How can the nurse best minimize a patients risk for infection during tracheostomy?

Otolaryngol Head Neck Surg. Author manuscript; available in PMC 2021 Jun 13.

Published in final edited form as:

PMCID: PMC8198753

NIHMSID: NIHMS1704794

Kara D. Meister, MD,#1,2 Vinciya Pandian, PhD, MBA, MSN, RN, ACNP-BC, FAANP, FAAN,#3,4 Alexander T. Hillel, MD,5 Brian K. Walsh, PhD, RRT, FAARC,6 Martin B. Brodsky, PhD, ScM, CCC-SLP,4,7,8 Karthik Balakrishnan, MD, MPH, FACS,1,2 Simon R. Best, MD,9 Steven B. Chinn, MD, MPH,10 John D. Cramer, MD,11 Evan M. Graboyes, MD, MPH, FACS,12,13 Brendan A. McGrath, MB ChB FRCP FRCA EDIC DICM AHEA FFICM MAcadMEd PhD,14 Christopher H. Rassekh, MD, FACS,15 Joshua R. Bedwell, MD, MS, FAAP, FACS,16,17 and Michael J. Brenner, MD, FACS18

Abstract

Objective.

In the chronic phase of COVID-19 pandemic, questions have arisen regarding care of patients with tracheostomy and downstream management. This review addresses gaps in the literature regarding post-tracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy.

Data Sources.

PubMed, Cochrane Library, Scopus, Google Scholar, Institutional guidance documents

Review Methods.

Literature through June 2020 on care of tracheostomy patients was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations.

Conclusions.

Best practices in caring for patients after tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol generating procedures; minimizing exposure risks to healthcare workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendation for personal protective equipment (PPE), equipment, care protocols, and personnel.

Implications for Practice.

Management of patients with tracheostomy in COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.

Keywords: tracheostomy, tracheotomy, COVID-19, pandemic, aerosol generating procedure, suction, laryngectomy, SARS-CoV-2, respiratory, N95, FFP3, patient safety and quality improvement, healthcare worker safety, laryngotracheal injury, subglottic stenosis, tracheal stenosis, tracheocutaneous fistula, venous thromboembolism, deep venous thrombosis, pulmonary embolism, DVT, PE, VTE, SARS

Introduction

The emergence of the novel Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) has led to a high-risk patient care environment, wherein risk of viral infection via droplets and aerosolized respiratory secretions seems omnipresent.1–7 Multidisciplinary team members (otolaryngologists, anesthesiologists, emergency physicians, intensivists, nurses, respiratory therapists, and speech-language pathologists) managing patients with tracheostomy are at elevated risk of COVID-19 infection (Odds ratio: 4.2 [1.5 – 11.5]), and previously unrecognized risk for patients are becoming apparent.8–19 Efforts to devise safety standards and protocols for intubation and tracheostomy have been initiated across institutions and endorsed nationally.20–23

Amid this intense focus on the tracheotomy procedure, including indications, timing, and technique, far less attention has been afforded to several high-stakes post-procedural considerations.24–29 This paucity of guidance is understandable, because many of these pressing issues –such as occlusion risk due to highly tenacious COVID-19 secretion or high rate of bleeding arising from aggressive prophylactic anticoagulation to counteract thrombotic stroke risks in COVID-19 – only came to light after significant clinical experience of downstream effects of pandemic care.30,31 Furthermore, the high virulence nature of SARS-CoV-2 is of concern, as many healthcare workers are still inadequately trained regarding precautions during aerosol-generating procedures (AGPs).8,32 Divergent institutional philosophies and social governances across the United States have led to notable variation in hospital policies, availability of personal protective equipment (PPE), and staffing ratios. There is a pressing need for standardization of patient-centered quality care, and although widespread consensus may be difficult to achieve across institutions and patient populations, this paper aims to outline topics and aspects of care which should be considered when determining care at the local level.

The purpose of this state-of-the-art review is to outline best practices for providing care to patients with a tracheostomy during COVID-19.33 This review covers a spectrum of postoperative care, including stoma care, suctioning, and tracheostomy changes as well as considerations of iatrogenic anatomical alterations to laryngotracheal anatomy, regardless of setting (e.g., ICU, inpatient rehabilitation, skilled nursing facility, home health, or outpatient clinics).

