Journal Pre-proof

COVID-19: Team preparation and approach to tracheostomy

Cleveland Clinic COVID-19 Tracheostomy Working Group, Alejandro C. Bribriesco,

MD, Monisha Sudarshan, MD MPH, Colin Gillespie, MD, Paul Bryson, MD, Brandon
Hopkins, MD, Donna Tanner, RRT-ACCS, Siva Raja, MD PhD, Usman Ahmad, MD,
Daniel Raymond, MD, Sudish C. Murthy, MD PhD

PII: S2666-2507(20)30718-5
DOI: https://doi.org/10.1016/j.xjtc.2020.11.023
Reference: XJTC 473

To appear in: JTCVS Techniques

Received Date: 19 November 2020

Accepted Date: 19 November 2020

Please cite this article as: Cleveland Clinic COVID-19 Tracheostomy Working Group, Bribriesco AC,
Sudarshan M, Gillespie C, Bryson P, Hopkins B, Tanner D, Raja S, Ahmad U, Raymond D, Murthy SC,
COVID-19: Team preparation and approach to tracheostomy, JTCVS Techniques (2021), doi: https://
doi.org/10.1016/j.xjtc.2020.11.023.

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Copyright © 2020 The Authors. Published by Elsevier Inc. on behalf of The American Association for
Thoracic Surgery
1 COVID-19: Team preparation and approach to tracheostomy
2 Guidelines & Recommendations from
3 Cleveland Clinic COVID-19 Tracheostomy Working Group
4 Alejandro C. Bribriesco1* MD, Monisha Sudarshan1* MD MPH, Colin Gillespie2 MD, Paul
5 Bryson3 MD, Brandon Hopkins3 MD, Donna Tanner4 RRT-ACCS, Siva Raja1 MD PhD, Usman
6 Ahmad1 MD, Daniel Raymond1 MD, Sudish C. Murthy1 MD PhD
7

8 Author Affiliations:
1
9 Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute,

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10 Cleveland Clinic

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11 Section of Interventional Pulmonology, Respiratory Institute, Cleveland Clinic
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12 Department of Otolaryngology, Head and Neck Institute, Cleveland Clinic
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13 Department of Intensive Care and Resuscitation, Anesthesia Institute, Cleveland Clinic
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14 *Both authors contributed equally
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15 Justification for more than 4 authors: Multidisciplinary team effort involving representatives
16 from key stakeholders of different specialties at Cleveland Clinic contributing to creation of
17 guidelines, recommendations and manuscript.
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19 Key words: COVID-19, Tracheostomy, Simulation, SARS-CoV-2

20 Conflicts of interest: Siva Raja is a consultant for Smiths Medical
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21 Source of Funding: None

22

23 Corresponding Author
24 Alejandro C. Bribriesco, MD
25 Cleveland Clinic; Department of Thoracic and Cardiovascular Surgery
26 9500 Euclid Ave / Mail Stop J4-1
27 Cleveland, OH 44195
28 Email: bribria@ccf.org
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30 Word Count: 747/ 750

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31
32 Central Picture

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33
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34 Central Picture Legend

35 Multidisciplinary approach to devising a protocol for tracheostomy in COVID-19 patients
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37 Central Message
38 Tracheostomy in COVID-19 patients is a necessary but high exposure risk procedure. A
39 multidisciplinary approach with use of simulation is invaluable for development of a safe and
40 efficient protocol.
41

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42 Introduction

43 Tracheostomy has become a common surgical intervention performed on patients with severe

44 COVID-19 as mechanical ventilation is required in 10-15% of patients 1. High risk of aerosolization

45 during the intervention is a serious concern for personnel involved both during and after tracheostomy

46 placement. We present our experience developing a multidisciplinary algorithm to tracheostomy for

47 COVID-19 respiratory failure. We recognize that this process will vary based on institutional policy and

48 will evolve with further data on transmission and respiratory consequences of COVID-19.

