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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 73-77

Surgical tracheostomies in SARS-CoV-2-positive patients: The otolaryngologists' perspective


1 Department of Otolaryngology Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Otorhinolaryngology and Head and Neck Surgery, All India Institute of Medical Sciences, Bibinagar, Telangana, India

Date of Submission24-May-2021
Date of Acceptance28-Aug-2021
Date of Web Publication09-Dec-2021

Correspondence Address:
Dr. Neemu Hage
Department of Otorhinolaryngology, All India Institute of Medical Sciences, Bibinagar - 508 126, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aiao.aiao_13_21

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  Abstract 


Aims: Operating under personal protective equipment (PPE) has become the new norm. This study aims at assessing how the ear, nose, and throat surgeons coped with the changes, with tracheostomy as the procedure of interest. Materials and Methods: Chart review of 30 patients who underwent tracheostomy from March 23, 2020, to December 31, 2020, was done. A questionnaire was given to the senior residents in charge of the procedures after each tracheostomy and their experience on the various aspects of the procedure. The responses were compiled and various factors affecting the surgical experience and outcome were analyzed. Results: Vast majority of patients underwent tracheostomy for prolonged intubation (90%), which made preoperative assessment of cases difficult. The average time was 12.33 ± 2.54 min. Delay in procedures and difficulties of operating under PPEs made COVID-positive tracheostomy challenging. Conclusions: It is possible to perform aerosol-generating procedures safely with adequate protective gears. Tracheostomy in COVID-19 patients needs to be after careful considerations by intensive care specialists and streamlining of various logistical factors is very essential for effective utilization of Operation theatre and surgeons' time.

Keywords: COVID-19, pandemic otolaryngology, personal protective equipment, tracheostomy


How to cite this article:
Muraleedharan M, Panda NK, Patro SK, Sharma V, Hage N. Surgical tracheostomies in SARS-CoV-2-positive patients: The otolaryngologists' perspective. Ann Indian Acad Otorhinolaryngol Head Neck Surg 2021;5:73-7

How to cite this URL:
Muraleedharan M, Panda NK, Patro SK, Sharma V, Hage N. Surgical tracheostomies in SARS-CoV-2-positive patients: The otolaryngologists' perspective. Ann Indian Acad Otorhinolaryngol Head Neck Surg [serial online] 2021 [cited 2022 Jan 18];5:73-7. Available from: https://www.aiaohns.in/text.asp?2021/5/2/73/332061




  Introduction Top


It has been more than a year since the world has been forced to live with an unseen but extraordinarily resilient foe in the form of COVID-19 virus. The health-care sector has undergone a paradigm shift. Aerosols and protection from them had been a hot topic of discussion and focus of research in the medical circles.

Surgical tracheostomy is a basic lifesaving tool in an otolaryngologist's armamentarium. However, it is no doubt that the procedure is second to none when it comes to the amount and spread of infective aerosols. It is, thus, of no surprise that multiple bodies and professional forums have come up with guidelines regarding the safe conduct of tracheostomies starting from the initial days of pandemic. The physical and psychological effects of these changes are enormous. Hence, well-being of the surgeons working under these challenging times and the safety of the surgical staff require a closer examination directing validation and improvement of current practices. This would help us in improving the present system and also keep ourselves well equipped for such exigencies in future.


  Materials and Methods Top


Charts of patients who have undergone tracheostomy in a tertiary referral center between the period of March 23, 2020, and December 31, 2020, were reviewed. There were 30 COVID-19-positive surgical tracheostomies which were included for the purpose of the study. All the cases were COVID-19 positive by real-time polymerase chain reaction done within 48 h of performing the procedure and happened in the COVID-19 OT present in the hospital block which served as a specialized and isolated block for admission and treatment of the positive patients.

A questionnaire was given to the senior residents in charge of the procedures after each tracheostomy and their experience on the various aspects of the procedure – including the patient and disease factors, logistical issues, surgical time, comfort of operating with personal protective equipment (PPE), the confidence as a surgeon, and complications associated. The responses were compiled and various factors affecting the surgical experience and outcome were analyzed.


