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Diathermy and bone sawing are high aerosol yield procedures. Bone Joint Res 2023; 12:636-643. [PMID: 37813391 PMCID: PMC10562079 DOI: 10.1302/2046-3758.1210.bjr-2023-0028.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
Aims Orthopaedic surgery uses many varied instruments with high-speed, high-impact, thermal energy and sometimes heavy instruments, all of which potentially result in aerosolization of contaminated blood, tissue, and bone, raising concerns for clinicians' health. This study quantifies the aerosol exposure by measuring the number and size distribution of the particles reaching the lead surgeon during key orthopaedic operations. Methods The aerosol yield from 17 orthopaedic open surgeries (on the knee, hip, and shoulder) was recorded at the position of the lead surgeon using an Aerodynamic Particle Sizer (APS; 0.5 to 20 μm diameter particles) sampling at 1 s time resolution. Through timestamping, detected aerosol was attributed to specific procedures. Results Diathermy (electrocautery) and oscillating bone saw use had a high aerosol yield (> 100 particles detected per s) consistent with high exposure to aerosol in the respirable range (< 5 µm) for the lead surgeon. Pulsed lavage, reaming, osteotome use, and jig application/removal were medium aerosol yield (10 to 100 particles s-1). However, pulsed lavage aerosol was largely attributed to the saline jet, osteotome use was always brief, and jig application/removal had a large variability in the associated aerosol yield. Suctioning (with/without saline irrigation) had a low aerosol yield (< 10 particles s-1). Most surprisingly, other high-speed procedures, such as drilling and screwing, had low aerosol yields. Conclusion This work suggests that additional precautions should be recommended for diathermy and bone sawing, such as enhanced personal protective equipment or the use of suction devices to reduce exposure.
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Management of abdominal gas leakage from surgical trocars in laparoscopic surgery: a preclinical study. MINIM INVASIV THER 2023; 32:183-189. [PMID: 37288765 DOI: 10.1080/13645706.2023.2211661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/01/2023] [Indexed: 06/09/2023]
Abstract
Introduction: There is an ongoing concern about the potential infectious risk due to pneumoperitoneal gas leakage from surgical trocars in laparoscopic surgery. We aimed to visually confirm the presence of leakage from trocars and investigate the changes in the leakage scale according to intra-abdominal pressures and trocar types. Material and methods: We established a porcine pneumoperitoneum model and performed experimental forceps manipulation using 5-mm grasping forceps with 12-mm trocars. The gas leakage, if any, was imaged using a Schlieren optical system, which can visualize minute gas flow invisible to the naked eye. For measuring the scale, we calculated the gas leakage velocity and area using image analysis software. Four types of unused and exhausted disposable trocars were compared. Results: Gas leakage was observed from trocars during forceps insertion and removal. Both the gas leakage velocity and area increased as the intra-abdominal pressure increased. Every type of trocar we handled was associated with gas leakage, and exhausted disposable trocars had the largest scale gas leakage. Conclusions: We confirmed gas leakage from trocars during device traffic. The scale of leakage increased with high intra-abdominal pressure and with the use of exhausted trocars. Current protection against gas leakage may not be sufficient and new surgical safety measures and device development may be needed in the future.
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The effect of clinical face shields on aerosolized particle exposure. JOURNAL OF 3D PRINTING IN MEDICINE 2023; 7:3DP2. [PMID: 38051985 PMCID: PMC9870239 DOI: 10.2217/3dp-2022-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/16/2022] [Indexed: 12/07/2023]
Abstract
Background Face shields protect healthcare workers (HCWs) from fluid and large droplet contamination. Their effect on smaller aerosolized particles is unknown. Materials & methods An ultrasonic atomizer was used to simulate particle sizes equivalent to human breathing and forceful cough. Particles were measured at positions correlating to anesthetic personnel in relation to a patient inside an operating theatre environment. The effect of the application of face shields on HCW exposure was measured. Results & Conclusion Significant reductions in particle concentrations were measured after the application of vented and enclosed face shields. Face shields appear to reduce the concentration of aerosolized particles that HCWs are exposed to, thereby potentially conferring further protection against exposure to aerosolized particles in an operating theatre environment.