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49 The role and benefits of multidisciplinary team and simulation

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As the COVID-19 crisis unfolded, virtual meetings were held to develop a unified institutional

approach for tracheostomy with multidisciplinary stakeholders: Thoracic Surgery, Otolaryngology,

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52 Pulmonology, Critical Care, Anesthesiology and Respiratory Therapy. Discussions centered on
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53 indications, contraindications, timeline to tracheostomy and special procedural considerations

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54 (Supplemental Table 1).

55 Next, we performed high fidelity tracheostomy simulation in our lab to rehearse and fine-tune
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56 procedural details including proper donning and doffing of PPE (PAPRs). Based on our experience and
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57 aligned with other groups2, we strongly recommend simulation when devising a COVID-19 tracheostomy

58 protocol (Figure 1).

59 Special considerations for tracheostomy in COVID-19 patients

60 A dedicated multidisciplinary team evaluates the patient and employs a standardized pre-

61 tracheostomy checklist (Supplemental Table 2). As there is no current evidence to suggest early

62 tracheostomy (<7 days) or delayed tracheostomy (>2-3 weeks) is of particular benefit in this population,

63 we consider tracheostomy a minimum of 7 days after intubation and preferably after 10-14 days in order

64 to enter the convalescent phase of the disease, gain the benefits of the procedure and permit time for

65 prognostication of overall recovery. We do not advocate waiting until a repeat negative COVID-19 test,

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66 as this could unnecessarily prolong time to tracheostomy given possibility of persistently positive test

67 (one series3 with median 20 days, longest 37 days) which likely represents continued non-infectious viral

68 shedding.4 In addition, we always advocate for maximum available PPE regardless of a negative

69 COVID-19 tests to protect health care workers (HCWs).

70 Our approach to tracheostomy in COVID-19 patients

71 Location and Tracheostomy Approach

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72 Our default location is bedside in ICU to minimize patient transport and exposure risk with the

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73 operating room utilized for particularly high risk cases. For bedside tracheostomies, an enclosed negative

74 pressure ICU room is preferred if available and logistically feasible. Our team favors percutaneous over
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75 the open technique with deference to operator preference and patient anatomy.
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76 Tracheotomy details
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77 The type of tracheostomy appliance is largely based on the institutional preference and available
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78 supply. Our group favors an appliance without inner cannula to mitigate exposure risk of inner cannula
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79 exchange. Step by step details of the tracheostomy procedure with modifications to minimize

80 aersolization are listed in Table 1.

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81 In COVID-19 patients, we arrange all ventilator control and intravenous lines outside the room so

82 care can be delivered without repeatedly entering the space. The sterile tracheostomy tray is prepared out

83 of the enclosed room.

84 A moist Kerlix roll is packed in the oropharynx to minimize aerosolization as the endotracheal

85 tube is withdrawn into the subglottis. This obviates the need for a protective box/tent. A disposable

86 bronchoscope is used to avoid exposure during cleaning and processing of a soiled bronchoscope.

87 The endotracheal tube is pulled back with cuff inflated into the subglottic position. Further

88 retraction can be facilitated by removing the minimal necessary amount of air from the cuff. After

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 89 guidewire insertion, we perform the remainder of the procedure under apnea and attempt to limit

90 procedural time to 60-90 seconds.

91 Conclusion

92 Performing tracheostomy in the COVID-19 era exemplifies how a previously straight-forward

93 clinical decision for an essential-elective procedure has been reimagined when the safety of more than

94 just the patient must be considered. The balance of anticipated benefits and risks for major stakeholders

95 (patient, health care system and HCW) will vary between different locations during various stages of the

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96 COVID-19 pandemic as evidenced by a multitude of available guidelines 5 (Supplemental Table 3). A

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97 multi-disciplinary team is essential in developing a center-specific protocol for COVID-19 tracheostomy

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with an indispensable role for simulation and team rehearsal. This activity allows providers who may not
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99 have previously worked together to pool shared experience and knowledge to develop a tailored, efficient
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100 and safe protocol. Following this protocol, our team has performed more than 20 percutaneous

101 tracheostomies (including 4 patients on ECMO) in the ICU without untoward patient events or evidence
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102 of COVID-19 transmission to HCWs. It is through synergistic collaboration that the optimal delivery of
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103 healthcare can be safely achieved during this continued pandemic.