Methods

Multidisciplinary tracheostomy experts from the American Academy of Otolaryngology-Head & Neck Surgery and Global Tracheostomy Collaborative prioritized key considerations. PubMed/MEDLINE, Scopus, and Cochrane through June 2020 were searched for peer-reviewed, English-language publications on the care of patients with a tracheostomy, emphasizing postoperative management. Core search terms included tracheostomy, tracheotomy, tracheostomy care, suction, tracheocutaneous fistula, tracheostomy change, aerosol-generating procedures, tracheobronchoscopy, and terms relating to laryngotracheal injury, along with grey literature for consensus statements, national guidelines, and institutional recommendations during COVID-19.34 Evidence, key concepts related to tracheostomy management, and knowledge gaps surrounding tracheostomy care during COVID-19 were curated. Consensus among experts was achieved through a forecasting framework based on multiple rounds of iterative communication via Zoom, email, and phone.

Discussion

Aerosol Generating Procedure (AGP)

Many viruses, including SARS-CoV-2, are transmitted by droplets (5-10 μm), which are thought to be relatively large and travel less than one meter in air.4,35 Airborne transmission, however, can occur beyond two meters’ distance when smaller virus-containing particles (less than 5μm) are aerosolized4 and remain in the environment for up to 3 hours (median estimates of half-life: 1.1 – 1.2 hours [95%CI: 0.64, 2.64] hours).4 AGPs can disperse particles at varying distances ranging up to 100cm (Figure 1).36–45 Tracheostomy attached to a closed-circuit ventilatory system is considered to be a low-risk AGP; however, when the circuit is disconnected for suctioning, nebulization of medication, or tracheostomy tube change, they are considered high-risk AGPs (Table 1).32,46,47 Tracheostomy increases risk of aerosolization because of the shorter distance from the high-viral density alveolar surface to the stoma.3 The amount of care tracheostomy patients require increases the duration of exposure, and accumulation of secretions around the stoma places clinicians at close contact with infected fluids, increasing risk of transmission.4,48 Precautions must be taken to prevent exposure to aerosolized particles by streamlining care and increasing efficiency using time-outs and checklists (Table 2).49–53

Commonly employed oxygen/pressure sources result in dispersion of air particles ranging from 0 cm (Continuous Positive Airway Pressure (CPAP) to 100 cm (oxygen via nasal cannula) based on data from human simulations. Coughing without a mask from a semi-recumbent position in a bed results in particle dispersion nearly 70 cm towards the end of the bed. Coughing while wearing a surgical mask limits particle dispersion to 30 cm (laterally). Coughing while wearing an N95 mask (not shown) results in particle dispersion 15 cm laterally. Although chest compressions during cardiopulmonary resuscitation does generate aerosol spread, the travel distance has not been quantified.

Table 1:

Summary of lower and higher risk aerosol-generating tracheostomy care activities

Table 2.

Methods for reducing aerosolization in tracheostomy care

Personal Protective Equipment (PPE) Considerations during AGP

Appropriate PPE is an important modifiable factor for infection control and prevention when caring for patients with a tracheostomy.54 Institutional PPE policies differ based on the baseline prevalence of COVID-19, local resources, and the availability of supplies and testing. The minimal recommended PPE for the care of tracheostomy includes use of gloves, eye protection, and a procedural mask.55–57 Majority of institutions also consider a long-sleeved disposable gown as part of minimal PPE for tracheostomy care, to avoid soiling of clothes with aerosolized particles. When performing AGPs for COVID-19 positive patients or persons under investigation (PUI), an N95 respirator with face shield or Powered Air Purifying Respirator (PAPR) is strongly recommended.58–61 While some have recommended using an N-95 concurrently with a PAPR, robust data validating the efficacy remains limited.29,62

Using Signage to Minimize Risk of Transmission

Signage regarding presence of tracheostomy, type of tracheostomy tube, COVID-19 status, and emergency airway management algorithms should be placed in the window or doorway, where they are easily visualized or accessed by clinicians prior to entering the room, facilitating efficient management in case of an emergency.8,63,64 Signage should be agreed upon by local key stakeholders and uniform for institutions in appearance and location. Tracheostomy patients should be placed in a private room, if possible. If patients are COVID-19 positive (or PUI), they should be placed in a negative pressure room if available.

