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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 79-83

Tracheostomy: A shift in paradigm from a simple bedside procedure to a potential source of spread of COVID-19

Department of ENT, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission21-May-2021
Date of Acceptance25-Jun-2021
Date of Web Publication15-Sep-2021

Correspondence Address:
Dr. Sandeep Trehan
Department of Otorhinolaryngology and Head and Neck Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EHP.EHP_17_21

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Introduction: Tracheostomy is defined as the creation of stoma at the skin surface that leads into the tracheal lumen. Tracheostomy in critically ill patients is usually performed in order to assist in weaning of prolonged ventilation. Objective: This article outlines the necessary changes to be adapted during the procedure of tracheostomy in the wake of COVID-19 pandemic. Methods: The methods suggested in the present study were obtained by performing a detailed observation of the many cases which were performed in a Tertiary Government Hospital in India. Results: The methods presented in this study were followed for every tracheostomy procedure performed since the emergence of COVID-19 pandemic. This resulted in reduced exposure to a great extent, the involved healthcare workers did not contact with COVID-19 infection. Conclusion: Modifications are necessary for the protection of healthcare workers in the absence of healthcare infrastructure like negative pressure/laminar flow operation theaters.

Keywords: COVID-19, personal protective equipment, tracheostomy

How to cite this article:
Nagendra S, Trehan S, Kaul R. Tracheostomy: A shift in paradigm from a simple bedside procedure to a potential source of spread of COVID-19. Educ Health Prof 2021;4:79-83

How to cite this URL:
Nagendra S, Trehan S, Kaul R. Tracheostomy: A shift in paradigm from a simple bedside procedure to a potential source of spread of COVID-19. Educ Health Prof [serial online] 2021 [cited 2022 Dec 6];4:79-83. Available from: https://www.ehpjournal.com/text.asp?2021/4/2/79/325997

  Introduction Top

The current pandemic due to COVID-19 has resulted in many significant changes in the Global Healthcare system and has forced us to rethink our usual standard protocols in the field of head and neck surgery. The approach toward a particular patient or a clinical scenario had to be substantially modified in order to combat the amount of emerging cases by circumventing further spread of the disease and thereby reducing the disease burden in the community. The healthcare workers (HCWs) have courageously assumed their roles in the frontline of this battle equipped with available infrastructure amid continuously changing scenarios and protocols.

Coronavirus disease 2019 (COVID-19) is caused by a newly emergent novel respiratory tract virus that was first recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that it is a single-stranded ribonucleic acid-encapsulated beta-coronavirus closely linked to the SARS virus.[1]

Epidemiology and virologic studies suggest that transmission mainly occurs from infected people to others by direct transmission of SARS-CoV-2 by inhalation of contaminated droplets or ocular projection or indirect transmission by contact with contaminated hands, surfaces, or objects.[2],[3],[4],[5] Clinical and virologic studies that have collected repeated biological samples from confirmed patients demonstrate that shedding of SARS-CoV-2 is highest in the upper respiratory tract (URT) early in the course of the disease.[6],[7],[8]

Majority of the procedures, both elective and emergency, which are performed by the otorhinolaryngology teams, can result in generation of aerosols. Thus, aerosol-generating otorhinolaryngological procedures are considered high-risk procedures which may escalate the spread of the infection. This keeps the HCWs involved in such scenarios at a high risk of infection (symptomatic/asymptomatic) resulting in a possibility of further transmission of the disease. Such arduous and trying times call for the formulation of recommendations which can be followed in the Indian healthcare settings in order to curtail the spread of infection and to reduce the disease burden in our country to a certain extent.