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Abstract
BACKGROUND Aerosol delivery via high-flow nasal cannula (HFNC) has attracted clinical interest in recent years. However, both HFNC and nebulization are categorized as aerosol-generating procedures (AGPs). In vitro studies raised concerns that AGPs had high transmission risk. Very few in vivo studies examined fugitive aerosols with nebulization via HFNC, and effective methods to mitigate aerosol dispersion are unknown. METHODS Two HFNC devices (Airvo 2 and Vapotherm) with or without a vibrating mesh nebulizer were compared; HFNC alone, surgical mask over HFNC interface, and HFNC with face tent scavenger were used in a random order for 9 healthy volunteers. Fugitive aerosol concentrations at sizes of 0.3-10.0 μm were continuously measured by particle sizers placed at 1 and 3 ft from participants. On a different day, 6 of the 9 participants received 6 additional nebulizer treatments via vibrating mesh nebulizer or small-volume nebulizer (SVN) with a face mask or a mouthpiece with/without an expiratory filter. In vitro simulation was employed to quantify inhaled dose of albuterol with vibrating mesh nebulizer via Airvo 2 and Vapotherm. RESULTS Compared to baseline, neither HFNC device generated higher aerosol concentrations. Compared to HFNC alone, vibrating mesh nebulizer via Airvo 2 generated higher 0.3-1.0 μm particles (all P < .05), but vibrating mesh nebulizer via Vapotherm did not. Concentrations of 1.0-3.0 μm particles with vibrating mesh nebulizer via Airvo 2 were similar with vibrating mesh nebulizer and a mouthpiece/face mask but less than SVN with a mouthpiece/face mask (all P < .05). Placing a surgical mask over HFNC during nebulization reduced 0.5-1.0 μm particles (all P < .05) to levels similar to the use of a nebulizer with mouthpiece and expiratory filter. In vitro the inhaled dose of albuterol with vibrating mesh nebulizer via Airvo 2 was ≥ 6 times higher than vibrating mesh nebulizer via Vapotherm. CONCLUSIONS During aerosol delivery via HFNC, Airvo 2 generated higher inhaled dose and consequently higher fugitive aerosols than Vapotherm. Simple measures, such as placing a surgical mask over nasal cannula during nebulization via HFNC, could effectively reduce fugitive aerosol concentrations.
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Outcomes of tracheostomy in COVID-19 patients in National Guard Health Affairs, Riyadh, Saudi Arabia. Saudi Med J 2021; 42:1217-1222. [PMID: 34732554 PMCID: PMC9149735 DOI: 10.15537/smj.2021.42.11.20210505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: To evaluate coronavirus disease 2019 (COVID-19) patient tracheostomy outcomes. Methods: All COVID-19 patients at the National Guard Hospital, Riyadh, Saudi Arabia, were retrospectively recruited. Those who had tracheostomies between April and December 2020 were included. Results: The population was 45 patients, of which 30 (66.7%) were males, 15 (33.3%) were females and the mean age was 66.76±12.74 years. The tracheostomy indications were anticipated prolonged weaning in 40 (88.9%) and failed extubation in 5 (11.1%) of the patients. The mean intubation to tracheostomy duration was 20.62±7.21 days. Mortalities were high, with most attributed to COVID-19. Mortality and a pre-tracheostomy C-reactive protein (CRP) uptrend were significantly related (p=0.039). Mortality and intubation to tracheostomy duration were not significantly related. The mean post-tracheostomy time to death was 10.64±6.9 days. Among the survivors, 20 (44.4%) males and 11 (24.4%) females were weaned off mechanical ventilation; 9 (20%) remained on ventilation during the study. The mean ventilation weaning time was 27.92±20 days. Conclusion: The high mortality rate was attributed to COVID-19. Mortality and a pre-tracheostomy CRP uptrend were significantly related; uptrend patients experienced far more mortalities than downtrend patients. Unlike previous findings, mortality and intubation to tracheostomy duration were not significantly related.
