Critical Care Innovations (Oct 2020)
Novel approaches in the post-tracheostomy care of the COVID-19 patient.
Abstract
INTRODUCTION: SARS-CoV-2 is a novel strain of coronavirus that has caused illness in over 6 million people worldwide as of June 2020. Patients with severe illness are treated with invasive mechanical ventilation, as such, tracheostomy has become a topic of interest. Traditional schema employed during independent breathing trials in patients with tracheostomies employ the use of a collar mask attached to flexible corrugated tubing with humidified oxygen from a wall source. One drawback of this arrangement is the creation of an open circuit with the potential for viral aerosolization. MATERIAL AND METHODS: We adapted high flow oxygen (HFO) therapy to patient’s tracheostomy tube and devised a rapid decannulation protocol for patients recovering from Covid-19. Corrugated flexible tubing with a heating element is attached to the HFO meter-blender/heated humidifier apparatus and then connected directly to one end of a Y-adapter. An in-line suction kit specified for tracheostomy patients is also placed. Humidified air is delivered to the patient using the heating element of the HFO system obviating the need for a heat moisture exchanger. A second corrugated tube is attached to the free end of the Y-adapter and a non-conductive viral particle filter is attached to its free end to limit viral aerosolization. RESULTS: The mean time to tracheostomy placement is 18 days from initiation of mechanical ventilation (5-39 days). To date 20/52 (38%) patients have undergone tracheostomy tube removal, and of those 13 have been discharged. The mean time to decannulation is 15 days (8-32 days). Three patients failed decannulation requiring repeat endotracheal intubation (5.7%). SARS-CoV-2 was not detected in 22/24 patients undergoing repeat polymerase chain reaction testing on day 45 after initial positive test. CONCLUSIONS: Utilizing HFO to tracheostomy scheme creates a closed circuit theoretically reducing the risk of COVID-19 exposure, while also helping patients breathe independently. This schema coupled with a rapid decannulation protocol is a reasonable alternative in select patients recovering from severe COVID-19.
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