While most people with COVID-19 develop only mild (40%) or moderate (40%) disease, approximately 15% develop severe disease that requires oxygen support, and 5% have critical disease with complications such as respiratory failure, acute respiratory distress syndrome (ARDS), sepsis and septic shock, thromboembolism, and/or multi-organ failure, including acute kidney injury and cardiac injury.[9] Patients with severe COVID-19 with ARSD are expected to be considered for tracheal intubation and mechanical ventilation to assist prospective recovery from the illness, and in 4–5% of such patients with difficult upper airway, invasive mechanical ventilation (IMV) is required.

Tracheostomy is defined as the creation of stoma at the skin surface that leads into the tracheal lumen.[10] Tracheostomy in critically ill patients is usually performed in order to assist in weaning of prolonged ventilation. Less discomfort may also allow a reduction in analgesic, sedative, and muscle relaxant drugs; clearance of airway secretions; mouth care; and facilitation of enteral nutrition. Airway resistance and anatomical dead space are reduced, reducing the work of breathing and improving the speed and overall success in weaning from assisted ventilation. Tracheostomy allows a seamless transition between different modes of assisted ventilation and weaning modes without trials of extubation and reintubation.[11]

According to the International Severe Acute and Emergent Respiratory Consortium (ISARIC), as of June 2020, the duration of stay in ICU/HDU had a mean of 10.8 days and a median of 7.5 (SD: 10.4 days)—estimated on only those cases with complete records for ICU/HDU duration or ICU/HDU start/end dates (n = 5574). Out of these patients, a total of 4092 patients received IMV. The mean and median durations from admission to receiving IMV were 3.6 and 2 days, respectively (SD: 7 days)—estimated from records on cases with complete records on dates of hospital admission and IMV onset (n = 3648).[12] These data show that the severe respiratory symptoms caused due to COVID-19 either progress or resolve rapidly. Thus, the requirement of tracheostomy in weaning of such patients is less.

Almost all of the elective surgeries are put on a hold countrywide in the wake of COVID-19 global pandemic. Tracheostomy is a procedure which cannot be avoided even in elective cases, taking into consideration the benefits and reduction of morbidity in critically ill patients. This article aims to provide guidelines for performing a safe tracheostomy in an Indian scenario during these challenging times.

  Pre-operative Considerations Top

Patient selection

Consider elective tracheostomy in a patient on mechanical ventilation only when the benefits of the procedure outweigh the risks, including cases in which weaning is feasible or can be accelerated with tracheostomy; patients with copious secretion; patients with >14 days of intubation; and patients with considerable hemodynamic stability. SARS-CoV-2 testing by RT-PCR is recommended 24–48 h before the planned procedures. A multidisciplinary team consisting of experienced doctors from Anaesthesiology, Critical Care, and Otorhinolaryngology department is needed in formulating a unique and cordial approach, which can help toward reduction in disease spread.


The procedure has to be ideally performed in a well-equipped, well-ventilated, and well-lit operation theater. Though performing the procedure bedside eliminates the risk of exposure due to patient transportation, it is not advisable unless the ICU is equipped with negative pressure ventilation and separate compartment (which is not the scenario in most of the ICUs in Indian setup at present), as tracheostomy is an aerosol-generating procedure (AGP) and can expose other susceptible critically ill patients in the proximity to SARS-CoV-2. In the absence of negative-pressure rooms, it is recommended that procedures take place in rooms with high-efficiency particulate air filters. In an ideal hospital setting, one air exchange removes ~63% of the virus.[13] After five air exchanges in the room, there is <1% of the original viral load. Five exchanges take ~25 min in most clinical environments. However, in the ICU or operating room, the air exchange is more frequent and five exchanges will take 12 min. Hence, a minimum duration of 20–30 min between each procedure is recommended.

A dedicated entrance (not accessible to the general population or all hospital employees) was used in our hospital for shifting the patients from ICU to the operation theater, to minimize the chances of spread during transportation.

The instruments and anesthetic setup should be ready prior to the shifting of the patient into the operation theater. The personnel in the operation theater should be kept minimal—an anesthetist, two surgeons, and a well-trained nursing officer. Once the patient has entered the theater, it is advisable to keep the doors closed and movement of personnel in and out of the operating theater should be avoided during the procedure.

