Oral Oncology 105 (2020) 104682

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Oral Oncology
journal homepage: www.elsevier.com/locate/oraloncology

Editorial

CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway T

management

Introduction personal protection equipment (PPE). Furthermore, in the worst-case

scenario, PPE shortage or improper use could threaten health workers
The recent outbreak of SARS-CoV-2 has reached worldwide pro- beyond the already high risk of infection. Few guidelines were recently
portions since it began in late 2019 [1]. Due to the high virulence via released for tracheostomy procedures in COVID-19 positive patients
aerosol transmissions, to date COVID-19 has infected more than [5–8]. The rationale of covering should be a multilayer donning and
575,444 people all over the world, causing 26,654 confirmed deaths doffing in order to minimize the possibility of contamination and re-
[2]. Italy is the leading nation in the world for infections, counting generate reusable PPE (i.e. goggles, surgical wears and theater clogs)
about 86,498 (15.0%) confirmed positive people, as for number of Sars- [9].
CoV-2 associated deaths, reached 8460 people on march 28th, 2020. Before dressing, bracelets and other jewelry must be removed for
The high rate of hospital and intensive care unit (ICU) admission pro- surgical scrubbing.
voked a serious congestion across hospitals and extreme measures have
been taken to avoid a health-service collapse. – Cap and shoe covers: are considered necessary for safely dressing;
According to official online data, roughly 10% of Italians that are – Mask: FFP3 (Europe) or N99 (US) masks must be preferred than any
infected are health-care workers, which account for 7763 people [3]. other option. In case of FFP3 mask shortage, FFP2 or N95 masks can
Indeed, health workers incur a higher risk of infection and among these, be used, covered by surgical mask. FFP mask covering with surgical
anesthetists and surgeons are most prone to exposure. mask seems reasonable to facilitate multi-layer doffing;
Sedated ICU patients who require prolonged intubation, often re- – Goggles: eyes protection can be reached by surgical goggles, pre-
quire a safer management of the airway, biasing for tracheostomy. A ferably, or a face shield;
recent systematic review revealed how early tracheostomy, performed – Gown: use of double gown is preferable, where available;
in the first 7 days after orotracheal intubation, is associated with a – Gloves: use of double nitrile gloves is suggested;
reduction of mechanical ventilation duration, mortality rate and length
of stay in ICU [4]. Despite surgical tracheostomies being routinely Consider additional coverage such as surgical hoods. Alternatively,
performed in the surgeon’s daily practice, the surgeon’s risk of exposure face shield can be worn on top of goggles.
to COVID-19 during this procedure is consistent. Due to the direct ac- Once dressing is completed, full “buddy check” is recommended to
cess to the airway and the mechanical ventilation, which generates a prevent incorrect or incomplete covering.
huge amount of droplets in case of air-leakage from the cuff, tra-
cheostomies place surgeons to be the highest risk category, together OR for operating room setting
with ICU nurses and doctors. Surgical tracheostomy on sedated and
intubated patient is, by far, preferable than awake patient tracheostomy Where available, tracheostomy should be performed in the oper-
or percutaneous cricothyrotomy for which air-flow cessation cannot be ating room. Alternatively, and probably more frequently, a provisional
obtained and droplets emission is inevitably higher. operating room can be set up in the ICU, ideally employing a negative
Due to the expected rise of tracheostomy procedures in such sce- pressure room. If any of these circumstances is not available, tra-
nario, we propose a step-by-step approach in order to minimize the cheostomy should be performed in an aerial-isolated room (i.e. doors
operator infection risk and avoid health worker shortage. and windows closed).
The CORONA-steps acronym aims to create easy to remember steps The procedure requires precise planning in timing and it should be
that the tracheostomy must be accompanied by: Covering yourself (C), performed on an already intubated and sedated patient.
Operating Room setting (OR), Opening the trachea (O) and Nursing and Because of the risk-related procedure, the operating room must host
Airway management (NA). For this purpose, an illustrative and in- only strictly required workers, meaning surgeons, an anesthesist and
tuitive memorandum has been created (Fig. 1). nurses.
Surgery: within a surgical department, a tracheostomy-team can be
The CORONA method step-by-step settled in order to avoid infection exposure by rotating shifts. For this
reason, no more than two surgeons per procedure should be involved.
C for covering In addition, expert surgeons would guarantee fast and effective tra-
cheostomy comparing to less experienced surgeons or residents.
Up to date there is no evidence-based guidelines on the use of Surgeons are required to check for the disposition of the correct surgical

https://doi.org/10.1016/j.oraloncology.2020.104682
Received 2 April 2020; Accepted 2 April 2020
Available online 06 April 2020
1368-8375/ © 2020 Elsevier Ltd. All rights reserved.
Editorial Oral Oncology 105 (2020) 104682

Fig. 1. Illustration of the CORONA-steps for a safe tracheostomy in COVID-19 positive patient.

instruments, which can vary according to operator habit. setting allows an appropriate and rapid instrument dismissing and re-
Anesthesia: if not indicated, a single anesthesist would be sufficient conditioning. Along with instruments, the non-fenestrated cuffed tra-
for mechanical ventilation and tube removal after tracheal incision. cheostomy tube with expected diameter-size should be prepared on the
Nurse: a scrub nurse and an assistant nurse should cope with sur- surgical table. A handy and close storage for different-size cannulas
gical table and anesthesist assistance. Most of ORs and ICUs are must be rapidly accessible to the assistant nurse.
equipped with disposable surgical kits while surgical instruments for
tracheostomy should be stored in dedicated kits. These arrangements
can help in avoiding extra and unnecessary surgical instruments. This

2
Editorial Oral Oncology 105 (2020) 104682

O for open the trachea cannula change can be delayed 30 days after.