  Results Top


Various logistical difficulties were faced during the procedure which makes the tracheostomies during COVID-19 a different ball game. Due to the restrictions associated with visiting hospital blocked earmarked for COVID-19 cases, detailed preoperative assessment of the patients was not possible in 27/30 cases as these cases were managed in the critical care department of the COVID-19 block and the surgeon had to depend on the critical care physicians managing the intensive care units (ICUs) (90%). The three cases of laryngotracheal trauma, stridor, and faciomaxillary trauma could be analyzed and a plan was made by the surgeon preoperatively [Table 1].
Table 1: Patient and disease factors (n=30)

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In a usual hospital setup, the time spent in the operating room (OR) doing the procedure is usually considered as the “operating time.” This might be because of the fact that surgeons could involve themselves in other activities such as academic sessions, postoperative review of previously operated patients, or even some quality time relaxing while a patient is being shifted and being prepped for surgery. The COVID-19 tracheostomies required the surgeon to be totally dedicated for the procedure after donning, with no other activity, even discussions over telephones being restricted in view of strict infection control protocols. Up to 60% (n = 18) of cases had the surgeon waiting for more than 30 min in the OR before the first incision could be made. The pre-incision waiting period and delay were negligible in only seven cases (7/30, 23.3%). The most common cause for delay was the unavailability of support staff required for shifting the patient from wards/ICUs to the OR (17/23, 73.9%). Delay in procuring the oxygen cylinders required for the shifting and miscommunication between the teams in OR and ward were the other causes (2 each, 8.6%). There were instances of procedures being delayed due to technical issues in the OT and other procedures such as central venous catheter insertion being performed before the procedure (1 each, 4.34%) [Table 2].
Table 2: Logistical difficulties faced: COVID-19 tracheostomy

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In an overwhelming majority of the procedures (60%, n = 18), surgeons used both face shields and goggles for eye/face protection. In 8 cases (26.7%), only a face shield was used, while in 4 (13.3%), only goggles were used [Table 3].
Table 3: Use of personal protective equipment and COVID-19 tracheostomy

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The question on the gear for eye protection attains significance as, during the initial days, restriction of vision due to the various layers of PPE and fogging of goggles and face shield was a crippling difficulty faced by surgeons. Surgeons performing tracheostomy complained of at least moderate visibility issues in 80% (n = 24) of the cases. Luckily, there were no cases of complications happening because of the visual difficulty.

Although the extent visual difficulties did not affect the surgical outcome, in 100% of the occasions, the surgeons complained of facing some degree of visual difficulties along with difficulties in communicating with the anesthetists/assistant surgeons/scrub nurses. About 66.7% (n = 20) complained of physical restriction due to the PPE affecting their efficiency. Suffocation (46.7%, n = 14) and pain over the nose due to the masks (43.3%, n = 13) were fairly common complaints too. Headache (30%, n = 9) and rhinorrhea (20%, n = 6) also made operating difficult. In 7/30 cases (23.3%), surgeons felt that the reduced tactile sensation due to multiple layers of gloves was bad enough to cause difficulties in case the procedure went difficult technically [Table 3].

The psychological effect of operating under PPE, with a looming threat of extensive aerosolization of respiratory secretions and possible cross-infection, is also worth looking at. After 33.3% of procedures (n = 10), the surgeons recorded that they felt physically vulnerable at some point after donning. While none of the surgeons were diffident about the procedure they were about to perform, 11/30 cases (36.7%) had them feeling less confident because of the unavailability of easy back up due to the severe restrictions in communication with the outer world after donning and the time-consuming steps to be followed in case someone has to come in for help in case of procedure-related technical difficulties.

An elective surgical tracheostomy usually takes <10 min in experienced hands. While 16/30 (53.3%) of the procedures could be completed in <10 min, in 46.7% of cases, it took more than 10 min (n = 14). The mean operating time for COVID-19-positive tracheostomy was 12.33 ± 2.54 min. Only visual difficulty showed a statistically significant association with increased operating time (P = 0.009) [Table 4].
Table 4: Factors affecting operating time

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  Discussion Top


It has been a century since the world has faced a pandemic of this scale, thus leaving the whole of humanity underprepared and clueless about the way forward. Life as humans knew it changed almost overnight around the globe. The medical field had to fight the war in two fronts. While the novelty of COVID-19 and its management was overwhelming the system, equally tough was keeping the regular services running. “'Found wanting' refers to the lack of all that was needed or expected, which in this case as mentioned are- the workforce, finances and infrastructure.”, with “Workforce, finances, and infrastructure – everything was found wanting.”

Elective surgeries almost totally stopped in the initial days. Emergency surgeries thus provided the chances to get used to the new normal and to try out operating in the protective gears and improvising. Tracheostomies played a big role in making the ear, nose, and throat surgeons at the institute getting used to operating with personal protective instruments and under the constraints which the pandemic had put on staff and equipment. Tracheostomy as a procedure is short and straightforward enough and thus served well the role of “surgeries of initiation” into a pandemic world. However, it is a highly aerosol-generating procedure and thus demands the caution of the highest order to prevent the surgical team getting infected. Tracheostomy thus acted as the “representative” surgery of the pandemic times and the analysis of the experience of performing it can be a surrogate marker of the trials and tribulations of performing such surgeries. The insights can thus help us improve and improvise our training and be better prepared for such contingencies in future.