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104

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105

106 References
107 1. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease
108 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese
109 Center for Disease Control and Prevention. JAMA. 2020.
110 2. LoSavio PS, Eggerstedt M, Tajudeen BA, et al. Rapid implementation of COVID-19 tracheostomy
111 simulation training to increase surgeon safety and confidence. Am J Otolaryngol.
112 2020;41:102574.
113 3. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with
114 COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395:1054-1062.
115 4. Sethuraman N, Jeremiah SS, Ryo A. Interpreting Diagnostic Tests for SARS-CoV-2. JAMA. 2020.
116 5. Chiesa-Estomba CM, Lechien JR, Calvo-Henriquez C, et al. Systematic review of international

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117 guidelines for tracheostomy in COVID-19 patients. Oral Oncol. 2020;108:104844.

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120

121 Tables and Figures

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123 Table 1. Step by Step Approach to Percutaneous Tracheostomy in COVID-19 patients
Heath care workers (HCW) involved

Inside room: 2-3 HCW (to be limited as much as possible)

Bronchoscopy/Airway: Staff provider (Thoracic surgery, IP, ICU, or ENT)

Operator/Tracheostomy Insertion: Staff Provider (Thoracic surgery, IP or ENT)

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Outside room: as needed

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ICU Respiratory Therapist (ventilator located outside room)
• Assist with ventilator including period of apnea
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Bedside / ICU RN (IV pumps outside room)
• Administer ordered/prescribed sedation and paralytics
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• Adjust vasoactive drips as necessary and/or directed
Intensivist
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• Ready to donn PPE and enter for assistance if required

• Additional airway provider
• Additional medications for sedation, paralysis and hemodynamic support
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***Team members must coordinate on key signs to convey the following (since verbal communication
limited with PAPRs and two members will be inside room)
• Ventilator on (thumbs up)
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• Ventilator off (thumbs down)

• Need for additional help (wave in)
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Key steps of bedside percutaneous tracheostomy

1. Patient deeply sedated and paralyzed for procedure
• Recommend initiating sedation process (under direction of Intensivist) prior to
tracheostomy team entering room
• Ensure deep sedation prior to administrating paralysis
• Administer paralysis at least 3-5 min prior to insertion of bronchoscope to allow effect
2. Pre-oxygenate with 100% FiO2 for a minimum of 3 minutes
3. Preparation of equipment outside room
• Tracheostomy tray under sterile condition outside the patient’s room
• Bronchoscopy cart with disposable bronch, ensure proper functioning
• Shoulder roll for neck extension
4. Donn PPE: (1) PAPRs if available or N95 (not both), (2) Full face shield/visor, (3) Hair covers,
shoe covers, (4) Disposable gown and (5) Double gloving
5. Both Operator and Bronchoscopist enter room

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 6. Preparation inside room
• Operator scrubs in and preps and drapes area
• Bronchoscopist positions patient neck in optimally in extension with roll support and
packs oropharynx with moist Kerlix roll (not gauze squares to avoid retention)
7. Visualized ETT withdrawal using controlled deflation of cuff over bronchoscope to subglottic
position
• Removal of minimal amount of air from cuff may likely be required to withdraw
ETT to level needed for appropriate visualization
8. Communication through visual cue that ventilation needs to be paused/apnea time starts
9. Insertion of angiocatheter once 1st tracheal ring identified
• Insertion between 1st-2nd or 2nd-3rd tracheal rings
• Serial dilation (Moist gauze available on field to cover neck stoma as needed)

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• Insertion of tracheostomy
10. With tracheostomy in place immediately insert bronchoscopy into tracheostomy for

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confirmation that tip is above carina and no significant bleeding
11. Remove bronchoscope from tracheostomy immediately connect HME + in-line suctioning to
tracheostomy -p
12. Connect to ventilator. Hand signal to start ventilation
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• Estimated apnea time <1min
13. After satisfied no issues with procedure remove endotracheal tube and place immediately
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into biohazard bag

14. Secure tracheostomy with sutures and strap per routine
15. Proper Doffing of PPE before existing
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124
125 *PPE: personal protective equipment
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126 *IP: Interventional Pulmonology