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Effectiveness of a Simulation-Based Training Program in Improving the Preparedness of Health Care Workers Involved in the Airway Management of COVID-19 Patients. Cureus 2021; 13:e17323. [PMID: 34557368 PMCID: PMC8450013 DOI: 10.7759/cureus.17323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 11/05/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) has currently emerged as a global threat and a significant public health issue. The role of simulation-based training (SBT) during such a pandemic becomes more relevant for teaching a team approach and building capacity especially when there is a threat to health care workers due to aerosol generation and there is a huge demand for manpower during the pandemic. Objective To assess the effectiveness of a simulation-based training program in improving knowledge and concept of teamwork of health care workers involved in airway management of suspected or confirmed COVID-19 patients. Methods After institutional review committee approval, a prospective analytical study was conducted in the department of medical education on participants from various specialties undergoing COVID-19 airway training. The purpose of the study was to assess team dynamics during simulation scenarios and compare test scores at baseline, immediately post-training, and seven days post-training (using online forms). Scores were compared using the Friedman test followed by post-hoc testing. Sub-group comparison was done using an unpaired t-test. Results Median scores were significantly higher in the immediate post-training test and seven days post-training test (online) compared to baseline pretest scores in the overall participant group and in individual sub-groups. There was no significant difference in immediate versus seven-day post-training test scores overall and in all subgroups. In the sub-group comparisons, median improvement in score was significantly better in the non-anesthesia group and in the resident group. It was observed that team performance in terms of role clarity, closed-loop communication, and idea acceptance improved substantially during the subsequent scenarios. Conclusion Simulation-based training was effective in improving knowledge and team dynamics amongst health care workers regarding airway management in COVID-19 patients, with retention of up to one week. Similar future research can be planned for the affective and psychomotor domains.
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Abstract
OBJECTIVE The aim of this study was to assess the outcomes of tracheostomy in patients with COVID-19 respiratory failure. SUMMARY BACKGROUND DATA Tracheostomy has an essential role in managing COVID-19 patients with respiratory failure who require prolonged mechanical ventilation. However, limited data are available on how tracheostomy affects COVID-19 outcomes, and uncertainty surrounding risk of infectious transmission has led to divergent recommendations and practices. METHODS It is a multicenter, retrospective study; data were collected on all tracheostomies performed in COVID-19 patients at 7 hospitals in 5 tertiary academic medical systems from February 1, 2020 to September 4, 2020. RESULT Tracheotomy was performed in 118 patients with median time from intubation to tracheostomy of 22 days (Q1-Q3: 18-25). All tracheostomies were performed employing measures to minimize aerosol generation, 78.0% by percutaneous technique, and 95.8% at bedside in negative pressure rooms. Seventy-eight (66.1%) patients were weaned from the ventilator and 18 (15.3%) patients died from causes unrelated to tracheostomy. No major procedural complications occurred. Early tracheostomy (≤14 days) was associated with decreased ventilator days; median ventilator days (Q1-Q3) among patients weaned from the ventilator in the early, middle and late groups were 21 (21-31), 34 (26.5-42), and 37 (32-41) days, respectively with P = 0.030. Compared to surgical tracheostomy, percutaneous technique was associated with faster weaning for patients weaned off the ventilator [median (Q1-Q3): 34 (29-39) vs 39 (34-51) days, P = 0.038]; decreased ventilator-associated pneumonia (58.7% vs 80.8%, P = 0.039); and among patients who were discharged, shorter intensive care unit duration [median (Q1-Q3): 33 (27-42) vs 47 (33-64) days, P = 0.009]; and shorter hospital length of stay [median (Q1-Q3): 46 (33-59) vs 59.5 (48-80) days, P = 0.001]. CONCLUSION Early, percutaneous tracheostomy was associated with improved outcomes compared to surgical tracheostomy in a multi-institutional series of ventilated patients with COVID-19.