This chapter will not discuss the surgical steps for tracheostomy, but Conclusions
rather it will outline some crucial hints which can be helpful to
downplay passages at risk. Although tracheotomy is a widely described surgical technique, the
The patient in supine position, with hyper-extended head and face current literature does not contain guidelines on the safe execution and
covered by drapes, requires a deep neuromuscular blockade in order to management of this procedure in COVID-19 positive patients.
avoid swallowing and cough reflexes. Oxygenation must be achieved In this setting, CORONA-steps aims to promote a safe method for
with positive end-expiratory pressure (PEEP). Once the anterior wall of tracheostomy management in COVID-19 positive patients.
the trachea is exposed, the anesthetist:
Declaration of Competing Interest
– reduces the oxygen-percentage of the inflated air to 21%;
– pushes the tube as caudally as possible, so as to avoid cuff breach; The authors declare that they have no known competing financial
– hyper-inflates the tube cuff to ensure lower airway isolation. interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Rapidly, the surgeon incises the trachea avoiding cuff damage and
creates a window according to the most common technique. Tracheal References
incision must be performed as much cranially as possible (e.g. 1° or 2°
inter-tracheal space). The anterior tracheal wall can be sutured to the [1] Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia
skin to facilitate insertion and post-operative management. in China, 2019. N Engl J Med 2020. https://doi.org/10.1056/NEJMoa2001017.
Tracheal tube removal and tracheal cannula insertion represents the [2] World Health Organization (WHO). Coronavirus disease (COVID-19) Pandemic.
https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Published
most hazardous step for infection spread. At this stage ventilation is 2020.
stopped entirely, the tracheal tube is lifted, without extubating the [3] Istituto Superiore di Sanità (ISS). Integrated Surveillance of COVID-19 in Italy; 2020.
patient, until its bottom side passes the tracheal window, then cannula https://www.epicentro.iss.it/coronavirus/bollettino/Infografica_28marzo ENG.pdf.
[4] Adly A, Youssef TA, El-Begermy MM, Younis HM. Timing of tracheostomy in patients
is inserted in the tracheal lumen. Promptly, the cannula cuff is inflated with prolonged endotracheal intubation: a systematic review. Eur Arch
at the appropriate pressure level and a non-fenestrated inner tube along Otorhinolaryngol 2018;275(3):679–90. https://doi.org/10.1007/s00405-017-
with the heat and moisture exchanger is positioned: only then the 4838-7.
[5] UK E. Framework for Open Tracheostomy in COVID-19 Patients; 2020.
ventilation is resumed by close airway circuit attachment. Tracheal
[6] Canadian Society of Otolaryngology - Head and Neck Surgery. Recommendations
cannula should be considered correctly positioned until CO2 value is from the CSO-HNS Taskforce on Performance of Tracheotomy During the COVID-19
displayed, avoiding stethoscope contamination by thoracic ausculta- Pandemic; 2020.
[7] Cheung JC-H, Ho LT, Cheng JV, Cham EYK, Lam KN. Staff safety during emergency
tion. Only at this point endotracheal tube is completely removed to-
airway management for COVID-19 in Hong Kong. Lancet Respir Med February 2020.
gether with the sterile drape covering the face and tracheal cannula is doi: 10.1016/S2213-2600(20)30084-9.
secured to the neck with sutures and staples. Dressing should be per- [8] Società Italiana di Otorinolaringoiatria (SIO). La Tracheostomia in Pazienti Affetti Da
formed so that no cannula change would be required for 7 days. Even COVID-19; 2020.
[9] Harrod M, Petersen L, Weston LE, et al. Understanding workflow and personal pro-
PPE doffing is a crucial moment which should be carried out in a se- tective equipment challenges across different healthcare personnel roles. Clin Infect
parate area, even then with “buddy check”. OR should be decontami- Dis 2019;69(Supplement_3):S185–91. https://doi.org/10.1093/cid/ciz527.
nated according to the local guidelines.
Barbara Pichia, Francesco Mazzolaa, , Anna Bonsembianteb,
⁎

NA for nursing and airway management Gerardo Petruzzia, Jacopo Zocchia, Silvia Morettoa,
Armando De Virgilioc,d, Raul Pellinia
a
Tracheal cannula management must be performed in a BSL-3 setting Department of Otolaryngology and Head & Neck Surgery, IRCCS “Regina
which is nowadays the standard for regular ward and ICUs hosting Elena” National Cancer Institute, Via Elio Chianesi 53, 00144 Roma, Italy
b
COVID-19 positive patients. In the first 7 days tracheal cannula man- Ear Nose and Throat and Audiology Department, University Hospital of
agement should be performed by trained nursing staff and includes safe Ferrara, Via Aldo Moro, 44124 Ferrara, Italy
c
suction with a close airway circuit and regular checks of cuff-pressure. Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele
No dressing change should be performed unless evidence of local in- (MI), Italy
d
fection and cannula cuff should not be deflated unsafely. The cannula Department of Otorhinolaryngology Head and Neck Surgery, IRCCS
should be held during any passive movement of the patient to avoid air Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56,
leakage from the stoma. 20089 Rozzano (MI), Italy
Cannula change can be planned 7–10 days later using the same E-mail address: [email protected] (F. Mazzola).
standards (PPE utilization and airflow interruption). Subsequent

⁎
Corresponding author.