127 *ICU: Intensive Care Unit
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128 *ENT: Ear, Nose and Throat

129 *RN: Registered Nurse
130 *HME: Heat and Moisture Exchanger
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139
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141 Figure 1. Approaching tracheostomy insertion in the COVID-19 patient

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144 Videos
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146 Video 1 – COVID-19 Tracheostomy Simulation
147 Narrated and annotated video demonstrating our step-by-step approach to performing percutaneous
148 tracheostomy in COVD-19 patients using a high fidelity simulation model. (Length of movie: 9 min 9
149 sec)

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Table 1. Step by Step Approach to Percutaneous Tracheostomy in COVID-19 patients

Heath care workers (HCW) involved

Inside room: 2-3 HCW (to be limited as much as possible)

Bronchoscopy/Airway: Staff provider (Thoracic surgery, IP, ICU, or ENT)

Operator/Tracheostomy Insertion: Staff Provider (Thoracic surgery, IP or ENT)

Outside room: as needed

ICU Respiratory Therapist (ventilator located outside room)

• Assist with ventilator including period of apnea

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Bedside / ICU RN (IV pumps outside room)
• Administer ordered/prescribed sedation and paralytics

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• Adjust vasoactive drips as necessary and/or directed
Intensivist
• Ready to donn PPE and enter for assistance if required
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• Additional airway provider
• Additional medications for sedation, paralysis and hemodynamic support
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***Team members must coordinate on key signs to convey the following (since verbal communication
limited with PAPRs and two members will be inside room)
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• Ventilator on (thumbs up)

• Ventilator off (thumbs down)
• Need for additional help (wave in)
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Key steps of bedside percutaneous tracheostomy

1. Patient deeply sedated and paralyzed for procedure
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• Recommend initiating sedation process (under direction of Intensivist) prior to

tracheostomy team entering room
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• Ensure deep sedation prior to administrating paralysis

• Administer paralysis at least 3-5 min prior to insertion of bronchoscope to allow effect
2. Pre-oxygenate with 100% FiO2 for a minimum of 3 minutes
3. Preparation of equipment outside room
• Tracheostomy tray under sterile condition outside the patient’s room
• Bronchoscopy cart with disposable bronch, ensure proper functioning
• Shoulder roll for neck extension
4. Donn PPE: (1) PAPRs if available or N95 (not both), (2) Full face shield/visor, (3) Hair covers,
shoe covers, (4) Disposable gown and (5) Double gloving
5. Both Operator and Bronchoscopist enter room
6. Preparation inside room
• Operator scrubs in and preps and drapes area
• Bronchoscopist positions patient neck in optimally in extension with roll support and
packs oropharynx with moist Kerlix roll (not gauze squares to avoid retention)
 7. Visualized ETT withdrawal using controlled deflation of cuff over bronchoscope to subglottic
position
• Removal of minimal amount of air from cuff may likely be required to withdraw
ETT to level needed for appropriate visualization
8. Communication through visual cue that ventilation needs to be paused/apnea time starts
9. Insertion of angiocatheter once 1st tracheal ring identified
• Insertion between 1st-2nd or 2nd-3rd tracheal rings
• Serial dilation (Moist gauze available on field to cover neck stoma as needed)
• Insertion of tracheostomy
10. With tracheostomy in place immediately insert bronchoscopy into tracheostomy for
confirmation that tip is above carina and no significant bleeding
11. Remove bronchoscope from tracheostomy immediately connect HME + in-line suctioning to

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tracheostomy
12. Connect to ventilator. Hand signal to start ventilation

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• Estimated apnea time <1min
13. After satisfied no issues with procedure remove endotracheal tube and place immediately
into biohazard bag -p
14. Secure tracheostomy with sutures and strap per routine
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15. Proper Doffing of PPE before existing
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*PPE: personal protective equipment

*IP: Interventional Pulmonology
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*ICU: Intensive Care Unit

*ENT: Ear, Nose and Throat
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*RN: Registered Nurse

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*HME: Heat and Moisture Exchanger

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