Benefits of Negative Pressure Rooms

A negative pressure room that reduces diffusion of airborne particles when aerosolized and provides a lower risk of cross-contamination between patient rooms or the spread of infection outside of the room was shown to be of significant benefit during the Severe Acute Respiratory Syndrome (SARS) epidemic.65 The Surviving Sepsis Campaign recommends the use of negative pressure rooms with a minimum of 12 air-flow changes per hour or at least 160 L/second/patient in facilities with natural ventilation. If negative pressure rooms are unavailable, a portable HEPA filter can capture viral particles, and may reduce viral transmission.66

Complications of Prolonged Intubation and/or Tracheostomy

Otolaryngologists have important leadership in management of laryngotracheal complications from prolonged intubation and tracheostomy, overseeing assessment, diagnosis, and treatment of injury. The sequelae of prolonged intubation have been long-recognized, but are of particular concern in the COVID-19 pandemic due to aggressive cuff over-inflation, amid fears of infection. Risk factors include both extrinsic (duration of intubation and size of endotracheal tube) and intrinsic (diabetes, ischemic disease) (Table 3).67–70 Prior to the COVID-19 pandemic, there were efforts to advocate for smaller endotracheal tubes and shorter intubation periods in high-risk patients.67,71,72

Table 3:

Risk factors and treatment principles for laryngotracheal injury from intubation and tracheostomy

The COVID-19 pandemic has resulted in a significantly increased need for prolonged ventilation in patients with respiratory failure. Extant literature addresses indications for tracheostomy in COVID-19 patients and factors surrounding decision to proceed with tracheostomy. Many indications are similar to non-COVID-19 population but discussions surround concerns of AGP. The surge in critically ill patients with advanced respiratory disease has led to prolonged intubation with a proportional increase in tracheostomy.5–8 We are beginning to see the resultant injury, with limited mobility of one or both vocal cords and subglottic/tracheal scar accumulation (Figure 2). Leopard and Moorhouse reported one case of adhesions in the middle third of the glottis thought to be related to mucosal inflammatory response to COVID-19.73 Gervasio et.al. found two patients with tracheal stenosis post intubation for COVID-19 pneumonia.74 Some injuries are identified in the hospital or during rehabilitation by failure to extubate or decannulate whereas other injuries become evident later, with patients reporting dysphonia, dysphagia, and dyspnea on exertion during follow-up appointments.

Laryngeal injury secondary to long-term intubation for COVID-19. A) Subglottic ulcerative injury with exposed cartilage. B) Posterior glottic diastasis demonstrating posterior glottic gap despite maximum adduction.

Treatment of laryngotracheal injury should address mucosal (and cartilaginous) injury and subsequent local inflammation and infection to preserve an adequate airway and maintain voice and swallow function. Early endoscopic intervention has been shown to improve the outcome of post-intubation airway stenosis.9,75 Such interventions include inhaled steroids and antibiotics with anti-inflammatory effects, such as macrolides and trimethoprim/sulfamethoxazole, to promote mucosal healing and target local bacteria.76,77 Early operative assessment with debridement of necrotic mucosa complements medical therapy to limit mature scar formation.75,77 Later intervention to address obstructive mature scar primarily includes open surgery, such as cricotracheal resection for subglottic/tracheal injury and laryngoplasty with placement of rib graft for laryngeal injury.78,79

Other COVID-inspired Risks and Complications – Bleeding, Occlusion, and Displacement

In addition to the growing prevalence of laryngotracheal injuries associated with prolonged intubation, COVID-19 care itself has greatly exacerbated certain previously described tracheostomy risks. The most notable increased complication is bleeding. Many hospitals routinely have COVID-19 patients on pharmacologic anticoagulation because COVID-19 causes a hypercoagulable state, increasing already high baseline risks of deep venous thrombosis and pulmonary embolus,80 as well as other sites of vascular thrombosis leading to amputations and strokes. The tracheostomy bleeding and oozing routinely seen by otolaryngologists is greatly increased in frequency and volume amid anticoagulation, with attendant risks of aspiration or hemodynamic perturbations with mortality risks approaching 10%.81 The authors are aware of numerous near-miss events in which sizable clots were retrieved from the airway.