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Humidification via high-flow nasal cannula oxygen therapy does not generate aerosols. Br J Anaesth 2021; 127:e109-e110. [PMID: 34217469 PMCID: PMC9436467 DOI: 10.1016/j.bja.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 12/05/2022] Open
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Analysis of Droplet Splatter Patterns During Coblation Tonsil Surgery in the Covid-19 Pandemic. Ann Otol Rhinol Laryngol 2021:34894211018909. [PMID: 34027704 DOI: 10.1177/00034894211018909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess droplet splatter around the surgical field and surgeon during simulated Coblation tonsil surgery to better inform on mitigation strategies and evaluate choice of personal protective equipment. METHODS This was an observational study performed using a life-size head model to simulate tonsil surgery and fluorescein-soaked strawberries to mimic tonsils. The Coblation wand was activated over the strawberries for 5 minutes. This was repeated 5 times with 2 surgeons (totalling 10 data sets). The presence of droplet around the surgical field and anatomical subsites on the surgeon was assessed in binary fashion: present or not present. The results were collated as frequency of droplet detection and illustrated as a heatmap; 0 = white, 1-2 = yellow, 3-4 = orange, and 5 = red. RESULTS Fluorescein droplets were detected in all 4 quadrants of the surgical field. The frequency of splatter was greatest in the upper (nearest to surgeon) and lower quadrants. There were detectable splatter droplets on the surgeon; most frequently occurring on the hands followed by the forearm. Droplets were also detected on the visor, neck, and chest albeit less frequently. However, none were detected on the upper arms. CONCLUSION Droplet splatter can be detected in the immediate surgical field as well as on the surgeon. Although wearing a face visor does not prevent splatter on the surgical mask or around the eyes, it should be considered when undertaking tonsil surgery as well as a properly fitted goggle. LEVEL OF EVIDENCE 5.
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Effect of Wearing Personal Protective Equipment (PPE) on CPR Quality in Times of the COVID-19 Pandemic-A Simulation, Randomised Crossover Trial. J Clin Med 2021; 10:jcm10081728. [PMID: 33923620 PMCID: PMC8072569 DOI: 10.3390/jcm10081728] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 02/07/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) is considered an aerosol-generating procedure. Consequently, COVID-19 resuscitation guidelines recommend the use of personal protective equipment (PPE) during resuscitation. In this simulation of randomised crossover trials, we investigated the influence of PPE on the quality of chest compressions (CCs). Thirty-four emergency medical service BLS-providers performed two 20 min CPR sequences (five 2 min cycles alternated by 2 min of rest) on manikins, once with and once without PPE, in a randomised order. The PPE was composed of a filtering facepiece 3 FFP3 mask, safety glasses, gloves and a long-sleeved gown. The primary outcome was defined as the difference between compression depth with and without PPE; secondary outcomes were defined as differences in CC rate, release and the number of effective CCs. The participants graded fatigue and performance, while generalised estimating equations (GEE) were used to analyse data. There was no significant difference in CC quality between sequences without and with PPE regarding depth (mean depth 54 ± 5 vs. 54 ± 6 mm respectively), rate (mean rate 119 ± 9 and 118 ± 6 compressions per minute), release (mean release 2 ± 2 vs. 2 ± 2 mm) and the number of effective CCs (43 ± 18 vs. 45 ± 17). The participants appraised higher fatigue when equipped with PPE in comparison to when equipped without PPE (p < 0.001), and lower performance was appraised when equipped with PPE in comparison to when equipped without PPE (p = 0.031). There is no negative effect of wearing PPE on the quality of CCs during CPR in comparison to not wearing PPE.
