McGill team develops safe tracheostomy technique for COVID-19 patients
A team at McGill University has developed what is believed to be one of the first techniques in North America –and perhaps the world – for safely performing a percutaneous tracheostomy on COVID-19 patients.
The procedure itself dates back many years, but there have been widespread concerns that a tracheostomy is too dangerous to undertake for COVID-19 patients because of the risk of infection to healthcare workers. Early on in the spread of COVID-19, it was deemed to be one of the riskiest procedures, so hospitals around the world often avoided or delayed tracheostomy on these patients, instead keeping them on a ventilator for long periods.
“In this procedure, we spend our time working in the airways, which is the source of the virus,” says Karen Kost, MD, FRCSC, director of the Voice and Dysphagia Laboratory at McGill University. “But if it can be done safely, it would allow patients who would otherwise be on mechanical ventilation for an extended period to have a tracheostomy in a timely fashion.
Risks of mechanical ventilation
“We know that having an endotracheal tube in your throat for longer than 10-14 days can lead to long-term damage, including scarring and injury to the larynx,” says Dr. Kost. “It also tends to prolong a patient’s stay in the ICU.
“The idea then is to take the tube out of the mouth and throat by surgically creating an airway directly through the neck to the trachea,” she explains. “This facilitates weaning from the ventilator faster, which means they leave ICU faster, freeing up a bed. For many COVID-19 patients, there are numerous benefits to doing a tracheostomy.”
In April, Dr. Kost’s team received a consultation call from the ICU.
“They knew our concerns about doing a tracheostomy in a COVID positive patient,” she says. “This patient had been on a ventilator for about a month. They expected him to survive and were worried about him being on a ventilator so long.
“He really needed a tracheostomy. It made me think, ‘This is not good medicine. We are not doing tracheostomies on people who need them because of fear of infection.’”
Dr. Kost, far left, with McGill’s COVID-19 “SWAT Team.”
Minimizing exposure using an adapted tent
A team was assembled and the solution agreed upon: for COVID-19 patients, the tracheostomy would be done in the ICU, at the patient’s bedside, with the patient in a tent, and the surgical team outside the tent.
“We got our hands on a demistifier tent that’s used to administer anti-viral agents,” Dr. Kost explains.
The team made modifications to the clear plastic tent as needed, including sealing the existing openings and creating holes with a seal for the surgeon’s arms. They estimated where the surgeon’s arms needed to enter the tent and attached surgical gloves at those entry points. Another arm opening was made for the respiratory therapist.
“Normally this procedure requires five to six people, but we trimmed it down to three inside the room, in order to limit exposure to the virus,” says Dr. Kost. “We had the surgeon, the physician doing the bronchoscopy and the respiratory therapist. To minimize the risk to nurses, we had the nurse distanced at more than two metres from the patient with a line extension for administering intravenous medication. We did this procedure at the bedside to avoid the risks of transporting critically ill COVID-19 positive patients to the operating room.”
To date, Dr. Kost’s team has carried out eight tracheostomies on ventilated COVID-19 patients, with plans to continue. They are now consulted for a tracheostomy for patients who have been on a ventilator for about 14 days.
The team has submitted details of the modified procedure for publication in the hopes of more widely sharing what they see as the safest tracheostomy option for many ventilated COVID-19 patients.
Guy Tropper | July 9, 2020
WILLIAM KING | July 8, 2020