COVID-inspired modifications in management of tracheal secretions and cuffs have also amplified risks to patients with tracheostomy. Secretions in patients with COVID-19 are also unusually thick and tenacious, predisposing to tracheostomy tube occlusions, a widely recognized cause of hypoxia and respiratory arrest.8,81–83 Such risks are increased by both mindful reduction in frequency of suctioning as well as a general aversion to suctioning altogether, relating to fears of transmission or due to clogging of in-line suction devices. Another concern relates to prolonged and overzealous inflation of cuffs, often performed in efforts to minimize leak and minimize risk of aerosolization. Such practices can be highly problematic by leading to short-term complications of tracheal dilation and tracheomalacia that cause airway injury and difficulty maintaining a seal as well as longer-term complications of tracheal ischemia with resultant subglottic or tracheal stenosis. Large number of tracheostomies in some facilities, such as New York University Langone that performed about 220 tracheostomies in COVID-19 patients over a 4 month period, has also increased the likelihood of delayed diagnosis of false tracts and malpositioned or displaced tracheal tubes.5,7,84

Tracheostomy Securement, Stoma Care, and Patient Transport

Tube Securement, Stoma, and Tube Care

Two main types of securements are typically used—twill ties and foam straps. Foam straps place minimal stress on the skin and decrease risk of skin breakdown; these straps reduce the need for frequent skin assessments and reduce duration of exposure to pathogens.85 When sutures are used to secure the tracheostomy tube, sutures should be removed within 7 – 10 days, and preferably before discharge, unless required to secure the airway during prone ventilation.86–89

Some institutions mandate use of dressing under the neck plate for all patients with a tracheostomy, while others use them only when there is evidence of skin deterioration around the stoma from mechanical trauma or infectious secretions. Placement and removal of dressing under the neck plate requires manipulation of the tracheostomy tube, causing patient discomfort and potentially stimulating cough; unnecessary disconnection of a ventilator circuit may also result in exposure to aerosolized particles. The need for tracheostomy dressing should be assessed carefully, with dressing changes performed only when soiled to decrease frequency of tracheostomy tube manipulation. Sites should be re-evaluated daily.90 Xeroform dressings, custom tracheostomy tubes with stoma seals, and Silflex silicone pads can improve the seal around the tracheostomy and decrease aerosolized viral particles. Disposable inner cannulas are preferred to avoid risks from cleaning and handling reusable inner cannulas.

Transporting tracheostomy patients

During patient transport, safety of patients, healthcare workers, and bystanders can be improved by equipping the tracheostomy with a heat moisture exchange (HME) with viral filter or a negative pressure tent, if the patient is not mechanically-ventilated. Additionally, surgical masks should be worn over both the patient’s face and the tracheostomy tube.60,91 If the patient is mechanically-ventilated, then the cuff should be optimally inflated with a closed-circuit to decrease aerosolization; avoid bag mask ventilation.92–95

Administration of inhaled medications

Administration of medications via jet nebulizer can aerosolize viral particles up to 80cm, increasing risk of exposure16,40,45,96,97 and is discouraged in tracheostomy patients. For non-mechanically-ventilated patients, a spacer should be used for delivery of metered-dose inhaled medications via tracheostomy tube.92,94,95 For mechanically-ventilated patients, vibrating mesh nebulizers, which do not require disconnection of closed-circuit systems, are recommended.21

Suctioning

Tracheostomy tube obstruction from mucus plugging is one of the most common reasons for airway rapid response activation.98,99 Special attention is required in COVID-19 positive patients with tracheostomy; due to poor pulmonary reserve and thick tenacious secretions that heightened risks to patients, but also because emergency management of tube obstruction has high aerosolization risk. Airway obstruction from mucus plugging is particularly challenging in instances of altered anatomy, as may occur with tracheocutaneous fistula with distal tracheal stenosis. Frequent suctioning can prevent mucus buildup and airway obstruction, with the caveat that tracheostomy tube suctioning typically generates a negative pressure of 100 –200 cmH2O, with increased aerosolization of viral particles in previous H1N1 outbreaks.37 Suctioning is of particular importance in pediatric patients with narrow lumen, single cannula tracheostomy tubes and limited respiratory reserve. Appropriate PPE is required to protect healthcare workers (Table 4).

