Piedmont Bronchoscopy and Percutaneous Tracheostomy Guidelines
Last Revised 3/30/20
Bronchoscopy:
Outpatient: Currently allowing only time- sensitive cases, to be evaluated on a daily basis
Inpatient: Please avoid pulmonary toilet bronchoscopies unless absolutely necessary. Do NOT send BAL for cell count unless crucial for decision making. The techs in the lab have to do it manually and it is a huge exposure to them.
Outpatient flow:
Patient to be screened the day prior to procedure. If symptomatic, cancel procedure and direct to the hotline 1-866-460-1119
If asymptomatic proceed with scheduling bronchoscopy, patient will get tested for COVID 19 day of procedure
Both outpatient and inpatient:
Limit staff to only those necessary to safely perform procedure. Minimize intra-procedure staff changes
Recommend full PPE regardless of status
PAPR preferred or N95
Eye protection (if not using PAPR)
If using N95 surgical mask to be placed on top to protect N95
Gown and gloves, surgical cap
Recommend negative pressure room
All cases to be performed under general anesthesia with ETT (closed ventilation) in place to minimize any aerosolization
Recommend all entry and exit with scope to be done under ventilatory pause/apnea
Tracheostomy Guidelines
Tracheostomy can be considered in patients with stable pulmonary status but should not be performed prior than 14-21d since intubation in COVID positive patients.
Perform at bedside to minimize transportation and cross contamination.
Consider testing for COVID in patients whose initial diagnosis was not COVID related due to concern for cross contamination.
Bedside percutaneous tracheostomy preferred method. Bedside open tracheostomy second. Open tracheostomy in the OR should be last resort.
Perform in a negative pressure room.
Limit staff to only those necessary to safely perform procedure. Minimize intra-procedure staff changes.
Adhere to strict donning and doffing procedures
Step 1: Pre-procedural Preparation
On the day of the planned procedure, the following procedural items will be assembled outside the room by the nursing staff and respiratory therapy:
Cook Medical BlueRhino (regularly comes with Shiley size # 8)
Shiley #6 for female patients
Bronch Adapter
Package of sterile gauze
Bottle of saline and sterile bowl
Medications, including continuous ICU sedatives, RSI kit (for paralytics, additional meds)
Sterile towels
Other supplies per proceduralist discretion (please discuss prior to procedure)
On the day of the planned procedure, the following PPE items will be assembled outside the room by nursing staff and respiratory therapy:
Four PAPRs with hoods
Four N95s
Four sets of sterile surgical gloves, with sizes at the discretion of operators
Four non-sterile regular PPE gowns
One sterile gown for operator
Four foot / boot covers
Two red biohazard bags
The tracheostomy team members assembled:
Interventional Pulmonology attending/Designated Surgeon
RT
ICU RN
Step 2: Procedural Set-up
Once all materials have been assembled outside the room, team members will meet for a sign-in and procedural pause outside the room. Assembled tracheostomy team members will decide upon designated roles: bronchoscopist and operators, nurse, RT. Ideally only these three or four people will enter the room with standard PPE precautions as well as PAPR devices and maximal body coverage, including non-sterile gowns, gloves, eye protection, head and foot covering.
Patient to be placed on 100 FiO2 upon entering the room.
Role 1: Bronchoscopist. This person will be responsible for airway management, including bronchoscopy and possible need for flexible intubation. They will stand at the head of the bed and help position the head. They will be responsible for managing the airway during the procedure, including positioning of the endotracheal tube, packing the nose and mouth, deflating the cuff at the appropriate time.
Role 2: Nurse. This person stands at the right side of the patient and is responsible for managing the ventilator and medications during the procedure as instructed by operator. They will monitor hemodynamics and provide feedback.
Role 3: Operator (may need two people for this role). This person(s) will stand at the right side of the patient and perform the tracheostomy. They will position and examine the neck to decide upon optimal procedure. They will put on open supplies and trays, put on sterile materials, and prepare the tracheostomy tube.
Step 3: Tracheostomy Procedure (Percutaneous)
The following steps describe a modified percutaneous tracheostomy approach that minimizes exposure to aerosols. All manipulation of the ETT (cuff deflation, moving, insertion/removal of scope) should be done under apnea/ ventilatory pause. If the operators feel that the procedure cannot be performed safely because of anatomy, then skip this step and proceed to open / surgical tracheostomy.
The operator will position the patient in the standard position and examine the neck (palpation +/- ultrasound to identify anatomy). They will cleanse neck with chlorhexidine and then put on sterile gowns and gloves. They will drape the neck and body.
The bronchoscopist will cover and pack nose and mouth gauze/ packs or sponges to minimize exposure to secretions or aerosols.
Final pause to be made and all next steps to be verbally verified by all team members.
Nurse to pause ventilation. The RT will place bronchoscope double swivel adapter under apnea.
The bronchoscopist will place scope through the ETT, nurse to resume ventilation. Perform pulmonary toilet as necessary to provide visualization.