Recommendations for COVID-19-positive tracheostomy

The importance of tracheostomy and the challenges it poses were identified quite early on in the pandemic as evident from the various guidelines which came out in the initial days of the pandemic itself. Many of the suggestions were intuitively associated with reducing the aerosol formation.

ENT UK was one of the earliest bodies to come up with tracheostomy recommendations for the same.[1] They suggested the use of only cuffed nonfenestrated tube. First tube changes were not recommended before 10 days or till the patient turns negative and subsequently after 30 days. The OR should have the least number of people as possible and the senior most of the members should preferably be doing the procedure so as to reduce the time and chances of complications. They also put forward a suggestion to avoid changing the dressings after tracheostomy unless there were frank signs of infection. Systemic reviews of international guidelines also put forward the need for a specific airway team for tracheostomies so as to reduce the exposure and improve the expertise.[2] This was evident from our study too as the difficulties as recorded in the questionnaire came down from the first tracheotomy to the 30th one. Furthermore, individual surgeons felt that every subsequent tracheostomy felt easier as they got used to the physical discomforts caused by the protective gears.

The “apnoeic approach” was put forward to reduce the aerosolization while making the tracheal opening.[1],[3] This involves pausing the mechanical ventilation before giving the incision. The whole process of making the incision and putting a tracheostomy tube would take <2 min in experienced hands. In case there is an alarming fall in saturation, it was suggested to cover the stoma with gauze, ventilate, and then go forward with the process. In a slight modification of this approach, before making the opening, the ventilation can be stopped, cuff deflated followed by advancing the tube. The cuff is then inflated and the patient ventilated again. A tracheal stoma is then made after stopping the ventilation.[1] This has the advantage of faster and more effective ventilation lest the saturation falls during the process of making tracheal window.

The use of electrocautery over the skin and also after opening the trachea is also to be avoided in an attempt to bring down aerosol generation.[2],[4]

Perioperative considerations

The timing of converting an orotracheal tube into a tracheostomy tube has always been a matter of debate. Early tracheostomy has been associated with lesser chances of development of subglottic stenosis and better chances at weaning off the ventilatory support. On the other hand, the sequelae of tracheostomy in the form of decannulation protocols and phonatory and swallowing difficulties make it a difficult decision to make.[5]

In a study of the preliminary results of tracheostomy after COVID intubation, Bartier et al. concluded that almost all were performed for ventilation withdrawal. They found that the rate of laryngotracheal sequelae was high, especially in late tracheostomies. The average period of endotracheal intubation before tracheostomy was 17 days.[6] A similar study came up with an average time from intubation of 15 days.[7] Tang et al., on the other hand, found that the only variable significantly associated with mortality was the timing of tracheostomy. After adjusting for the comorbidities and the disease state, tracheostomies within 14 days were associated with higher mortality.[8]

Takhar et al. recommend doing tracheostomy after 14 days of intubation. Every decision has to be individualized and reviewed by two intensive care consultants and deemed necessary. The PEEP should be <10 cm H20 and FiO2 <50%.[9] This also makes sure that the patient can tolerate the period of apnea associated with making the tracheal stoma and inserting the tracheostomy tube. It is also preferable to deter tracheostomy if the prognosis is not clear. A deep neuromuscular blockade is preferred to prevent any movement or cough of the patient during the procedure and subsequent aerosolization.[10]

Percutaneous versus surgical tracheostomy

Percutaneous tracheostomy is intuitively a better option during the pandemic. The logistical difficulties we faced were mostly associated with shifting the patient to the OR. The percutaneous method helps in overcoming this difficulty.

Studies have shown that there were no differences in patient outcome or surgeon safety.[4] The reduction of surgical time was found to be a significant advantage. However, the chances of aerosolization and cross-contamination preclude the use of bronchoscopic assistance. This, on the other hand, increases the risk of tracheal injury/injury to cricoid and associated sequelae.

Outcomes of COVID-positive tracheostomy

The data and studies are still coming in concerning patient outcomes and surgeon safety following COVID-positive tracheostomies.

Angamuthu et al. studied the transmission of infection among the health-care workers performing surgical tracheostomies.[7] Sixty-seven percent of the cases were from intensive care, while the mean age was 58 years (90% and 48 years respectively in our series). The positivity rate among surgeons performing tracheostomy was 18.6%. None of the surgeons turned positive performing tracheostomy in our institute.