Personal protection

  • Personal protective equipments (PPEs) are protective gears specifically designed to safeguard the health of medical personnel by minimizing the exposure to a biological agent.

  • According to the Ministry of Health and Family Welfare India, activities which involve aerosol generation require the usage of full component PPE.[14] Components of PPE are goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons), head cover, and shoe cover.

  • All the personnel involved in the procedure must be instructed in detail about the importance and correct use of PPE. There has to be separate donning and doffing areas to avoid contamination.

    This flow chart illustrates the proper donning of PPE [Figure 1].
    Figure 1: Steps of the proper donning of PPE

    Click here to view

    Patient transfer

    Deep endotracheal tube suctioning has to be done using a closed suction tubing apparatus in the ICU before the patient is being shifted by the shifting personnel clad in full PPE.

    HCWs in direct contact with the patient should steer clear of touching environmental surfaces (door handle and elevator buttons) during transport. A separate path should be used for patient transfer.

      Operative Procedure Top

    Performing the procedure

    The operating team has to be ready in the operation theater, wearing full PPE for receiving the patient. Deep endotracheal tube suctioning and thorough oropharyngeal suctioning have to be repeated before starting the procedure. Preliminary checking of the endotracheal tube, cuff, anesthetic tubing, and the machine is to be done by the anesthetist to ensure that there is no leakage. An intubation box made of glass is used to separate the patient’s upper airway from the operating field and the anesthetist. This will minimize aerosol spread. This glass box is later sterilized after the procedure using necessary precautions.

    The procedure has to be performed by an experienced surgeon so as to reduce the operating time (skin to trachea time <5 min). There should be use of only artery forceps for soft tissue division. Avoiding usage of monopolar or bipolar cautery in order to minimize surgical plumes and aerosol generation should be followed.

    Precautions prior to making a tracheostome

    It should be made sure that the patient is fully relaxed. The position of the endotracheal tube is checked and the cuff of the endotracheal tube to be hyperinflated to ensure minimal aerosolization during the procedure. Ventilation can be stopped for a few seconds while making the tracheostome in order to minimize aerosolization.

    An adequate sized tracheostome is to be swiftly made. Ventilation has to cease prior to tracheostomy tube insertion, which has to be rapid and accurate.

    A non-fenestrated cuffed tracheostomy tube of adequate size is to be inserted and cuff inflated immediately. The circuit is then connected to the ventilator and the position of the tracheostomy tube is confirmed by etCO2. Proper oropharyngeal suctioning should be done prior to removal of the endotracheal tube. Proper and prompt disposal of the endotracheal tube is to be ensured. Proper doffing of the PPE kit by the personnel is of at most importance.

    The steps to be followed while doffing are mentioned in [Figure 2].
    Figure 2: Steps to be followed while doffing of PPE

    Click here to view

      Post-operative Precautions Top

    The patient has to be transferred to the ICU by the same personnel who were responsible for transferring the patient to the OT with all the necessary precautions. The patient has to be connected to a ventilator which is equipped with a heat and moisture exchanger (HME) and a viral filter.

    Closed suction apparatus is to be used for regular tracheostomy tube suctioning, to be done by personnel in PPE. PPE is to be used by personnel responsible for tube suctioning and care. Cuff to remain inflated for a minimum of 24 h after the procedure. Spacer devices are to be used for nebulization purposes and proper handling of oropharyngeal secretions to be followed.

      Preparation for Decannulation/Discharge Top

    Patient education and the sensitization of the relatives play a major part in post-tracheostomy care. The patient must be given an HME filter and the cleaning and maintenance of this to be explained in detail. The patient has to be trained in proper oropharyngeal hygiene and prompt and safe disposal of materials such as tissues used for the same.

