COVID-19 Tracheostomy and Mechanical Ventilation

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The 2019 novel corona virus COVID-19 pandemic has resulted in an increase in patients intubated and use of mechanical ventilation. The United States and globally, we are likely to see an increase in tracheostomy as well, as patients may have difficulty weaning and require longer periods of time on a vent. COVID-19 also has implications for healthcare workers, as there are shortages with workers becoming ill from the virus. Infection control is paramount in controlling the outbreak and protecting patients, healthcare workers and the community
corona virus tracheostomy

Approximately 20-30% of hospitalized patients with COVID-19 and pneumonia have required intensive care for respiratory support (Huang, et al 2020; Wang et al, 2020).  Critically ill patients were older (median age 66 years versus 51 years), and were more likely to have underlying co-morbid conditions (72% versus 37%) in comparison to non-ICU patients with COVID-19 (Wang et al, 2020).   Among critically ill patients admitted to an intensive care unit, 11–64% received high-flow oxygen therapy and 47-71% received mechanical ventilation; some hospitalized patients have required advanced organ support with endotracheal intubation and mechanical ventilation (4–42%)(CDC, 2020).  The most common diagnosis of severe COVID-19 is pneumonia (World Health Organization, 2020).

Reported illnesses have ranged from mild symptoms to severe illness and death for confirmed coronavirus disease 2019 (COVID-19) cases.  Symptoms include fever, cough and shortness of breath.  Risk factors associated with respiratory failure requiring mechanical ventilation are not clearly described in published reports, although from the limited available data, risk factors associated with a critical illness/ICU admission included older age (>60 years), male gender, and the presence of underlying comorbidities (Critical Care Guideline, 2020). 

 

Below is a 3D rendering of a COVID-19 patient’s lung.  Lung damage is diffuse and broad throughout the lung. 

Infection Prevention for Covid-10 and tracheostomy and mechanical ventilation

Preventing the spread of Covid-19 is a priority and responsibility for everyone.  Healthcare workers around the globe are fighting to slow the spread of the disease.  Infection control measures are paramount to protecting workers and patients.  

The World Health Organization indicates to initiate infection prevention and control at the point of entry of the patient to hospital.  Screening should be done at first point of contact at the emergency department or outpatient department/clinics.  Suspect patients should be given a mask and directed to separate area.  Keep at least 1 m distance between suspected patients. 

Standard Precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting.  Healthcare professionals entering the room of a patient with known or suspected COVID-19 should adhere to standard precautions and wear a respirator or facemask, gown, gloves and eye protection.  Respirators including N95 masks are preferred when available.  Hand hygiene is the most effective way to prevent the spread of infection. Standard precautions also include prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.

In addition to standard precautions, health care workers should do a point-of-care risk assessment at every patient contact to determine whether additional precautions (e.g. droplet, contact, and/or airborne) are required. 

AIrborne measures should be taken for aerosol generating procedures.  The World Health Care Guidelines indicates the following: “Ensure that health care workers performing aerosol-generating procedures (e.g. open suctioning of respiratory tract, intubation, bronchoscopy, cardiopulmonary resuscitation) use the appropriate PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection). A scheduled fit test should not be confused with a users’ seal check before each use. Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with a minimum of 12 air changes per hour or at least 160 L/second/patient in facilities with natural ventilation. Avoid the presence of unnecessary individuals in the room. Care for the patient in the same type of room after mechanical ventilation commences.” (WHO, 2020). 

Endotracheal intubation and Covid-19

Patients with Adult Respiratory Distress Syndrome (ARDS), especially young children or those who are obese or pregnant, may desaturate quickly during intubation. Pre-oxygenate with 100% FiO2 for 5 minutes, via a face mask with reservoir bag, bag-valve mask, high-flow nasal oxygen (HFNO) or NIV. Rapid sequence intubation is appropriate after an airway assessment that identifies no signs of difficult intubation. 

Mechanically Ventilated Adults and Pediatrics with ARDS

The World Health Organization has a few recommendations specific for patients mechanically ventilated with ARDS.  Patients may continue to have increased work of breathing or hypoxemia even when oxygen is delivered via a face mask with reservoir bag (flow rates of 10–15 L/min, which is typically the minimum flow required to maintain bag inflation; FiO2 0.60–0.95). Hypoxemic respiratory failure in ARDS commonly results from intrapulmonary ventilation-perfusion mismatch or shunt and usually requires mechanical ventilation.   Here are the recommendations from the WHO (2020):

 Implement mechanical ventilation using lower tidal volumes (4–8 mL/kg predicted body weight, PBW) and lower inspiratory pressures (plateau pressure < 30 cmH2O). Remarks for adults: This is a strong recommendation from a clinical guideline for patients with ARDS, and is suggested for patients with sepsis-induced respiratory failure who do not meet ARDS criteria. The initial tidal volume is 6 mL/kg PBW; tidal volume up to 8 mL/kg PBW is allowed if undesirable side-effects occur (e.g. dyssynchrony, pH < 7.15). Permissive hypercapnia is permitted. Ventilator protocols are available. The use of deep sedation may be required to control respiratory drive and achieve tidal volume targets. Remarks for children: In children, a lower level of plateau pressure (< 28 cmH2O) is targeted, and lower target of pH is permitted (7.15–7.30). Tidal volumes should be adapted to disease severity: 3–6 mL/kg PBW in the case of poor respiratory system compliance, and 5–8 mL/kg PBW with better preserved compliance. 

