Outpatient Clinic Setting
Certain practices can minimize transmission of this highly contagious virus in the outpatient setting, the most effective measure being the deferral of all non-urgent visits and performing telemedicine visits when a physical exam is not necessary (i.e. pathology and radiographic imaging results). The federal government has taken steps to greatly expand telemedicine services under Medicare and Medicaid with HIPAA flexibilities and this was made retroactive to January 27, 2020.20
When in-office visits are absolutely necessary (e.g. postoperative visits, tracheoesophageal prosthesis (TEP) complications, symptoms concerning for cancer recurrence, etc.), screening prior to the visit for symptoms of COVID-19 and self-quarantine measures may help reduce transmission risks. An example of pre-arrival instructions for patients are listed in Table 1. To minimize aerosolized particle spread from a laryngectomy patient, the tracheostoma should be covered with a heat moisture exchanger (HME), preferably with an integrated viral/bacterial hydroscopic filter, and a physical barrier over the stoma such as a surgical mask, scarf, or shirt, prior to their arrival to the clinic.21,22
Two major manufacturers (Atos, InHealth) produce an HME with these filters: Atos Provox® Micron HME™ filters virus and bacterial particles (https://www.atosmedical.com/product/provox-micron-hme/), and the InHealth Technologies® Blom-Singer® HME filters bacterial particles (https://www.inhealth.com/category_s/47.htm). In addition laryngectomy patients should, where feasible, be encouraged to use adhesive base plates such as the Provox® StabiliBase™ (https://www.atosmedical.com/product/provox-stabilibase/) or the Blom-Singer TruSeal Adhesive Housing (https://www.inhealth.com/product_p/truseal_standard.htm). These incorporate the HME and when properly applied will prevent airflow outside of the HME, and reduce mucous contamination of clothing or other physical barriers.
While scarves and shirts are not as effective as surgical masks in reducing inhaled aerosol spread, they do provide some protection in reducing aerosol projection.21,22 Attempts should be made to minimize the time the patient spends in common areas and check-in procedures should be expedited or performed in an examination room when possible.
During the visit, only necessary personnel should enter the patient room with the appropriate PPE as noted above. Defer nasopharyngoscopy and tracheoscopy if possible. Pledgets with lidocaine and/or oxymetazoline are preferable to atomized medications if anesthesia and decongestion are necessary. When performing flexible tracheoscopy, attempts should be made to minimize mucosal stimulation and resultant coughing. Following flexible tracheoscopy, the scope should be immediately handed off and cleaned to prevent contamination of counters and scope holders in the exam room. If suctioning is required, having patients self-suction will allow for providers and staff to leave the room during the time of suctioning. However, it should be noted that viable SARS-CoV-2 has been recovered from aerosols for up to 3 hours.23 Following the visit, institutional protocol for room decontamination should be followed while allowing an appropriate wait time for aerosols to settle. For patients with moderate to high risk of COVID-19, consider disinfecting all surfaces to reduce the risk of transmission, as SARS-CoV-2 has been shown to be viable on some surfaces for up to 24-72 hours.24
Management of TEP Complication s
TEP complications are unique to the laryngectomy population, including device dislodgement and leakage related to device failure in the tract. Typically, these complications can be managed in the office using standard PPE. However, due to the potential risk of SARS-CoV-2, the standard management and timing to address these complications is subject to change. Optimally, a negative pressure room and HEPA filtration can minimize the risk of viral transmission, and should be considered in the COVID-19 era.25 However, this is not necessarily practical from a healthcare resource utilization and workflow standpoint. Figure 1 presents a possible decision algorithm in managing TEP complications including dislodgement of the prosthesis and leak around the prosthesis.
A patient with a TEF or leak around a TEP is at an increased risk of aspiration with potential sequelae including pneumonia, which could lead to devastating outcomes if patients contract COVID-19. In the event of a dislodged TEP, radiographic imaging can serve as a diagnostic tool to replace flexible bronchoscopy or tracheoscopy in evaluating for an airway foreign body. This can begin with standard X-rays of the chest and abdomen but may be augmented with CT imaging.26Certainly, if the patient is in respiratory distress from an aspirated TEP, urgent surgical intervention is indicated regardless of COVID-19 status. As noted above, these patients should be presumed to be COVID-19 positive until proven otherwise and enhanced PPE should be implemented. Precautions to minimize aerosolization of particles while in transport to the operating room and prior to intubation should be taken, such as covering the stoma with an HME and surgical mask. For patients who do not have an HME or laryngectomy tube, a tracheotomy tube with an HME can be considered, though this may worsen their coughing.
In the stable patient, the main goal is to safely temporize and troubleshoot any TEP complications until the risk of COVID-19 transmission is sufficiently lowered or testing is readily available. Management at home should initially be attempted by the patient. If the patient has a TEP plug, this can be placed to attempt to reduce any leakage, though this will result in aphonia. Additionally, patients can try alternative diet measures such as thickened liquids to reduce leakage. A dislodged (non-aspirated) TEP may also be conservatively managed at home by placing a red rubber catheter or dilator into the TEF, if the patient is familiar with this procedure. An advantage to this measure is that the red rubber catheter can serve as alternate means of nutrition until TEP replacement becomes a viable option.
If in-office evaluation is necessary, ideally the patient should be tested for COVID-19 prior to evaluation. If testing is negative and symptoms are mild, the patient can undergo quarantine for 48 hours and then return to the clinic at a later date for TEP insertion. Some centers recommend a second rapid COVID-19 test is recommended following the 48-hour quarantine prior to evaluation of intervention to mitigate risk associated with false negative results.27However, this algorithm may remain infeasible until national testing supplies and capacity are no longer severely limited.
In the event of a TEP complication for a known COVID-19 positive patient, all efforts should be made by the patients to temporize themselves at home without coming to the hospital, so long as they are medically stable to remain at home. Once the patient is recovered from the infection, they may then proceed with further management. For COVID-19 positive patients, we strongly recommend the use of PAPR for all personnel in the room during any procedures that manipulate the airway.15 If a PAPR is not available, consider the use of a level 4 surgical gown with helmet in addition to donning an N95 respirator and shoe covers. Involved personnel should be kept to the bare minimum during instrumentation of the stoma in a known COVID-19 positive patient.