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Guidelines for Robotic Flexible Endoscopy at the Time of COVID-19. Front Robot AI 2021; 8:612852. [PMID: 33718439 PMCID: PMC7947201 DOI: 10.3389/frobt.2021.612852] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/20/2021] [Indexed: 12/22/2022] Open
Abstract
Flexible endoscopy involves the insertion of a long narrow flexible tube into the body for diagnostic and therapeutic procedures. In the gastrointestinal (GI) tract, flexible endoscopy plays a major role in cancer screening, surveillance, and treatment programs. As a result of gas insufflation during the procedure, both upper and lower GI endoscopy procedures have been classified as aerosol generating by the guidelines issued by the respective societies during the COVID-19 pandemic-although no quantifiable data on aerosol generation currently exists. Due to the risk of COVID-19 transmission to healthcare workers, most societies halted non-emergency and diagnostic procedures during the lockdown. The long-term implications of stoppage in cancer diagnoses and treatment is predicted to lead to a large increase in preventable deaths. Robotics may play a major role in this field by allowing healthcare operators to control the flexible endoscope from a safe distance and pave a path for protecting healthcare workers through minimizing the risk of virus transmission without reducing diagnostic and therapeutic capacities. This review focuses on the needs and challenges associated with the design of robotic flexible endoscopes for use during a pandemic. The authors propose that a few minor changes to existing platforms or considerations for platforms in development could lead to significant benefits for use during infection control scenarios.
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Droplet and bone dust contamination from high-speed drilling during mastoidectomy. Clin Otolaryngol 2021; 46:614-618. [PMID: 33533176 DOI: 10.1111/coa.13725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/05/2021] [Accepted: 01/16/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this study was to examine contamination from otolaryngologic procedures involving high-speed drilling, specifically mastoid surgery, and to assess the adequacy of PPE in such procedures. DESIGN AND SETTING Mastoid surgery was simulated in a dry laboratory using a plastic temporal bone, microscope and handheld drill with irrigation and suction. Comparisons of distance of droplet and bone dust contamination and surgeon contamination were made under differing conditions. Irrigation speed, use of microscope and drill burr size and type were compared. MAIN OUTCOME MEASURES Measurement of the distance of field contamination while performing simulated mastoidectomy and location of surgeon contamination. RESULTS There was a greater distance field contamination and surgeon contamination without the use of the microscope. Contamination was reduced by using a smaller drill burr and by using a diamond burr when compared to a cutting burr. The use of goggles and a face mask provided good protection for the surgeon. However, the microscope alone may provide sufficient protection to negate the need for goggles. CONCLUSIONS While the risks of performing mastoid surgery during the coronavirus pandemic cannot be completely removed, they can be mitigated. Such factors include using the microscope for all drilling, using smaller size drill burrs and creating a safe zone around the operating table.
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Nebuliser Type Influences Both Patient-Derived Bioaerosol Emissions and Ventilation Parameters during Mechanical Ventilation. Pharmaceutics 2021; 13:199. [PMID: 33540764 PMCID: PMC7912998 DOI: 10.3390/pharmaceutics13020199] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 12/11/2022] Open
Abstract
COVID-19 may lead to serious respiratory complications which may necessitate ventilatory support. There is concern surrounding potential release of patient-derived bioaerosol during nebuliser drug refill, which could impact the health of caregivers. Consequently, mesh nebulisers have been recommended by various clinical practice guidelines. Currently, there is a lack of empirical data describing the potential for release of patient-derived bioaerosol during drug refill. This study examined the release of simulated patient-derived bioaerosol, and the effect on positive end expiratory pressure during nebuliser refill during mechanical ventilation of a simulated patient. During jet nebuliser refill, the positive end expiratory pressure decreased from 4.5 to 0 cm H2O. No loss in pressure was noted during vibrating mesh nebuliser refill. A median particle number concentration of 710 particles cm-3 above ambient was detected when refilling the jet nebuliser in comparison to no increase above ambient detected when using the vibrating mesh nebuliser. The jet nebuliser with the endotracheal tube clamped resulted in 60 particles cm-3 above ambient levels. This study confirms that choice of nebuliser impacts both the potential for patient-derived bioaerosol release and the ability to maintain ventilator circuit pressures and validates the recommended use of mesh nebulisers during mechanical ventilation.
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Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries. Otolaryngol Head Neck Surg 2020; 164:1136-1147. [PMID: 33138722 DOI: 10.1177/0194599820961985] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.