Table 4:

Precautions and Personal Protective Equipment

Suctioning can be performed safely via a closed-circuit suctioning system for mechanically-ventilated patients using an inline suction catheter (Figure 3). Patients who are not on a ventilator should also be suctioned via a closed circuit with an inline suction catheter using a T-connector or a Kelley Circuit, to decrease aerosolization risk during COVID-19 pandemic (Figure 4).100,101 Instillation of saline before suctioning is avoided, given increased risk of coughing and aerosolization and little evidence of benefit.102 If thick secretions result in recurrent occlusion of inline circuits, placement of patients in a negative pressure room or room with HEPA filter may facilitate necessary suctioning protocols.

Closed-circuit suction system commonly used to suction mechanically-ventilated patients can minimize aerosolization of viral particles. Use of a Heated Moisture Exchanger (HME) with viral filter further decreases the risk of exposure.

A closed-circuit suction system can be created with the use of a T-tube, inline suction catheter and a HME with viral filter as shown here to decrease exposure to viral particles.

Tracheostomy tube change

Prior to COVID-19, tracheostomy tube changes were usually performed 5-10 days postoperatively to ensure maturation, and routine tube changes thereafter ensure stomal hygiene. Tracheostomy tube changes stimulate coughing and aerosolization, however, making it an AGP. Therefore, in COVID-19 patients, tracheostomy tube changes may be deferred, if clinically not required.103 It is prudent to wait for viral loads to decrease before changing tubes, and pediatric patients are often sedated during the immediate postoperative period, until the first tracheostomy change is performed. Risks of prolonged sedation versus risks of changing tracheostomy tubes with appropriate PPE and after COVID testing must be weighed carefully. Full 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 (Table 4).104

Adequate planning for manpower, equipment, and patient preparation all reduce exposure risks. Safety huddles and timeouts with the multidisciplinary team are recommended.81,105–109 Positioning the patient optimally just before tracheostomy tube change can help decrease coughing episodes and need for excessive suctioning. Moreover, spraying the airways with 4% of lidocaine before the tube change may decrease coughing; however, care must be taken in the formulation and weight-based dosing for pediatric population, given concerns of overdosing (For pediatric considerations, see Table 5). Properly-sized tracheostomy tubes, lubricating jelly, 10cc syringe, tracheostomy tube securement, and cuff manometer are needed. Access to intubation equipment adds an additional margin of safety in patients with difficulty during reinsertion. In mechanically-ventilated patients, positive-pressure ventilation is suspended before ventilator circuits are disconnected from the tracheostomy tube. If possible, an HME device with viral filter is placed on the tracheostomy tube in the interim.

Table 5:

Modifications During Pandemic that May Increase Risk of Harm in Pediatric Patients and Suggested Alternative Approach

Heat and Moisture Exchanger (HME)

Current options for humidification via tracheostomy tubes include heated humidification (HH) and HME. HH, or tracheostomy mist, involves open flow of humidified air, which can aerosolize viral particles. A Cochrane study evaluating 33 trials (n=2833) showed equivalence between HH and HMEs in adequacy of humidification and prevalence of occlusion,110 HMEs are strongly preferred;111 however, not all HMEs can filter viral particles nor do they have oxygen ports and can be difficult to breathe through and requires frequent changes given the tenacious secretions. Therefore, HMEs with viral filters, filtration efficiency >99.9%, and bidirectional design are recommended for all COVID-19 positive patients.21 If filters are unavailable, HME still allows passive humidification of inhaled air and prevents gross aerosolization.

