Guidelines: Tracheotomy

1. Canadian Society of Otolaryngology-Head and Neck Surgery strongly advise against performing a tracheotomy in still infectious COVID-19 patients.
   • In positive patients, requests for tracheotomy should generally not be considered regardless of duration of endotracheal intubation. 
2. In emergency tracheotomy with unknown COVID-19 status: 
   • Manage patient as if COVID-19 positive. 
   • Intubation rather than tracheotomy is highly preferable.
   • Avoid use of high flow oxygen/high flow nasal cannula. 
   • Tracheotomy should always be performed by the most skilled and available airway manager (surgeon and anesthesiologist).
   • Limit team members to essential staff.
3. All patients undergoing elective tracheotomy should be COVID-19 tested prior to the intervention:
   • Decision-making should take in consideration surgical and ICU team in COVID-19 positive patient. 
4. Avoid circuit disconnection.
5. Suction via closed circuit is recommended.
6. Heat moister exchanger (HME) with viral filter or a ventilator filter should be placed if the tracheotomy tube is disconnected from mechanical ventilation. 
   • Avoid disconnecting HME but if necessary, disconnect distal to HME.
7. Avoid postoperative tracheostomy tube changes until COVID-19 negative.

These recommendations come from documents produced by the Canadian Society of Otolaryngology-Head and Neck Surgery, the American Academy of Otolaryngology-Head and Neck Surgery and ENT UK in regard of tracheotomy being a high-risk procedure because of aerosol-generation while in COVID-19 pandemic.

Sources :

1. Engels P., Weitzel E., Witterick I., et al (March 22, 2020). Recommendations from the CSO-HNS Taskforce on Performance of Tracheotomy During the COVID-19 Pandemic. Canadian Society of Otolaryngology-Head and Neck Surgery. Retrieved from https://www.entcanada.org/news-events/covid-19-alerts/
2. Harrison L., Ramsden J., Winter S., et al (March 19, 2020). Guidance for Surgical Tracheostomy and Tracheostomy Tube Change during the COVID-19 pandemic. ENT UK. Retrieved from https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic
3. Noah P., A.Schiff B., A.Fritz M., et al (March 27, 2020). Tracheotomy Recommendations During the COVID-19 Pandemic. American Academy of Otolaryngology-Head and Neck Surgery. Retrieved from  https://www.entnet.org/content/tracheotomy-recommendations-during-covid-19-pandemic