key: cord-1048504-1cr5uu9i authors: Bribriesco, Alejandro C.; Sudarshan, Monisha; Gillespie, Colin T.; Bryson, Paul C.; Hopkins, Brandon; Tanner, Donna; Raja, Siva; Ahmad, Usman; Raymond, Daniel P.; Murthy, Sudish C. title: Coronavirus disease 2019 (COVID-19): Team preparation and approach to tracheostomy date: 2020-12-07 journal: JTCVS Tech DOI: 10.1016/j.xjtc.2020.11.023 sha: bb0a50ee1dee963cf49272531596e70d52de926e doc_id: 1048504 cord_uid: 1cr5uu9i nan Tracheostomy has become a common surgical intervention performed on patients with severe coronavirus disease 2019 (COVID-19), as mechanical ventilation is required in 10% to 15% of patients. 1 High risk of aerosolization during the intervention is a serious concern for personnel involved both during and after tracheostomy placement. We present our experience developing a multidisciplinary algorithm to tracheostomy for COVID-19 respiratory failure. We recognize that this process will vary based on institutional policy and will evolve with further data on transmission and respiratory consequences of COVID-19. As the COVID-19 crisis unfolded, virtual meetings were held to develop a unified institutional approach for tracheostomy with multidisciplinary stakeholders: Thoracic Surgery, Otolaryngology, Pulmonology, Critical Care, Anesthesiology, and Respiratory Therapy. Discussions centered on indications, contraindications, timeline to tracheostomy, and special procedural considerations (Table 1 ). Next, we performed high-fidelity tracheostomy simulation in our laboratory to rehearse and fine-tune procedural details. including proper donning and doffing of personal protective equipment (powered, air-purifying respiratory). Based on our experience and aligned with other groups, 2 we strongly recommend simulation when devising a COVID-19 tracheostomy protocol ( Figure 1 ). A dedicated multidisciplinary team evaluates the patient and employs a standardized pretracheostomy checklist ( we consider tracheostomy a minimum of 7 days after intubation and preferably after 10 to 14 days to enter the convalescent phase of the disease, gain the benefits of the procedure, and permit time for prognostication of overall recovery. We do not advocate waiting until a repeat negative COVID-19 test, as this could unnecessarily prolong time to tracheostomy, given possibility of persistently positive test (one series 3 with median 20 days, longest 37 days), which likely represents continued noninfectious viral shedding. 4 In addition, we always advocate for maximum available personal protective equipment regardless of a negative COVID-19 tests to protect health care workers (HCWs). Our default location is bedside in intensive care unit (ICU) to minimize patient transport and exposure risk, with the operating room used for particularly high-risk cases. For bedside tracheostomies, an enclosed negativepressure ICU room is preferred if available and logistically feasible. Our team favors percutaneous over the open technique with deference to operator preference and patient anatomy. ENT, ear, nose, and throat; RN, registered nurse; IV, intravenous; PPE, personal protective equipment; PAPRs, powered, air-purifying respiratory; FiO 2 , inspired oxygen fraction; ETT, endotracheal tub; HME, heat and moisture exchanger. The type of tracheostomy appliance is largely based on the institutional preference and available supply. Our group favors an appliance without inner cannula to mitigate exposure risk of inner cannula exchange. Step-by-step details of the tracheostomy procedure with modifications to minimize aerosolization are listed in Table 3 and depicted in Video 1. In patients with COVID-19, we arrange all ventilator control and intravenous lines outside the room so care can be delivered without repeatedly entering the space. The sterile tracheostomy tray is prepared out of the enclosed room. A moist Kerlix roll is packed in the oropharynx to minimize aerosolization as the endotracheal tube is withdrawn into the subglottis. This obviates the need for a protective box/tent. A disposable bronchoscope is used to avoid exposure during cleaning and processing of a soiled bronchoscope. The endotracheal tube is pulled back with cuff inflated into the subglottic position. Further retraction can be facilitated by removing the minimal necessary amount of air from the cuff. After guidewire insertion, we perform the remainder of the procedure under apnea and attempt to limit procedural time to 60 to 90 seconds. Performing tracheostomy in the COVID-19 era exemplifies how a previously straightforward clinical decision for an essential-elective procedure has been reimagined when the safety of more than just the patient must be considered. The balance of anticipated benefits and risks for major stakeholders (patient, health care system, and HCW) will vary between different locations during various stages of the COVID-19 pandemic as evidenced by a (Table 4) . A multidisciplinary team is essential in developing a center-specific protocol for COVID-19 tracheostomy with an indispensable role for simulation and team rehearsal. This activity allows providers who may not have previously worked together to pool shared experience and knowledge to develop a tailored, efficient, and safe protocol. Following this protocol, our team has performed more than 20 percutaneous tracheostomies (including 4 patients on extracorporeal membrane oxygenation) in the ICU without untoward patient events or evidence of COVID-19 transmission to HCWs. It is through synergistic collaboration that the optimal delivery of health care can be safely achieved during this continued pandemic. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese center for disease control and prevention Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Interpreting diagnostic tests for SARS-CoV-2 Systematic review of international guidelines for tracheostomy in COVID-19 patients National Tracheostomy Safety Project. NTSP Considerations for tracheostomy in the COVID-19 outbreak Michigan medicine tracheostomy guidelines in COVID-19 era Recommendation of a practical guideline for safe tracheostomy during COVID-19 pandemic Tracheostomy in ventilated patients with COVID-19 CORONA-steps for tracheotomy in COVID-19 patients: a staff-safe method for airway management Performing tracheostomy during the Covid-19 pandemic: guidance and recommendations from the Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma Use of tracheostomy during the COVID-19 pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/ Association of Interventional Pulmonology Program Directors Expert Panel Report