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Brief Reports, Book & Media Reviews, Correspondence, Errata: Letter to the Editor

Elective Tracheotomy in COVID-19 Patients: A Team-Based Approach

Ander, Michael MD, FASA; Yang, Sara MD; Thorpe, Eric MD; Goyal, Amit MD; Bier-Laning, Carol MD, MBA, FACS

Author Information
doi: 10.1213/ANE.0000000000005106
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To the Editor

We recently read the editorial by Orser1 entitled "Recommendations for Endotracheal Intubation of COVID-19 Patients" from the May 2020 edition of Anesthesia & Analgesia. We found the article insightful and clinically useful for our coronavirus disease 2019 (COVID-19) patient population. Very little has been published regarding the challenges involved with other aerosol-generating procedures (AGPs), so we felt compelled to reply with our experience performing tracheostomies in COVID-19 patients.

COVID-19 presents an unprecedented challenge for anesthesiologists and otolaryngologists in particular because many of these specialties’ procedures involve working in the airway that often include high transmission risk AGPs such as intubation, extubation, bronchoscopy, and tracheostomy. Even patients who test negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction (PCR) testing in the nasopharynx may harbor a viral load in their lungs as evidenced by positive bronchoalveolar lavage (BAL) testing.2 Herein we describe techniques used that resulted in efficient and safe performance of tracheotomies in COVID-19 patients.

Before performing a tracheostomy on a COVID-19 patient, negative pressure room options were appraised. At our institution, the choices included a small number of intensive care unit (ICU) rooms and the bronchoscopy suite. Our goal was to perform 3–5 COVID-19 tracheostomies in a day at least once per week, and we felt that the negative pressure bronchoscopy laboratory would be our optimal procedural site location.

Next, we gathered representatives from all stakeholder groups including Anesthesiology, Otolaryngology, Intensive Care Medicine, Nursing, and Respiratory Therapy. Before this meeting, using peer-reviewed references, an initial COVID-19 Tracheotomy Guideline position statement was drafted and distributed to all representatives.3 This initial meeting took place onsite in the bronchoscopy suite to discuss the process and visualize the space. The discussion included personnel assignments and tabulating the equipment and supplies needed to perform surgery at this offsite procedural suite. This meeting elucidated important points ranging from a lack of surgical overhead lights to the concerns of supply disposal and equipment resterilization by our housekeeping and reprocessing staff. Despite the risk of exposure, our nurses were emphatic that a circulating nurse be present up until the first AGP, which we identified as the exchange from the transport ventilator to the anesthesia machine. Additionally, because we could not ensure consistency of staff from all teams involved, we created and distributed the full protocol and equipment checklist. These handouts included photographs of optimal ventilator circuit setup, which had a viral filter distal to the capnography sampling line.

On the day of the planned tracheostomies, the members of the operative team convened approximately 45 minutes early and performed a verbal walkthrough followed by a simulation. This rehearsal utilized aspects of Crew Resource Management (CRM) simulation-based training and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). These tools were developed by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.4 The points emphasized during this rehearsal included clear, closed-loop communication with call out and check back, a shared mental model with situational awareness, and emphasis that anyone has the authority to ask for clarity at any time. Another practical issue discussed involved difficulty hearing and understanding each other while wearing personal protective equipment (PPE) including N95 masks or powered air-purifying respirators (PAPRs). Other required PPE included impenetrable gowns, double surgical gloves, bouffants, shoe covers, and eye protection.

During the procedure, the team inside the bronchoscopy suite consisted of an anesthesiologist, 2 surgeons, and a scrub nurse. We also assigned a “backup” team who was positioned in full PPE immediately outside the negative pressure room to serve as a resource for the procedural team. This team consisted of a second anesthesiologist and 2 circulating nurses. Closed-loop communication was used before any AGP, which included exchange of transport ventilator and anesthesia machine as well as surgical entry into the patient’s trachea. The ventilators were turned off at least 10 seconds before an AGP to deflate the lungs and to minimize positive pressure aerosol generation. When the endotracheal tube was removed from the patient’s mouth, it was immediately disposed of in a red biohazard bag, and contaminated gloves were removed.

At the conclusion of the procedure, a 30-minute pause was performed after the last AGP to allow any aerosolized particles to settle and to allow for full air recirculation in the negative pressure room. After 30 minutes, 2 members of the backup team transported the patients back to their ICU room, while the procedural team began the disinfection process. All surfaces were wiped with Caviwipe disinfectant, and surgical instruments were sprayed with Prepzyme enzymatic foam spray before PPE doffing. Doffing was performed immediately on exiting the procedural suite. A member of the standby team wiped down any contaminated, reusable PPE equipment before removal. Contaminated PPE was removed systematically with gowns and top-layered gloves first and face masks or PAPRs removed last. Each staff member washed their hands for 30 seconds after removal of gloves. After another hour of allowing aerosolized particles to settle, the surgical equipment was removed for reprocessing and housekeeping and surgical service technicians performed another round of disinfection.

After handoff of the patient, the team performed a debriefing, and all members were questioned about their perception. Everyone had a positive impression of the procedure. One identified area of improvement included the anesthesia team only having equipment and medications that were going to be used left out on the workstations. We felt anything unused should be exchanged for clean equipment or disposed of between cases to minimize contamination or reexposure with subsequent patients.

The COVID-19 pandemic has caused our society to make difficult judgments and change the practice of common procedures, often with little guidance. We describe an evidence-based protocol for performing tracheostomies in COVID-19 patients that is coupled with simulation and a team-based approach, which has been used in other situations in health care that demand efficiency and safety. We have successfully used this approach to perform tracheostomies in numerous patients with COVID-19 and continue to refine our protocol based on postprocedure debriefing.

Michael Ander, MD, FASA
Department of Anesthesiology and Perioperative Medicine
Loyola University Medical Center
Maywood, Illinois
miander@lumc.edu

Sara Yang, MD
Eric Thorpe, MD
Department of Otolaryngology–Head and Neck Surgery
Loyola University Medical Center
Maywood, Illinois

Amit Goyal, MD
Department of Medicine Pulmonary and Critical Care Division
Loyola University Medical Center
Maywood, Illinois

Carol Bier-Laning, MD, MBA, FACS
Department of Otolaryngology–Head and Neck Surgery
Loyola University Medical Center
Maywood, Illinois

REFERENCES

1. Orser BA. Recommendations for endotracheal intubation of COVID-19 patients. Anesth Analg. 2020;130:1109–1110.
2. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA. 2020;323:1843–1844.
3. Parker NP, Schiff BA, Fritz MA, et al. AAO position statement: tracheotomy recommendations during the COVID-19 pandemic. Updated 2020. Available at: www.entnet.org/content/aao-position-statement-tracheotomy-recommendations-during-covid-19-pandemic. Accessed April 22, 2020.
4. Lundberg PW, Korndorffer JR Jr.. Using simulation to improve systems. Surg Clin North Am. 2015;95:885–892.
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