper.
de Souza, J.M., Ahumada, N.G. and Carraro Junior, H. (2020) Considerations about Timing to Per- form Elective Tracheostomies in Patients Hospitalized in COVID-19 Units. Surgical Science, 11, 237-241. https://doi.org/10.4236/ss.2020.119026