Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review
Otolaryngology--Head and Neck Surgery
Meister, K. D., Pandian, V., et al. (2020).
Otolaryngology--Head and Neck Surgery, 194599820961990.
This guideline from the American Academy of Otolaryngology–Head and Neck Surgery provides recommendations on the care of patients with a tracheostomy during the COVID-19 pandemic. Guidance presented from this document should be informed by local expertise, resources, and patient preferences.
American Academy of Otolaryngology–Head and Neck Surgery Foundation
<div>"An open tracheostomy tube lumen without an [heat and moisture exchanger] HME, one-way speaking valve, or cap likely increases risk of aerosolization. Patients who cannot tolerate cuff deflation or one-way speaking valves due to increased secretions should be offered augmentative options to facilitate communication" (p. 9).</div>
<div>If not clinically required, tracheostomy tube changes may be deferred in patients with COVID-19. "Full [personal protective equipment] PPE should be worn during tracheostomy tube management for obstruction, accidental decannulation, displacement into false passage, or need for cuffed tube placement for positive pressure ventilation in patients with COVID-19" (p. 8).</div>
<div>Considerations for cuff management during weaning from mechanical ventilator include the following:</div>
<ul>
<li>Once the patient successfully weans off the ventilator, a heat and moisture exchanger with a viral filter should be placed to reduce expulsion of viral particles through the tube.</li>
<li>The cuff may be deflated when the patient is considered to be at low risk of infectivity.</li>
<li>The tracheostomy tube may be changed to a cuffless tube when the patient is considered to be at low risk for mechanical ventilation.</li>
<li>When the patient can tolerate cuff deflation or a cuffless tube, consider a one-way speaking valve or capping to facilitate speech and prompt weaning off the tracheostomy tube.</li>
</ul>
<div>The following practices when suctioning tracheostomy tubes should be considered to reduce the risk of aerosolization during the COVID-19 pandemic:</div>
<ul>
<li>Requirement of appropriate personal protective equipment to protect healthcare workers when suctioning. </li>
<li>For patients undergoing mechanical ventilation, suctioning can be performed safely using a closed-circuit suctioning system with an inline suction catheter. </li>
<li>For patients who are not on a ventilator, suctioning should also be done via a closed circuit with an inline suction catheter and a T-connector or a Kelley circuit. </li>
<li>Avoid instillation of saline before suctioning due to the increased risk of coughing and little evidence of benefit. "If thick secretions result in recurrent occlusion of inline circuits, placement of patients in a negative pressure room or a room with a HEPA filter may facilitate suctioning protocols" (p. 7).</li>
</ul>
<div>Immediate placement of a heat and moisture exchanger (HME) should occur following disconnection from closed-circuit systems to minimize aerosolized particles. All discarded HMEs should be disposed of quickly and properly as they are considered infectious. "If an HME is unavailable and there is high risk of mucus plug in a patient with a single cannula tube, saline drops may be instilled through the inline suction port, with scheduled suctioning to reduce mucus buildup" (p. 8).</div>
<div>Aerosol-generating procedures (AGPs) require precautions, such as streamlining care and increasing efficiency via timeouts and checklists, to prevent exposure to aerosolized particles. The minimal recommended personal protective equipment (PPE) for tracheostomy care and related AGPs include the following:</div>
<ul>
<li>gloves; </li>
<li>eye protection; and </li>
<li>procedural mask.</li>
</ul>
<div>Many institutions also consider a long-sleeved disposable gown as minimal PPE for tracheostomy care. "While some have recommended using an N95 with a powered air-purifying respirator, robust data validating the efficacy remain limited" (p. 3).</div>
<div>The following risks should be considered when conducting a flexible endoscopic evaluation (FEES) or a videofluoroscopic swallow study (VFSS) during the COVID-19 pandemic:</div>
<ul>
<li>Swallowing assessments may elicit cough, gag, throat clear, or sneeze.</li>
<li>FEES is considered an aerosol-generating procedure and requires physical proximity to the patient.</li>
<li>VFSS may require a patient transport.</li>
<li>Pediatric patients often cry and sputter during FEES or VFSS, which may increase aerosolized particles.</li>
</ul>
<div>Therefore, patients at low risk for dysphagia may require alternative swallowing assessments, such as the blue dye test. "Patients at high risk for dysphagia may require FEES or VFSS, and clinicians should proceed with an N95 mask with goggles/fluid shield or a powered air-purifying respirator" (p. 9).</div>
