Children with Tracheostomy and Covid-19
Are children with tracheostomy at higher risk for contracting or transmitting Covid-19? The coronavirus SARS-CoV-2 and resulting Covid-19 disease has resulted in a global health…
Are children with tracheostomy at higher risk for contracting or transmitting Covid-19? The coronavirus SARS-CoV-2 and resulting Covid-19 disease has resulted in a global health…
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Benefits of tracheostomy during COVID-19 is that tracheostomy may accelerate weaning. Faster weaning can free up ventilator equipment, careproviders, and higher acuity beds.
Another significant benefit is that the patient will be in a closed system. When the cuff is inflated airflow and aerosols are maintained within the tubing. It also offers the ability to reduce sedation requirements, which can reduce sedation related delirium, improve patient comfort, provide less intensive nursing care and potentially a lower level of care. Prolonged intubation may also be related to increased laryngeal injury including tracheal stenosis, edema, vocal fold paresis or paralysis, desensitisation, dysphagia, dysphonia, or erythema.
Percutaneous, Surgical or Hybrid Tracheostomy?
If the medical team determines that a tracheostomy is necessary, there is debate over whether a percutaneous or surgical procedure is less aerosol generating, with local factors, expertise and competencies influencing the decision. Those performing tracheostomy are recommended to use the techniques and equipment that they are familiar and experienced in using (McGrath et al, 2020). Whether percutaneous or surgical, it is best practice to perform the procedure in an ICU room or operating room, preferably a negative pressure room. Reduce the team members to only essential personnel and only the most experienced staff to perform the procedure to provide efficiency. Rehearse the procedure and consider simulated procedures. All appropriate airborne PPE should be used during the tracheostomy procedure. Experts suggest the use of enhanced PPE with PAPRs, eye protection, fluid-repellent disposable surgical gown and gloves. If a PAPR is not available, the use of fit tested filtering face piece 3 (FFP3) or N95 mask with an additional fluid shield. During the tracheostomy procedure, establish complete paralysis using neuromuscular blockade to prevent coughing and aerosol dispersion (Heyd, et al, 2020). Procedure steps for surgery for a tracheostomy are outlined in A surgical safety checklist for performing tracheostomy in Covid-19 patients. The ENT_UK is another surgical guideline. In a single center study, percutaneous tracheostomy was performed with a protocol to use periods of apnea when disconnecting the ventilator circuit. All physicians were Covid-19 negative following the procedures (Boujaoude, Z. et al., 2021). Another recommendation is to only use cuffed, non-fenestrated tracheostomy tubes during the procedure and for any tracheostomy changes until the patient is confirmed Covid negative. The inflated tracheostomy cuff offers a closed system to help prevent cross contamination of staff. The size of the tracheostomy tube should be considered and is particularly important during Covid-19 as the smaller size of a stoma can reduce aerosol generation, reduce tracheostomy tube changes and reduce leakage around the cuff. Further details for management of patients with tracheostomy during COVID-20 can be found on the National Tracheostomy Safety Project and the American Academy of Otolaryngology Head and Neck Surgery."Avoid tracheotomy in COVID-19 positive or suspected patients during periods of respiratory instability or heightened ventilator dependence." "Tracheotomy can be considered in patients with stable pulmonary status but should not take place sooner than 2-3 weeks from intubation and, preferably, with negative Covid-19 testing. BAL is the most sensitive means of testing and is recommended for intubated patients to determine viral clearance. One proposed policy is two consecutive negative PCR tests 24 hours apart. However, universal testing may not be feasible due to the availability of testing and constraints for time. Any critically ill patient recovering from COVID-19 pneumonitis is considered high risk of infection to staff during tracheostomy insertion. Full airborne PPE precautions should be adhered to during all tracheostomy procedures during the Covid-19 pandemic and adhere to strict donning and doffing of PPE.
Cuff Deflation:
Cuff deflation is aerosol generating and risks and benefits should be reviewed. Cuff deflation can increase aerosolization because it frequently results in coughing. If cuff deflation is completed in a COVID positive patient, it should be done in a private room or in a designated cohorted COVID area (McGrath, B et al, 2020). Proper airborne PPE should be worn during cuff deflation trials for weaning. Patients should wear face masks and tracheostomy masks/shields to reduce risks of aerosols.
Speaking Valves:
Speaking valves can increase the potential for coughing which can result in aerolization. Therefore appropriate PPE should be worn. Patients should wear face masks during speaking valve use. A humidification bib can be placed over the tracheostomy tube and speaking valve for filtering the air to help protect the patient. Once a speaking valve is placed, exhaled air is redirected out the nose and mouth. Therefore face masks should be worn.
We will continue to update this resource page. However, information surrounding the coronavirus disease has been changing. Please continue to check on the references for further information. See references below.
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