Perioperative considerations during tracheotomy of COVID-19 patients (Table 5)
Tracheotomy is a procedure which generates aerosols and should be performed in negative-pressure isolation environments. Additionally, closed airway circuits can prevent aerosol leakage, and should be used except during controlled suctioning of the trachea. Antiviral/high efficiency particulate air filters (HEPA) (e.g. Medtronic ventilator filters) should be used at all times on ventilators during the clinical care of COVID-19 patients. There should be two filters per ventilatory circuit, one between the ventilator and its expiratory port as well as another on the exhalation outlet of ventilator.
Diathermy should be avoided in tracheotomy as much as possible. There is currently limited literature with regard to diathermy during tracheotomy but coagulation with diathermy can produce small particles that may act as a vehicle for the virus. While there are currently no reports of virus incubating in muscles, the risk of increased viral aerosolization cannot be completely ruled out. Surgical ties should considered instead, especially when ligating the thyroid isthmus to expose the trachea. Tracheotomy tube change should be delayed post-tracheotomy, with the cuff kept inflated, in-line suction used, and avoidance of circuit disconnection. This should be performed preferably when the patient is no longer positive for COVID-19.