An international working group has published consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.

“Tracheostomy in the COVID-19 era: global and multidisciplinary guidance” is the consensus of 30 experts. It offers guidance on patient selection, timing, performance, and optimal management after tracheostomy. The guidelines were published May 15 in The Lancet on May 15.

Single-use bronchoscopes with a sealed ventilator circuit are "preferable" for use during percutaneous tracheostomies, according to guidelines in the performance section.

Tracheostomy is a common procedure for critically ill patients requiring an extended period of time on mechanical ventilation. Percutaneous tracheostomy is done by dilating the stoma using the Seldinger technique.

The COVID-19 pandemic has led to an unprecedented number of patients requiring mechanical ventilation.

“Tracheostomy has a continuing role in managing weaning from extended periods of mechanical ventilation during the COVID-19 pandemic,” the article reads, “but the procedure might not always provide benefit, and tracheostomy and subsequent care pose risks to healthcare workers.”

Tracheostomy is an aerosol-generating procedure, which makes it risky.

The panel’s organizers recruited and convened an international tracheostomy consensus working group “by identifying individuals with relevant expertise in tracheostomy and previous experience in the development of guidelines or consensus documents.”

Approximately 8 to 13 percent of ICU patients who require mechanical ventilation have a tracheostomy, according to the article.

“Because tracheostomy is at the intersection of healthcare worker safety, resource allocation, and patient-centered care, sound guidance is crucial,” the article says.

Standard decision making in selecting patients for tracheostomy should be altered during the COVID-19 pandemic. Patient risks and benefits, as well as risks to healthcare workers, need to be considered, according to the consensus working group.

The group suggests delaying tracheostomy until after at least 10 days of mechanical ventilation. A conservative approach is recommended for attempted extubation, limited to patients with a high chance of success.

The article features a number of recommendations for performing the procedure in addition to the single-use guidance for percutaneous tracheostomies. Enhanced personal protective equipment is suggested, including eye protection and fluid repellent disposable surgical gowns and gloves. Powered air-purifying respirators should be used. ICU and surgical teams should review the options for location, weighing the risks to the patient and staff. And tracheostomies should be done with techniques and equipment that operators are familiar and confident with.

Lastly, the panel advises to focus only on essential care and avoid unnecessary interventions, especially ones that generate aerosols, after the tracheostomy.