Disconnection from closed-circuit systems warrants immediate placement of an HME to minimize aerosolization. All discarded HMEs are considered infectious and should be disposed quickly and properly. If HME is unavailable and there is high risk of mucus plug in a patient with single cannula tube, saline drops may be instilled through the inline suction port, with scheduled suctioning to reduce mucus buildup.112

Cuff management

Routine Cuff Management

A closed-circuit ventilation system used to decrease aerosolization can lose integrity if the tracheostomy tube cuff is inadequately inflated. National guidelines recommend that cuff pressure should be maintained between 20 – 30 cmH2O for air-filled cuffs, to avoid loss of tidal volume and prevent tracheal injury.113–115 Hyperinflation of cuffs to avoid any air leak is not uncommon in patients who are COVID-19 positive but incurs risk of tracheal injury.116 While cuff manometry is not applicable to water-filled cuffs, such cuffs should be filled with sterile water until air leak is not appreciated. In mechanically-ventilated patients, the cuff should be filled with sterile water until peak pressure is approximately 20 cmH2O, the precise volume should be noted, and cuff should be periodically assessed to ensure optimal volume and a closed-circuit ventilation system is maintained.

Cuff management during weaning from mechanical ventilator

Tracheostomy tube cuff is usually kept inflated throughout the weaning process from mechanical ventilation from ‘assisted’ to ‘pressure-support’ mode. Pressure support mode with an inflated cuff is preferred over spontaneous breathing trials using T-piece to avoid aerosol generation. If alveolar derecruitment occurs, the cuff may be temporarily hyperinflated to perform recruitment maneuversin collaboration with respiratory therapists. If the patient successfully weans off the ventilator, an HME with viral filter should be placed to decrease expulsion of viral particles through the tube. When the patient is considered low risk for infectivity, cuff may be deflated; and when patient is considered to be low-risk for requiring mechanical ventilation, tracheostomy tube may be changed to a cuffless tube. Once the patient is able to tolerate cuff deflation or cuffless tracheostomy tube, one-way speaking valves or capping may be considered to facilitate speech and prompt weaning off the tracheostomy tube.

Speech

One-way speaking valves or tracheostomy tube cap requires toleration of a deflated cuff or cuffless tube to allow passage of air through the vocal cords for phonation.92,117–120 Some clinicians argue that avoiding one-way speaking valves and tracheostomy tube caps may decrease nasopharyngeal airflow and thereby decrease expired viral load. Counter-arguments purport that the pressure and velocity of air passing from the lungs through an open tracheostomy lumen is much higher than through the nasopharynx, due to differences in distance and friction imposed by several structures in the upper airway. In addition, by the time patients have reached the stage where they can tolerate cuff deflation, viral load is higher in the lower respiratory tract than in the upper respiratory tract.1 Therefore, an open tracheostomy tube lumen without an HME, one-way speaking valve, or cap likely increases risk of aerosolization.60 Patients who cannot tolerate cuff deflation or one-way speaking valves due to increased secretions should be offered augmentative options to facilitate communication.121,122

Swallowing

Swallowing assessment can elicit cough, gag, throat clear, or sneeze. In patients at low-risk for dysphagia, alternative swallowing assessments may include blue dye test rather than flexible endoscopic evaluation of swallowing (FEES). FEES involves nasolaryngoscopy, is an AGP, and requires physical proximity to the patient. Videofluoroscopic swallow study (VFSS), another alternative swallow assessment, may involve patient transport.123–125 In pediatric patients, there is often crying and sputtering with FEES and VFSS, which may increase aerosolized particles. 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 PAPR.126–128

Decannulation

Patients are candidates for decannulation once the reason for tracheostomy has resolved, ventilatory support is not required, cough/swallow is adequate, suctioning is minimal, and there is no acute need for additional procedures.129 Decannulation should be ideally be deferred until SARS-CoV-2 testing of lower respiratory tract sputum is negative x 2, and proper PPE must be used to remove tracheostomy tubes (Table 4).130 In the pediatric population, SARS-CoV-2 testing should be negative prior to proceeding with any planned operative airway exam and hospital admission, which are often part of the decannulation process. After decannulation, an occlusive pressure dressing is placed to facilitate wound closure and limit exposure to tracheal secretions.

Diagnostics and Therapeutic Procedures

Indications

An urgent laryngoscopy or tracheobronchoscopy may be anticipated when diagnostic findings may significantly change clinical management or surgical decision-making; in other cases, alternative diagnostic and therapeutic options are encouraged. Assessment of laryngeal function or upper airway obstruction initially relies on clinical judgment or laryngeal ultrasound, rather than laryngoscopy, where possible. Still, timeless principles of safe airway management and diagnosis should be honored.14 If the patient is COVID-19 positive or PUI, these procedures are ideally performed in negative pressure rooms, with minimal personnel, and appropriate PPE (Table 4).

