key: cord-283696-3a0s64sm
authors: Haen, Pierre; Caruhel, Jean-Baptiste; Laversanne, Sophie; Cordier, Pierre-Yves
title: CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway management
date: 2020-04-20
journal: Oral Oncol
DOI: 10.1016/j.oraloncology.2020.104729
sha: 
doc_id: 283696
cord_uid: 3a0s64sm

nan

Phone: +33491617200, Fax: +33491617265 Type of paper:

Letter to the Editor (649 words) workers are expected to work every day with COVID-19 patients, and protecting them is essential to enable them work safely and avoid being infected. Airway management and, more specifically, tracheostomy procedures have a high risk of causing contamination because they generate aerosols [2] . Even if tracheostomy procedures can be used in COVID-19 patient management, no evidence-based recommendations for the protection of healthcare workers performing tracheostomies for these patients exist to date. Pichi et al. [1] [3] . No data about the specific contamination risk of each technique for healthcare workers are available. Published information from the SARS outbreak of 2003 showed that OT was preferred [2, 4, 5] (PT had a reputation for generating more aerosols than OT due to extensive airway manipulation), but we must also consider that PT techniques have advanced since then. Current guidelines on choosing OT or PT for COVID-19 patients differ between countries (table 1) [1, 6, 7] . We recommend PT in COVID-19 patients because it does not require transferring the patient to an OR and thus limits the risk of contamination. The duration of PT (and thus care workers' exposure time) is no longer than that of OT [3] , and opening the trachea with a guide enables better control of expiratory flow than with a surgical opening, which is more hazardous. Moreover, PT eliminates the risk of piercing the endotracheal cuff. PT procedure must be conducted in a sedated patient, and ventilation must be stopped entirely during the critical step of introducing the cannula.

Bronchoscopy control is safely performed using a deported screen. The bronchoscope is inserted by a specific opening valve that protects the operator from the respiratory flow, without repeated connection and disconnection from the ventilatory circuit. A double lumen endotracheal tube can also be used, with an upper channel that allows passage of a bronchoscope during PT and with a lower channel exclusively dedicated to patient ventilation [8] . We recommend performing a neck ultrasonography systematically before PT to ensure there is no large vessel in the puncture area or a large thyroid isthmus to prevent hematoma complication. Technical options must be discussed between the ICU specialist and the surgeon for patients with anatomical particularities (difficult neck). We think that the risk of a difficult cannula re-insertion in case of unexpected decannulation is controlled, provided the patient does not have any upper airway obstruction, which enables classical orotracheal intubation.

When OT must nonetheless be performed, we recommend performing it bedside in the ICU to avoid transfer to an OR, if possible. Otherwise, we recommend following all other measures suggested by Pichi et al. [1] when performing OT. A hybrid procedure with a surgical approach and dilatation of the trachea is for us a good option when it is feasible.

Keywords: Coronavirus Disease 2019, Airway Management, Tracheostomy, Healthcare Worker, Safety

CORONAsteps for tracheotomy in COVID-19 patients: A staff-safe method for airway management

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Infection control measures for operative procedures in severe acute respiratory syndrome-related patients

Safe tracheostomy for patients with severe acute respiratory syndrome

Safety Recommendations for Evaluation and Surgery of the Head and Neck During the COVID-19 Pandemic

Surgical Considerations for Tracheostomy During the COVID-19 Pandemic: Lessons Learned From the Severe Acute Respiratory Syndrome Outbreak

Improving staff safety during tracheostomy in COVID-19 patients

We declare no competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.