The operator will again cleanse with chlorhexidine and then instill lidocaine into the dermis and down to the tracheal rings. A incision will be made and dissection performed to the trachea without puncturing through. Consider dropping PEEP to zero at this time to allow for any positive pressure build up to wash out.
Then ventilation should be paused, cuff deflated, draw back the ET tube to the level of the subglottic space to allow visualization. Care should be taken so that the connections with the adaptor are tight, and then the adaptor and tube can be covered with sterile towels. Steps F-K should be able to be performed on ventilatory hold. If patient unstable and needs intermittent ventilation, the incision should be covered with wet gauze to minimize leak of aerosolized secretions.
Needle is placed through the incision and down to the trachea.
The needle will enter the trachea guided by direct visualization by the scope. Ideal placement will be between the 2nd and 3rd or between the 3rd and 4th rings, and the needle should enter between the 10:00 and 2:00 positions of the trachea as viewed by the scope.
Guidewire will be advanced through the needle and then needle removed. A wet lap sponge/gauze will be used around the incision site to minimize aerosol.
A 14Fr dilator is placed over the wire and used to dilate down to the trachea. Dilation is performed twice. Once the dilator is removed, wet gauze should be applied around the wire to minimize leak of aerosols.
The Rhino dilator will be placed over the wire and into the trachea with direct visualization of the appropriate sized black lines in the airway by the scope. The Rhino dilator will be removed, and further packing will be applied around the fresh stoma.
The tracheostomy introducer and tube will be placed over the wire and into the airway. The wire is removed, and the cuff of the tracheostomy tube will be inflated.
The bronchoscope will be used to ensure proper positioning of the tracheostomy tube.
Attach the regular ventilator tubing to the tracheostomy tube. Mechanical ventilation can be resumed through the tracheostomy tube.
The tracheostomy tube can then be secured in the routine fashion with padding, sutures, and tracheostomy ties. Consider surgicel packing to prevent need for further manipulation.
Non-reusable materials will be placed into red biohazard bags (doubled). Sharps will be discarded per routine. PAPR devices will be cleansed per routine.
Doffing: the gloves and gowns will be removed in the room and discarded within the biohazard bags. The operators will then leave the room, with PAPR’s in place. An assistant will wipe down the PAPR using SANI-WIPES per Infection Prevention protocol and will help remove the PAPR hoods. Hand washing and disposal of any other PPE will then be performed.
Tracheostomy Procedure (Open / Surgical)
If this is deemed to be necessary then every effort will be made to perform the procedure at bedside, but this may require transporting the patient to the OR with the COVID19 OR protocol in place. Every effort will be made to delay these procedures and extubate the patient rather than transporting to the OR for an open/surgical tracheostomy.
Timing:
Sign out between COVID ICU and designated personnel in the OR (attending anesthesiologist designated for the procedure and OR nursing) before transfer is initiated from COVID ICU to expedite transfer to assigned room
All open/surgical tracheostomy procedures will be performed during regular working hours when nursing personnel trained in this procedure are available
Personnel:
Nursing: 1 scrub nurse, 1 circulating nurse. Both must be ENT/thoracic trained and experienced in performance of tracheostomy procedure
Anesthesia: personnel must be experienced with tracheostomy procedure and comfortable with COVID19 protocols
Surgery: Attending otolaryngologist or thoracic surgeon
Pretransfer huddle
All members of the above team will huddle to ensure readiness (of anesthesia and surgical equipment and checklist of necessary PPE) before the attending anesthesiologist can perform a sign-out with COVID ICU to initiate transfer
PPE checklist
PAPRs with hoods (x 5)
N95 masks (x5)
sterile surgical gloves
sterile impermeable gowns (x3 for two surgeons, 1 scrub nurse)
non-sterile regular PPE gowns (x2 for anesthesiologist and circulating nurse)
impermeable boot covers
Red biohazard bags
Perform a time out (include COVID-19 specific language for positive patients. Include buddy checks for PPE. Include check of tracheostomy surgical equipment and choice of tracheotomy tube/s)
Surgical procedure
Standard prepping of neck and draping of patient
Inject trach site with 1% lidocaine with 1:100,000 epinephrine solution (at surgeon’s discretion)
Make a horizontal incision using Bovie cautery. Make sure fume evacuator is present and deployed
Dissect down to trachea quickly using vertical dissection strictly keeping to the midline and retracting. Divide thyroid isthmus only of needed to expedite procedure
Stop ventilation and paralyze the patient. Communicate with attending anesthesiologist about anticipated time of stopping ventilation as some of these patients will have poor reserve)
Make a vertical or horizontal incision in the tracheal wall (surgeon’s discretion). Make a Bjork flap if needed (as open tracheostomy will only be performed for anatomically unfavorable patients)
Remove endotracheal tube and insert tracheotomy tube. Dispose of the endotracheal tube safely (in a double biohazard bag)
Inflate the cuff on tracheostomy tube and connect to ventilator
Doffing per protocol