Procedure

When performing tracheobronchoscopy, a swivel adapter should be attached to the tracheostomy tube so that the end of the adapter can be connected to the ventilatory circuit in a mechanically-ventilated patient or to an HME in a patient not requiring ventilatory support. The adaptor has a pop-top or slit cap that allows a close-fit entry of the bronchoscope for evaluation. The bronchoscope should be covered with a suction sheath, essentially making it an in-line device.131 Videoscope or endoscopy towers place the provider’s face further from the patient, increasing safety. All samples and aspirates obtained are considered infectious and transported accordingly.

Disinfection of scopes

Endoscopes used during laryngoscopy or tracheobronchoscopy have high potential for viral contamination. They should be handled with proper PPE, preliminarily disinfected at location of procedure prior to transport, and transported while covered to the reprocessing area. Instrument processing staff should wear appropriate PPE and require training to disinfect scopes with working channels properly. For COVID-19 positive patients and PUIs, disposable nasopharyngolaryngoscopes and bronchoscopes are preferred; however, feasibility, optics, scope diameter, and quality/yield of exam with disposable scope must be weighed against concerns for contamination. If an endoscopy tower is used, the tower must be terminally cleaned by trained personnel prior to transport and reuse.

Discharge planning and Caregiver Education

Preparation of Equipment

The surge in demand for specialized equipment related to ventilation in COVID-19 patients has disrupted supply chains and caused shortages in equipment relating to home tracheostomy care and home ventilation. Prior to discharge, social workers and case managers should work with patients’ durable medical equipment supplier to ensure that key equipment—home ventilators and disposable supplies—are available in patients’ region and with timely delivery, repairs, and replacements.

Preparation of Receiving Facility

If the patient is transitioning to another care facility, the receiving facility should have personnel with appropriate education and training, as well as necessary equipment and PPE to ensure safety. Facilities should be transparent about their capability in caring for patients with tracheostomy to ensure a seamless transition of care. Regardless of discharge destination, all caregivers, including transportation staff, should have adequate PPE.

Preparation of Caregivers

Discharge planning for patients requiring tracheostomy ideally begin before insertion of a tracheostomy tube, and multidisciplinary approach is paramount.8,81,132,133 For home discharges, caregivers will need to demonstrate proficiency in routine and emergent care of tracheostomy, including tube changes per institutional protocol. In the pediatric population, more children have life-threatening or life-ending tracheostomy complications at home than in the hospital, partly because of the indications of tracheostomy placement, but this may be exacerbated in both pediatric and adult population given added anxieties around tracheostomy care and potential resistance to attend outpatient clinic appointments and seek emergency care when needed. Because of visitation limitations, scarcity of PPE, and deferral of routine trach changes, institutions should be open to alternative methods of caregiver education, such as online training and simulation-based education.134–136 Institutions are encouraged to develop standardized policies, education materials, and access to outpatient advice portals to decrease readmission rates.135,137,138 Telehealth home check-ins have been shown to support caregivers and troubleshoot potential pitfalls in transition to home after tracheostomy placement.139 Caregivers are encouraged to engage in peer-education. Although not a substitute for proficiency in skill and baseline knowledge, social media or other virtual approach may afford caregivers emotional and social support.140,141

Considerations for Ambulatory Care

When telehealth is not adequate to meet care needs, patients with a tracheostomy must obtain definitive care in outpatient settings. Screening or viral testing before outpatient visits protects clinicians and other patients.142,143 Patients and caregivers should be educated regarding safe transport, including masking before appointments.144 Testing recommendations are informed by baseline prevalence of COVID-19, testing availability, patients’ clinical presentation, and need for clinic visit. Patients should be provided two masks – one over the face, and another over the tracheostomy tube/stoma.145 Tracheostomy tube changes, tracheoscopy, and FEES should be performed only when medically necessary and in the most controlled environment possible, including negative pressure exam rooms, rooms equipped with HEPA filters, or rooms with the highest airflow exchange rate. For in-office appointments, providers and staff should wear appropriate PPE (surgical mask, eye protection, and gloves +/− gown).146–148 When possible, transition to virtual visit, telehealth visit, or phone is considered.