    The patients are to be advised to don a mask to cover the nose and mouth and also to be provided alcohol-based sanitizers. A closed suction tubing apparatus for tube care is to be used.

    Endoscopic/fiberoptic assessment of larynx is to be done with all necessary standard precautions in candidates of decannulation before commencing the said process.

    The summary of patient requiring tracheostomy in current pandemic is shown in [Figure 3].
    Figure 3: Summary of patient requiring tracheostomy in COVID-19 pandemic

    Click here to view

      Discussion Top

    In the current global scenario, the HCWs are faced with many difficult situations due to pandemic caused by SARS-CoV-2. They are at a high risk of infection and also transmission of this infection. The major spread of this virus is considered to be via contact and droplets, airborne (through aerosols), fomites, and also other minor routes (not enough clinical evidence to consider it significant) like feco-oral, breastmilk, and urine.[15]

    Prevention of the spread of this virus forms a major part in combating this pandemic, in which HCWs play the most important role. However, this pandemic situation does not mean that the burden of other diseases and situations like stroke, neuromuscular diseases, road traffic accidents, and tumors have reduced. The management of these cases may require a better approach than that was used before, as these patients are highly vulnerable in the current situation. The operative procedures which may result in a better care and recovery of the patients cannot be withheld under such circumstances. Among the operative procedures which are undertaken, tracheostomy is considered as an AGP and thus carries a very high risk of contamination by exposing the airway secretions to the clinical staff involved.[16]

    We must direct our combined efforts in making such procedures safer to both the patient and the involved HCWs. A few international studies have been published regarding the ideal setting and precautions to be followed during tracheostomy. Taking into consideration the unfortunate drawbacks in current medical infrastructure, we have tried to formulate a convenient strategy for dealing with performing a safe tracheostomy in an Indian setup. As healthcare professionals who live in the era where we are fortunate to experience various developments and major scientific breakthroughs, we must learn and adapt well to the newer circumstances in order to make way for a better world.

    Financial support and sponsorship


    Conflicts of interest

    There are no conflicts of interest.

      References Top

    World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance. Pediatr Med Rodz 2020;16:9-26.  Back to cited text no. 1
    Burke RM, Killerby ME, Newton S, Ashworth CE, Berns AL, Brennan S, et al; Case Investigation from Working Group. Symptom profiles of a convenience sample of patients with COVID-19—United States, January-April 2020. MMWR Morb Mortal Wkly Rep 2020;69:904-8.  Back to cited text no. 2
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    Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: Estimation and application. Ann Intern Med2020;172:577-82.  Back to cited text no. 4
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    Huang R, Xia J, Chen Y, Shan C, Wu C. A family cluster of SARS-CoV-2 infection involving 11 patients in Nanjing, China. Lancet Infect Dis 2020;20:534-5. Epub March 3, 2020.  Back to cited text no. 7
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    Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Vital surveillances: The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China. China CDC Weekly 2020;2:113-22.  Back to cited text no. 9
    Watkinson John C, Rayy C. Scott Brown’s Otorhinolaryngology and Head and Neck Surgery. 8. Vol 3. Boca Raton: CRC Press; 2018. p. 1041.  Back to cited text no. 10
    Barry BN, Bodenham AR. The role of tracheostomy in ICU. Anaesth Intensive Care Med 2004;5:375-8.  Back to cited text no. 11
    ISARIC (International Severe Acute Respiratory and Emerging Infections Consortium) Data Platform [internet] Available from: https://media.tghn.org/medialibrary/2020/06/ISARIC_Data_Platform_COVID-19_Report_8JUN20.pdf. [Last accessed on July 21, 2020].  Back to cited text no. 12
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    WHO—Transmission of SARS-CoV-2: Implications for Infection Prevention Precautions [internet] Available from: https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions. [Last accessed on July 21, 2020].  Back to cited text no. 15
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      [Figure 1], [Figure 2], [Figure 3]


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