Protective gears – The double-edged swords

The use of full personal protective instruments is mandated unanimously by almost all the guidelines for COVID-19-positive patient tracheostomies.[1],[2] This includes overalls, goggles with or without face shields, N-95 or Powered air-purifying respirator, and double gloves.

The use of PPE is associated with a plethora of problems. Headache, sweating, dehydration, reduced vision due to fogging, dermatological issues, cramps, and dizziness have been associated with the protective gears.[11] Masks, especially PPARs, have been found to increase the hearing thresholds by 40 dBs and speech discrimination dropped to 48%. If not this drastic, N-95 respirators have also been shown to reduce speech intelligibility by 17%.[12] The problems caused by fogging also make operating difficult.

Attempts at making the personal protective gears more ergonomic are very essential as we are in for a long haul and as newer infectious diseases emerge, operating in full protective gears may become commonplace even for routine cases. Incorporating the use of PPE into surgical training needs to be considered seriously.


  Conclusions Top


Streamlining of hospital services and improved interdepartmental co-operation can help in bringing down the surgical time associated with the surgical tracheostomy and make it a safe and more definitive way of securing the airway during the pandemic. The indications need to be carefully evaluated by a team approach. With full protective gears and by following the various recommendations for safe tracheostomy, it is possible to carry out tracheostomies without putting the health of surgeons at stake.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
COVID-19 Tracheostomy: Framework for open tracheostomy in COVID-19 patients [Internet]. ENT UK; 2020. Available from: https://www.entuk.org/sites/default/files/COVID%20tracheostomy%20guidance%20-%206%20April%202020%20update.pdf. [Last accessed on 2021 Oct 20].  Back to cited text no. 1
    
2.
Chiesa-Estomba CM, Lechien JR, Calvo-Henríquez C, Fakhry N, Karkos PD, Peer S, et al. Systematic review of international guidelines for tracheostomy in COVID-19 patients. Oral Oncol 2020;108:104844.  Back to cited text no. 2
    
3.
Papathanakos G, Andrianopoulos I, Zikou X, Papathanasiou A, Koulouras V. Tracheostomy in the COVID-19 era: The apneic approach. Otolaryngol Head Neck Surg 2020;163:1283-4.  Back to cited text no. 3
    
4.
Riestra-Ayora J, Yanes-Diaz J, Penuelas O, Molina-Quiros C, Sanz-Fernández R, Martin-Sanz E. Safety and prognosis in percutaneous vs surgical tracheostomy in 27 patients with COVID-19. Otolaryngol Head Neck Surg 2020;163:462-4.  Back to cited text no. 4
    
5.
Mcwhorter AJ. Tracheotomy : Timing and techniques. Curr Opin Otolaryngol Head Neck Surg 2003;11:473-9.  Back to cited text no. 5
    
6.
Bartier S, La Croix C, Evrard D, Hervochon R, Laccourreye O, Gasne C, et al. Tracheostomies after SARS-CoV-2 intubation, performed by academic otorhinolaryngologists in the Paris area of France: Preliminary results. Eur Ann Otorhinolaryngol Head Neck Dis 2021:S1879-7296(21)00049-1. Online ahead of print.  Back to cited text no. 6
    
7.
Angamuthu N, Geraldine Gagasa E, Baker D, Tsui J, Evan D'Souza R. Transmission of infection among health care personnel performing surgical tracheostomies on COVID-19 patients. Surgeon 2021;19:e304-e309.  Back to cited text no. 7
    
8.
Tang Y, Wu Y, Zhu F, Yang X, Huang C, Hou G, et al. Tracheostomy in 80 COVID-19 patients: A multicenter, retrospective, observational study. Front Med (Lausanne) 2020;7:615845.  Back to cited text no. 8
    
9.
Takhar A, Walker A, Tricklebank S, Wyncoll D, Hart N, Jacob T, et al. Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic. Eur Arch Otorhinolaryngol 2020;277:2173-84.  Back to cited text no. 9
    
10.
Gosling AF, Bose S, Gomez E, Parikh M, Cook C, Sarge T, et al. Perioperative considerations for tracheostomies in the era of COVID-19. Anesth Analg 2020;131:378-86.  Back to cited text no. 10
    
11.
Jose S, Cyriac MC, Dhandapani M. Health problems and skin damages caused by personal protective equipment: Experience of frontline nurses caring for critical COVID-19 patients in Intensive Care Units. Indian J Crit Care Med 2021;25:134-9.  Back to cited text no. 11
    
12.
Kempfle JS, Panda A, Hottin M, Vinik K, Kozin ED, Ito CJ, et al. Effect of powered air-purifying respirators on speech recognition among health care workers. Otolaryngol Head Neck Surg 2021;164:87-90.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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