Care of patients with tracheocutaneous fistula (Laryngectomy)

The recommendations above extend to patients with laryngectomy stoma and pediatric patients that have previously undergone laryngotracheal separation or glottic closure.149 While the upper airway and lower airway are discontinuous in these patients, they can still shed viral particles from the lower airway reservoir.111 It is important that these patients are easily identified as not being able to be intubated.83 Laryngectomy tubes with HME adaptors are available and should be used to prevent transmission both in symptomatic and asymptomatic patients.

Discontinuation of Transmission-Based Precautions

Establishing a patient’s immunity status and lack of infectivity can conserve PPE, although the notion of immunity passports has been fraught with ethical and logistical complexity, given uncertain infectious characteristics, variable duration of shedding, and inequities.150–152 For COVID-19, median duration of viral shedding has been 20 days, but shedding in survivors has been seen well beyond 30 days after infection.13 A further challenge in establishing lack of infectivity is low sensitivity of single COVID-19 RT-PCR tests.153 Ability to establish lack of infectivity may improve with serial COVID-19 –RT-qPCR testing. The CDC’s interim recommendations for discontinuation of transmission-based precautions for COVID-19 in healthcare settings is based on PCR testing or presence of symptoms.154,155 Transmission-based precautions may be discontinued in patients with prior COVID-19 who have not had symptoms and have negative results on at least two COVID-19 PCR tests at least one day apart. These recommendations are provisional and may be modified as new research emerges. Decisions about discontinuing transmission-based precautions should be made in discussion with institutions, experts, and other stakeholders.

Implications for Practice

Post-operative care of patients with tracheostomy during the COVID-19 pandemic requires thoughtful, multidisciplinary collaboration.156–158 This document provides a critical review of current literature, further informed by expert opinion in several complementary disciplines. The guidance presented herein should be informed by local expertise, resources, and patient preferences. An overarching principle from this review is that providing timely, high quality care for patients with tracheostomy is predicated on safe practices for both clinicians and patients relating to infectious transmission from AGPs. Furthermore, in light of unique characteristics of COVID-19 and COVID-inspired modifications to care, particular vigilance is warranted in addressing heightened risks of bleeding, mucus plugging, displaced airways, and laryngotracheal injury. Limiting unnecessary procedures and adopting novel ways to decrease aerosolization may afford long-lasting improvements in care, beyond the current pandemic. Proper PPE should be maintained across clinical practice settings for all clinicians and staff involved in care of tracheostomy. Last, institutions should develop, track, and report quality indicators on tracheostomy to learn from the current environment and to inform future pandemics.

Funding Support:

Financial Support for this study was provided by 1K23DC014758 (Simon R. Best), an NIDCD Mentored Patient-Oriented Research Career Development Award on laryngeal disorders; R01 DC018567 01 (Alexander T. Hillel) on pathogenesis of laryngotracheal injury; and R01 NIH 5-R017433 (Martin B Brodsky and Vinciya Pandian), on laryngeal injury post-extubation in intensive care unit settings

Disclosures:

1. Dr. Rassekh received an educational Grant from Cook Medical for 5th International Congress activities; Patent pending for Biocontainment device (ABCD)

2. Dr. Pandian serves as a consultant for Medtronic

3. Dr. Balakrishnan receives royalties for textbook royalties from Springer

4. Dr. Hillel is a Consultant for Ambu and has a Sponsored Research Agreement with Medtronic

5. Dr. Brenner is board member and incoming president for Global Tracheostomy QI Collaborative

6. All authors serve on AAO-HNS committees, AAO-HNS educational functions, or on OHNS Journal

This manuscript is sponsored by the AAO-HNS/F Patient Safety and Quality Improvement Committee and the Outcomes Research and Evidence-Based Medicine Committee.

Footnotes

Conflict of Interest:

The authors do not deem any of the relationships below to be conflicts of interest, but in the interest of comprehensive disclosure, we wish to list the financial relationships below. No product is mentioned by manufacturer name in this article.

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