Opinion

Surgical Considerations for Tracheostomy

VIEWPOINT
During the COVID-19 Pandemic
Lessons Learned From the Severe Acute
Respiratory Syndrome Outbreak

Joshua K. Tay, MBBS, Since the emergence of the coronavirus disease 2019 these PPE measures was validated, as all members of the
PhD (COVID-19) in December, 155 countries have reported tracheostomy surgical teams remained healthy after per-
Department of cases of COVID-19, including sustained community trans- forming a total of 23 tracheostomies documented across
Otolaryngology–Head
mission in several countries, such as China, Italy, and Iran. institutions.
and Neck Surgery,
National University As of March 21, 2020, there have been 275 434 cases It is important to note that the donning and re-
Hospital, Singapore; confirmed globally, including 11 399 deaths.1 While the moval of PPE are sequential processes requiring proper
and Department of situation in China has improved, many countries con- training and mask fitting. In the event that enhanced PPE
Otolaryngology–Head
and Neck Surgery,
tinue to struggle with escalating case numbers and systems are used, such as PAPRs, it is crucial that the
National University of strained health care systems that are threatened to be gowning and degowning procedures are carefully fol-
Singapore, Singapore. overwhelmed by the pandemic. lowed, as improper removal may result in operator con-
One of the World Health Organization’s strategic pri- tamination. In our institutions, these processes are
Mark Li-Chung Khoo, orities is to limit human-to-human transmission, includ- closely supervised by dedicated infection control nurs-
MBBS
Department of ing secondary infections among health care workers, ing staff.
Otolaryngology–Head which was a key feature of the severe acute respiratory Second, the location of the surgery should be care-
and Neck Surgery, Tan syndrome (SARS) epidemic in 2003 and accounted for fully considered. In most instances during the SARS out-
Tock Seng Hospital,
one-fifth of all cases globally. Although SARS and break, open tracheostomy was performed at the bed-
Singapore; and
Amandela ENT Head COVID-19 are both transmitted by droplets, it is now clear side in the ICU in negative-pressure rooms.5-8 This
and Neck Centre, that the infectivity and extent of spread of COVID-19 will avoided unnecessary transport of patients and re-
Mount Elizabeth far exceed that of SARS. peated connection and disconnection of ventilatory cir-
Novena Specialist
Centre, Singapore.
Despite the lower mortality rate in COVID-19 cuits during transfer. Negative-pressure ICU rooms with
compared with SARS (2.3% vs 11%), a notable fraction adjacent anterooms are ideal, as anterooms help to mini-
Woei Shyang Loh, of infected people (9.8%-15.2%) require invasive mize the escape of contaminated air and also serve as
MBBS mechanical ventilation or extracorporeal membrane an additional barrier should there be inadvertent entry
Department of oxygenation.2-4 In an epidemic setting, intensive care of health care workers without appropriate PPE. Appro-
Otolaryngology–Head
and Neck Surgery, units (ICUs) will quickly reach capacity. Patients with pro- priate clinical judgment in identifying patients with high
National University longed ventilation may require tracheostomy to opti- likelihood of progressing to tracheostomy, such as those
Hospital, Singapore; mize weaning from ventilatory support. Unsurpris- with multiple comorbidities or chronic respiratory con-
and Department of
ingly, open tracheostomy was the most common surgical ditions, and matching them to the most appropriate ICU
Otolaryngology–Head
and Neck Surgery, procedure performed on infected patients during the room can help to reduce movement of patients within
National University of SARS outbreak.5,6 the ICU.
Singapore, Singapore. We performed a literature review of tracheosto- Bedside tracheostomies in the ICU should be well-
mies during the SARS epidemic consisting of a PubMed orchestrated events, meticulously planned and re-
search with the terms SARS and tracheostomy, from hearsed. Specific considerations include the limited
which 3 case series (Table) and 2 case reports were avail- space in the ICU room, suboptimal positioning of the pa-
Author Audio
able for review.5-9 Drawing from these experiences as tient, and the movement of essential equipment and sur-
Interview
well as our own contingency plans for SARS and gical instruments. We find that consolidating all neces-
COVID-19 outbreaks, we wish to highlight several im- sary equipment into a single sterile pack greatly simplifies
portant perioperative considerations when planning for the movement and preparatory process in the ICU room.
open tracheostomy in an infected patient during the In the event that tracheostomy is performed in the
COVID-19 pandemic. operating room (OR),9 it should ideally be in negative-
First, it cannot be overemphasized that barrier pre- pressure ORs in well-demarcated areas within the OR
Corresponding cautions are of critical importance. Standard personal complex with dedicated routes for patient transport. For
Author: Woei Shyang protective equipment (PPE) is essential. This com- specific considerations for reorganization of the OR com-
Loh, MBBS, prises an N95 mask, surgical cap, goggles, surgical gown, plex, we highly recommend the article by Chee and
Department of
Otolaryngology–Head
and gloves. Of the published cases of tracheostomies colleagues.5
and Neck Surgery, performed in Singapore, Hong Kong, and Canada dur- Third, the time of exposure to aerosolized secre-
National University of ing the SARS outbreak, in addition to standard PPE, all tions intraoperatively should be minimized. This may be
Singapore, Singapore,
5 health care institutions further used enhanced PPE achieved by (1) ensuring complete paralysis of the pa-
1E Kent Ridge Rd, Level
7, Singapore 119228 measures ranging from face shields to powered air- tient throughout the procedure to prevent coughing,
([email protected]). purifying respirators (PAPRs).5-9 The effectiveness of (2) stopping mechanical ventilation just before enter-