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Multidisciplinary Safety Recommendations After Tracheostomy During COVID-19 Pandemic: State of the Art Review. Otolaryngol Head Neck Surg 2020; 164:984-1000. [PMID: 32960148 DOI: 10.1177/0194599820961990] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. DATA SOURCES PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents. REVIEW METHODS Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. CONCLUSIONS Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel. IMPLICATIONS FOR PRACTICE Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.
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Aerosol Dispersion During Mastoidectomy and Custom Mitigation Strategies for Otologic Surgery in the COVID-19 Era. Otolaryngol Head Neck Surg 2020; 164:67-73. [PMID: 32660367 PMCID: PMC7361126 DOI: 10.1177/0194599820941835] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective To investigate small-particle aerosolization from mastoidectomy relevant to potential viral transmission and to test source-control mitigation strategies. Study Design Cadaveric simulation. Setting Surgical simulation laboratory. Methods An optical particle size spectrometer was used to quantify 1- to 10-µm aerosols 30 cm from mastoid cortex drilling. Two barrier drapes were evaluated: OtoTent1, a drape sheet affixed to the microscope; OtoTent2, a custom-structured drape that enclosed the surgical field with specialized ports. Results Mastoid drilling without a barrier drape, with or without an aerosol-scavenging second suction, generated large amounts of 1- to 10-µm particulate. Drilling under OtoTent1 generated a high density of particles when compared with baseline environmental levels (P < .001, U = 107). By contrast, when drilling was conducted under OtoTent2, mean particle density remained at baseline. Adding a second suction inside OtoTent1 or OtoTent2 kept particle density at baseline levels. Significant aerosols were released upon removal of OtoTent1 or OtoTent2 despite a 60-second pause before drape removal after drilling (P < .001, U = 0, n = 10, 12; P < .001, U = 2, n = 12, 12, respectively). However, particle density did not increase above baseline when a second suction and a pause before removal were both employed. Conclusions Mastoidectomy without a barrier, even when a second suction was added, generated substantial 1- to 10-µm aerosols. During drilling, large amounts of aerosols above baseline levels were detected with OtoTent1 but not OtoTent2. For both drapes, a second suction was an effective mitigation strategy during drilling. Last, the combination of a second suction and a pause before removal prevented aerosol escape during the removal of either drape.
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Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report. Chest 2020; 158:1499-1514. [PMID: 32512006 PMCID: PMC7274948 DOI: 10.1016/j.chest.2020.05.571] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/19/2020] [Accepted: 05/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs). Methods A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report. Results Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure. Conclusion This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.
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Application of a Modified Endoscopy Face Mask for Flexible Laryngoscopy During the COVID-19 Pandemic. Otolaryngol Head Neck Surg 2020; 163:107-109. [PMID: 32423299 DOI: 10.1177/0194599820928977] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Diagnostic flexible laryngoscopy (DFL) is a critical tool in the armamentarium of an otolaryngologist. However, in the midst of the COVID-19 pandemic, DFL represents a high-risk procedure for patients and otolaryngologists due to the risk of aerosolization. In cases where DFL is required, in patients with COVID-19 positivity or unknown COVID-19 status, we describe the use of a modified endoscopy face mask as an adjunct to personal protection equipment to reduce occupational transmission of COVID-19 while performing DFL. Our modified endoscopy mask provides an additional barrier against the transmission of airborne pathogens. The modified endoscopy face mask may also serve as a useful tool for otolaryngologists as they return to performing more aerosol-generating procedures in the outpatient setting.
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Extubation barrier drape to minimise droplet spread. Br J Anaesth 2020; 125:e195-e196. [PMID: 32312570 PMCID: PMC7151245 DOI: 10.1016/j.bja.2020.03.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/31/2022] Open
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Extubation of patients with COVID-19. Br J Anaesth 2020; 125:e192-e195. [PMID: 32303376 PMCID: PMC7144617 DOI: 10.1016/j.bja.2020.03.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 12/17/2022] Open
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