In adult patients with severe ARDS, prone ventilation for 12–16 hours per day is recommended. Remarks for adults and children: Application of prone ventilation is strongly recommended for adult patients, and may be considered for paediatric patients with severe ARDS but requires sufficient human resources and expertise to be performed safely, protocols (including videos) are available (https://www.nejm.org/doi/full/10.1056/NEJMoa1214103). Remark for pregnant women: There is little evidence on prone positioning in pregnant women. Pregnant women may benefit from being placed in lateral decubitus position. 

Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion. Remarks for adults and children: This is a strong guideline recommendation; the main effect is to shorten the duration of ventilation. See reference for details of a sample protocol

In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is suggested. Remark 1: PEEP titration requires consideration of benefits (reducing atelectrauma and improving alveolar recruitment) vs risks (end-inspiratory overdistension leading to lung injury and higher pulmonary vascular resistance). Tables are available to guide PEEP titration based on the FiO2 required to maintain SpO2 (32). In younger children, maximal PEEP rates are 15 cmH20. Although high driving pressure (plateau pressure − PEEP) may more accurately predict increased mortality in ARDS compared with high tidal volume or plateau pressure (36). Data from RCTs of ventilation strategies that target driving pressure are not currently available. Remark 2: A related intervention of recruitment manoeuvres (RMs) is delivered as episodic periods of high continuous positive airway pressure (CPAP) (30–40 cmH2O), progressive incremental increases in PEEP with constant driving pressure, or high driving pressure; considerations of benefits vs risks are similar. Higher PEEP and RMs were both conditionally recommended in a clinical practice guideline. For PEEP, the guideline considered an individual patient data meta-analysis of three RCTs. However, a subsequent RCT of high PEEP and prolonged high-pressure RMs showed harm, suggesting that the protocol in this RCT should be avoided. Monitoring of patients to identify those who respond to the initial application of higher PEEP or a different RM protocol, and stopping these interventions in non-responders, is suggested.

 In patients with moderate-severe ARDS (PaO2/FiO2 < 150), neuromuscular blockade by continuous infusion should not be routinely used. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected.

Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis. 

Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection is required (for example, transfer to a transport ventilator).

Resources for Covid-19 and tracheostomy and mechanical ventilation

The World Health Organization has issued guidelines for the clinical management of severe acute respiratory infections for those that COVID-19 disease is suspected.  There are recommendations for oxygen therapy, management of acute respiratory distress syndrome including mechanical ventilation, tidal volumes, prone ventilation and PEEP levels.  

The Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) is a guideline to provide recommendations to support hospital clinicians managing critically ill adults with COVID-19 in the intensive care unit (ICU).  It includes information on infection control, testing, and supportive care (hemodynamic support, fluid therapy, vasoactive agents, ventilatory support, invasive ventilation, and therapy).

The Australian and New Zealand Intensive Care Society has provided guidelines for COVID-19.  Guidelines include ICU planning such as measures to reduce ICU demand and increasing the infrastructure.  Infection control strategies for testing, isolation and PPE are reviewed. 

The CDC has put in place infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease in healthcare settings through limiting germs, isolating infected patients and protecting healthcare professionals through hand hygiene and appropriate personal protective equipment (PPE).  There is a shortage of PPE in the United states for masks, gloves and gowns during this epidemic.  The CDC also has some recommendations to optimize PPE and extend supplies.

The National Tracheostomy Safety Project in the UK has also issued some guidance for management of patients with tracheostomy during the coronavirus outbreak. The recommendations include information regarding where to manage patients with tracheostomy, strategies for the actual tracheostomy procedure, and then mechanically ventilated versus spontaneously breathing patients.  

Information surrounding the coronavirus has been changing.  Please continue to check on the references for further information.  

References:

Alhazanni, W. et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19), 2020.  Society of Critical Care Medicine and the European Society of Intensive Care Medicine. 

Centers for Disease Control and Prevention, 2020. 
 

National Tracheostomy Patient Safety Project, 2020. 

World Health Organization, 2020. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. 

Zhonghua, Jie He He Hu Xi Za Zhi. Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus. 2020 Feb  20;17(0):E020. doi: 10.3760/cma.j.issn.1001-0939.2020.0020. 

 

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