Novel Use of Tracheostomy Shield for Emergency Tracheostomy in Covid 19 Era

Indian J Otolaryngol Head Neck Surg https://doi.org/10.1007/s12070-021-02632-7 ORIGINAL ARTICLE Novel Use of Tracheostomy Shield for Emergency Tracheostomy in Covid 19 Era Y. K. Kirti1 • Smita Soni1 • J. K. Yashveer1 • A. R. Anjali1 Received: 1 May 2021 / Accepted: 10 May 2021 Ó Association of Otolaryngologists of India 2021 Abstract To evaluate the problems in doing emergency tracheostomy and tracheostomy care of patients with unknown COVID-19 status. Study the usefulness of the specially designed Tracheostomy Shield. A prospective hospital-based study was conducted at a tertiary care center in India treating COVID and Non COVID patients. The study was done from April 2020 to December 2020. A total of 80 tracheostomy were done using Tracheostomy shield. Open tracheostomies were 38 while 42 patients were already intubated (closed circuit). The Tracheostomy shield was also used in 380 tracheostomy tubes changes. Two patients were found COVID positive on RT-PCR after tracheostomy. There was no scope for testing all tube changes with RT-PCR. The use of our indigenously designed Tracheostomy shield has been effective in reducing the aerosol spread and there was no COVID transmission reported. The use of patient Tracheostomy shield is of uttermost importance in reducing the respiratory droplets splashing on to the surgeon and assistant while doing awake tracheostomy. It is extremely useful while changing tubes as there are chances of false negatives antigen test which might be miss leading. The use of Tracheostomy shield is very important in the current context of new and fast evolving respiratory infections. Keywords Tracheostomy shield
Tracheostomy in COVID Era
Awake tracheostomy
Splash of respiratory secretions Introduction Tracheostomy in COVID-19(Corona virus disease of 2019) times brought out new challenges. Emergency tracheostomy in patients with upper airway obstruction whose COVID status is unknown is a nightmare for the surgeon and anaesthetist. The difficult situations are when patient cannot be intubated or ventilated, with progressive desaturation due to upper airway obstruction. Patients with neck abscess, subglottic foreign bodies, laryngeal malignancies were very well there when the whole medical fraternity was overwhelmed with COVID-19. Medical and surgical resources were also diverted to COVID care. There were lacune in literature as to how to deal with the other lot of patients who could be having laryngeal malignancy with stridor with or without COVID infection. Awake emergency tracheostomy being the only resort to save such patients [1]. Awake tracheostomy in patients with upper air way obstruction does not allow the use of endotracheal intubation, neuromuscular blockers and closed circuits. Changing tracheostomy tubes in outpatient department also poses aerosol generation hazard. Doing urgent tracheostomy in COVID era was a challenge which called for newer methods to deal with the splash and droplets which occurs as the trachea is opened. Changing tubes and doing suction cleaning still remained a grey area. With limited resources, repeated COVID testing was not possible. This problem led to do the present study. & Y. K. Kirti 1 Department of Otolaryngology, Gandhi Medical College, Bhopal, India 123 Indian J Otolaryngol Head Neck Surg Methods The present study was conducted in a tertiary care centre in central India where both COVID and non-COVID were being treated separately. It was a prospective study from April 2020 to December 2020. Inclusion criteria- All patients undergoing emergency tracheostomy and patients undergoing tracheostomy tube change in ward and outpatient department whose COVID status was unknown. The team for open tracheostomy consisted of otorhinolaryngologist, otorhinolaryngology residents, scrub nurse, anaesthetist and anaesthesia residents [2]. The PPEs are to be used based on the risk profile of the health care worker [3]. Rational PPE (personal protective equipment) for tracheostomy (N-95 mask, face shield, fluid resistant coveralls, shoe cover) with proper donning and doffing protocols were followed. For tube change N-95 mask, goggles, gloves and fluid resistant gowns were used. The tube change was performed in the minor OT (operation theatre) attached to the ward and OPD (outpatient department) set up. A special Tracheostomy shield indigenously designed was used to protect the operating surgeon and the operating room staff form the splash of respiratory secretions in an open tracheostomy. A steel frame was designed to fit over the patient in supine position, the top is covered with glass Fig. 1. The height-35 cm, breadth-40 cm at the head end, breadth- 50 cm across the chest, length- 50 cm. (tailor made to the existing operating table). Vertical incision was preferred for a faster bloodless approach. The patient was on spontaneous ventilation with oxygen support. Short acting muscle relaxants were given whenever it was feasible before giving the tracheal incision. A piece of tracheal cartilage was removed. Appropriately sized tracheostomy tube was inserted and cuff inflated. The HME (heat and moisture exchange) filter was attached with the circuit and the patient was ventilated, the etco2 was monitored, auscultation was avoided [4]. Diagnosis is usually confirmed by rRT-PCR of combined nasopharyngeal and oropharyngeal swabs. [5]. The whole frame can be sterilized by autoclaving. Since the surgeon looks through the glass his face is protected from unexpected splash without the problem of fogging. The Tracheostomy shield was used in conjunction with regular PPE kits. COVID test was sent but emergency tracheostomy was not delayed and carried out with all COVID protocol. The Tracheostomy shield was also used for changing tracheostomy tubes in OPD. After suction cleaning, 4% lignocaine was instilled through the tracheostomy tube to reduce the cough reflex. The new tube is inserted under vision using Tracheostomy shield. The respiratory secretions and droplets get deposited on the under surface of the glass. The same can be wiped and sterilized with sodium hypochlorite solution for next use. Results From April 2020 to December 2020 a total of 80 tracheostomy where done. Open tracheostomies were 38 while 42 patients were already intubated (closed circuit). The Tracheostomy shield was also used in 380 tracheostomy tubes changes. The advantages of using the Tracheostomy shield were: 1. No direct splash of respiratory secretion on to the surgeon’s face shield/visor. 2. Surgeons using spectacles used only goggles as the face shield causes a lot of fogging. 3. The big and small droplets are collected on the glass itself than contaminating the overalls/gown Fig. 2. 4. Gives a sense of security to the OT staff when the patients COVID status is unknown It was not feasible to send COVID samples in all OPD patients nor to wait for the COVID report to do the emergency tracheostomy/tube changes. The surgeon, anaesthetist, (...truncated)