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 Opinion Viewpoint

Table. Case Series of Open Tracheostomies Performed During the Severe Acute Respiratory Syndrome (SARS) Outbreak

Case series
Characteristic Chee et al5 Tien et al6 Wei et al7
Institution Tan Tock Seng Hospital, Singapore Sunnybrook and Women’s College Queen Mary Hospital, Hong Kong
Health Sciences Centre, Toronto, SAR, China
Ontario, Canada
No. of tracheostomies performed 15 3 3
Barrier precautions during surgery Standard PPE,a shoe covers, and powered Standard PPEa and Stryker T4 Standard PPE,a shoe covers, and
air-purifying respirator system Protection System additional plastic face shield worn
outside goggles
Setting of surgery Negative-pressure room in ICU Negative-pressure room in ICU Negative-pressure room in ICU or
operating room
Intraoperative steps to reduce Complete paralysis of the patient, Complete paralysis of the patient, Complete paralysis of the patient,
aerosolization mechanical ventilation stopped before mechanical ventilation stopped mechanical ventilation stopped
tracheotomy, limited suction used during the before tracheotomy, no suction used before tracheotomy, no suction used
procedure, no specific avoidance of after trachea was entered, throughout the procedure, diathermy
diathermy other than during tracheotomyb diathermy avoided when possible avoided as much as possible
Surgical team members Single dedicated team performing all Senior attending trauma surgeon Single surgeon, 1 intensive care
tracheostomies: experienced surgeon, and most senior surgical staff specialist, and 1 standby medical or
experienced anesthesiologist, 1 scrub nurse, member available, attending ICU nursing staff member
and 1 surgical assistantb anesthetist, and no circulating nurse
or scrub nurse
b
Abbreviations: ICU, intensive care unit; PPE, personal protective equipment. Personal experience from Mark Li-Chung Khoo, MBBS (February 23, 2020),
a
Standard PPE consists of an N95 mask, surgical cap, goggles, surgical gown, surgical lead for tracheostomies at Tan Tock Seng Hospital during the SARS
and gloves. outbreak.

ing into the trachea via tracheotomy, and (3) reducing the use of suc- a scrub nurse to perform tracheostomies will allow familiarity and
tion during the procedure. If suction is used, this should be within a minimize setup time. Communication plans within the room need
closed system with a viral filter. to be preestablished because conversing through PPE and PAPRs
In this regard, percutaneous tracheostomy involves more ex- can be extremely difficult.
tensive airway manipulation, such as bronchoscopy and/or serial di- Fifth, the postprocedure waste disposal and decontamination
lations during trachea entry. Patients with high ventilatory settings of equipment need careful consideration to minimize contamina-
may also require repeated connection and disconnection from the tion of the environment. Whenever possible, disposable equip-
ventilatory circuit. These factors result in increased aerosolization ment should be used. Personnel who handle the decontamination
risks compared with open tracheostomy, in which entry into the tra- of surgical equipment should also be appropriately protected in stan-
chea is performed quickly with an incision and aerosolization risks dard PPE.
are mitigated with the aforementioned measures. As such, open tra- For health care workers who experienced the SARS epidemic,
cheostomies were favored over percutaneous tracheostomies dur- memories of the fear of contracting SARS still linger, along with rec-
ing the SARS outbreak.5,6 It is noteworthy that techniques for per- ollections of infection control precautions implemented then. Sev-
cutaneous tracheostomy have advanced since then. However, to our enteen years on, COVID-19 is a far more extensive challenge facing
knowledge, the considerations, safety, and PPE requirements for per- the global medical community. Yet, the key principles of meticu-
cutaneous tracheostomy in an infected, aerosolized setting have yet lous team-based planning among stakeholders and strict adher-
to be established in the literature. ence to barrier precautions remain. As the COVID-19 situation es-
Fourth, the experience of the team is clearly of importance to calates, so will the requirement for tracheostomies in patients with
minimize time spent in the contaminated room. Having a dedi- prolonged ventilation. It is thus crucial that surgical and ICU teams
cated, experienced team comprising a surgeon, an anesthetist, and are well prepared and ready to act when called upon.

ARTICLE INFORMATION 3. Huang C, Wang Y, Li X, et al. Clinical features of patients with severe acute respiratory syndrome
Published Online: March 31, 2020. patients infected with 2019 novel coronavirus in (SARS). Can J Surg. 2005;48(1):71-74.
doi:10.1001/jamaoto.2020.0764 Wuhan, China. Lancet. 2020;395(10223):497-506. 7. Wei WI, Tuen HH, Ng RW, Lam LK. Safe
doi:10.1016/S0140-6736(20)30183-5 tracheostomy for patients with severe acute
Conflict of Interest Disclosures: None reported.
4. Wang D, Hu B, Hu C, et al. Clinical characteristics respiratory syndrome. Laryngoscope. 2003;113(10):
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