Dr. Matthew Rochefort and Dr. Anthony Coppolino prepared to perform a bedside percutaneous tracheostomy in a COVID+ patient.
How does one determine when to employ tracheotomy in COVID-19 patients requiring prolonged mechanical ventilation? It’s difficult to say given what relatively little we know about the disease at this point. Stephanie L. Nitzschke, MD, an acute care surgeon, trauma surgeon and surgical intensivist, is one of the clinicians developing guidelines on tracheotomy timing at Brigham and Women’s Hospital.
Dr. Nitzschke said that in order to balance the safety of patients and health care workers, the Brigham is delaying consideration of tracheotomy until 21 days after a positive test for COVID-19. But she stressed that all protocols related to this disease are subject to change.
“Like everyone else, I’m still learning about COVID-19, the patients, the disease trajectory for different patient populations,” Dr. Nitzschke said. “We’ve written our guidelines knowing they will likely change based on our clinical experience, and I think that’s probably similar to what others around the country are thinking in their approach to timing of tracheotomy.”
Concerns About Early Tracheotomy and COVID-19
Traditionally, early tracheotomy has been a common approach in patients who need prolonged mechanical ventilation. Recently, some centers in New York City have found it has improved management of COVID-19 patients. To date, this has not been the case at the Brigham.
Dr. Nitzschke and Raphael Bueno, MD, chief of the Brigham’s Division of Thoracic Surgery, said that a unique set of factors associated with COVID-19 patients may make it inadvisable to conduct tracheotomy early in the disease process. In particular:
- Early proning of COVID-19 patients with severe acute respiratory distress syndrome, which is done in many hospitals, can make tracheotomy positioning difficult. “Also, it would be a catastrophic situation if a new trach tube were to fall out and the patient lost their airway while they were being flipped over [into supine position],” Dr. Nitzschke said.
- Since these patients usually need a great deal of ventilator support and their respiratory status is tenuous, doing a tracheotomy at certain stages of their disease course would be dangerous. “At the point where the endotracheal tube is removed and the tracheotomy tube goes in, the patient’s not getting the normal title volumes or normal support that they had been getting from the ventilator,” Dr. Nitzschke explained. “So some physiologic criteria must be met before it’s considered safe to proceed with the procedure.”
- As an aerosol-generating procedure, tracheotomy presents significant risk to providers. “The COVID virus lives in the airway and pharyngeal mucosa, so the concern is about contamination of the environment of the patient and the health care worker during the tracheotomy or as you open and close the tube,” Dr. Bueno said.
Considerations like these have convinced the Brigham to put off tracheotomy in ventilated COVID-19 patients until at least 21 days when possible. However, Dr. Nitzschke said the decision on timing ultimately is based on the patient’s individual circumstances and the risk of exposure to providers.
She added that tracheotomy is ideally done in a negative-pressure room to minimize the spread of aerosolized droplets. Bedside tracheotomy can help prevent viral exposure as well, though doctors should also account for where they feel most comfortable performing the procedure (which may be in an operating room).
Collaboration in COVID-19 Care
Collaboration at the Brigham is a key element in managing the influx of COVID-19 patients. Dr. Nitzschke is leading a multidisciplinary team that is writing guidelines for minimizing viral exposure to health care workers during tracheotomy. Dr. Bueno noted that a team of five dedicated thoracic surgeons is performing the procedure on COVID-19 patients and working in concert with ICU teams, pulmonologists and critical care doctors in caring for these patients.
“Everything we’re doing is collaborative and based on ever-changing information, both from our hospital and others,” Dr. Bueno concluded. “Our shared goal is to optimize patient safety and outcomes as well as everyone else’s safety, keeping in mind that we’re learning about this viral infection as we speak.”