To the Editor
In the Video in Clinical Medicine by Hashimoto et al. (Nov. 12 issue),1 the authors describe a technique for percutaneous tracheostomy that can reduce risks to health care workers when performing aerosol-generating procedures during the Covid-19 pandemic. However, some pandemic-related modifications to practice may imperil patients. Therefore, provisions are necessary to ensure patient safety. For example, pausing ventilation during tracheostomy reduces the risk of viral transmission to clinicians but may result in life-threatening derecruitment in critically ill patients.2 For this reason, we believe that an apnea test2 is advisable before pausing ventilation to ensure that the patient can safely withstand the transient loss of positive end-expiratory pressure.
Another consideration is monitoring. The video by Hashimoto et al. depicts a nurse exiting the procedure room to minimize exposure; however, having a dedicated person present to monitor vital signs and sedation improves patient safety. Task-focused proceduralists cannot reliably provide this surveillance.
Finally, the video discourages the practice of suturing tracheostomy tubes to minimize the risk of skin erosion; however, there are reliable strategies for protecting skin integrity, and the use of outer flange security sutures to anchor the tracheostomy tube reduces the risk of adverse events, including bleeding3 — a critical consideration for patients with Covid-19.4 Dislodgment of the tracheostomy tube remains distressingly common after tracheostomy, which underscores the importance of assessing precautionary measures that may reduce the risk of airway-related adverse events.5
Brendan A. McGrath, Ph.D.
Manchester University NHS Foundation Trust, Manchester, United Kingdom
Vinciya Pandian, Ph.D.
Johns Hopkins University, Baltimore, MD
Michael J. Brenner, M.D.
University of Michigan Medical School, Ann Arbor, MI
[email protected]
No potential conflict of interest relevant to this letter was reported.
This letter was published on February 3, 2021, at NEJM.org.
-
1. Hashimoto DA, Axtell AL, Auchincloss HG. Percutaneous tracheostomy. N Engl J Med 2020;383(20):e112–e112.
-
2. McGrath BA, Brenner MJ, Warrillow SJ, et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. Lancet Respir Med 2020;8:717–725.
-
3. Halum SL, Ting JY, Plowman EK, et al. A multi-institutional analysis of tracheotomy complications. Laryngoscope 2012;122:38–45.
-
4. Musoke N, Lo KB, Albano J, et al. Anticoagulation and bleeding risk in patients with COVID-19. Thromb Res 2020;196:227–230.
-
5. Brenner MJ, Pandian V, Milliren CE, et al. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth 2020;125(1):e104–e118.
To the Editor
We have observed several limitations of percutaneous tracheostomy in our practice. Bleeding from a damaged thyroid does not resolve spontaneously, and in the case of patients with Covid-19, establishment of hemostasis requires intervention, which increases the risk of infection among the staff. Therefore, a preoperative ultrasound examination of the neck may help prepare for surgery. Occasionally, the cuff of a tracheostomy tube is overfilled to avoid leakage of air from the trachea; however, an overfilled cuff increases the risk of damage to the trachea and the likelihood of later tracheal stenosis. In addition, percutaneous tracheostomy involves the use of a bronchoscope; therefore, it is not feasible to perform a series of tracheostomies in a short period when the number of bronchoscopes is limited and because of the long sterilization time. Because of these issues, we believe that in patients with Covid-19, open tracheostomy is preferable over percutaneous tracheostomy.1,2
Dmitry Tretiakow, M.D., Ph.D.
Andrzej Skorek, M.D., Ph.D.
Medical University of Gdańsk, Gdańsk, Poland
[email protected]
No potential conflict of interest relevant to this letter was reported.
This letter was published on February 3, 2021, at NEJM.org.
-
1. Sood RN, Dudiki N, Alape D, Maxfiel MW. Healthcare personnel safety during percutaneous tracheostomy in patients with COVID-19: proof-of-concept study. J Intensive Care Med 2020 December 16 (Epub ahead of print).
-
2. Kwak PE, Connors JR, Benedict PA, et al. Early outcomes from early tracheostomy for patients with COVID-19. JAMA Otolaryngol Head Neck Surg 2020 December 17 (Epub ahead of print).
To the Editor
The video by Hashimoto et al. on percutaneous tracheostomy in patients with Covid-19 shows that a minimum of three medical personnel must be present to safely perform the procedure: the bedside surgeon, a bronchoscopist, and a respiratory therapist. As clinicians, we need to be aware of signs of clinical instability in patients in the intensive care unit and of the anesthetics used to induce sedation and paralysis. For that reason, we include an intensivist as part of our team to assist with the bronchoscopy and with the selection and administration of medications and to monitor the patient’s condition during the procedures that take place in the intensive care unit.
The technique shown by Hashimoto et al. involves two periods of apnea, which is similar to the technique we use. During the first period, we shorten the tracheal tube by 5 to 7 cm to allow better maneuverability of the bronchoscope. Although a sealed adapter is used in the video, aerosol spillage can occur during bronchoscopy1; such spillage can be avoided with the use of a plastic cover.1,2 Withdrawal of the tracheal tube to the subglottis does not require deflating the cuff; without such deflation, the cuff can be anchored below the vocal cords. The second period of apnea seemed too long (>100 seconds) and predisposes the patient to clinically significant drops in oxygen saturation.3 Instead, it may take approximately 40 seconds from the time of dilation to placement of the tracheostomy tube.
Pablo Álvarez-Maldonado, M.D., M.H.A.
Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
[email protected]
Erick Vidal-Andrade, M.D.
José L. Sanjurjo-Martínez, M.D., M.Ed.
Hospital Español de México, Mexico City, Mexico
No potential conflict of interest relevant to this letter was reported.
This letter was published on February 3, 2021, at NEJM.org.
-
1. Koehler P, Cornely OA, Kochanek M. Bronchoscopy safety precautions for diagnosing COVID-19 associated pulmonary aspergillosis — a simulation study. Mycoses 2021;64:55–59.
-
2. Al Yaghchi C, Ferguson C, Sandhu G. Percutaneous tracheostomy in patients with COVID-19: sealing the bronchoscope with an in-line suction sheath. Br J Anaesth 2020;125(1):e185–e186.
-
3. Niroula A, Van Nostrand KM, Khullar OV, et al. Percutaneous tracheostomy with apnea during coronavirus disease 2019 era: a protocol and brief report of cases. Crit Care Explor 2020;2(5):e0134–e0134.
Response
With regard to monitoring, although we ask the nurse to exit the procedure room to minimize exposure to personnel, as recommended by the American College of Chest Physicians and others,2 the nurse monitors vital signs from outside the room and is ready to enter quickly to provide assistance. Another issue raised is whether to suture tracheostomy tubes. This is an ongoing matter of debate in the literature. At our institution, the practice across thoracic surgery, acute care surgery, and interventional pulmonology is not to suture a tracheostomy tube to the skin because institutional data have suggested that sutures do not prevent inadvertent decannulation but do increase the risk of peristomal skin ulceration. Other institutions should assess their own experience to determine whether a change in practice is warranted.
The choice of open or percutaneous tracheostomy is made by the physician performing the procedure. However, a Cochrane review that compared techniques showed no difference in mortality, life-threatening events, or major bleeding with the percutaneous tracheostomy and that the risk of wound infection was reduced with the use of the percutaneous approach.3 A multidisciplinary, multi-institutional group has suggested that both open and percutaneous approaches can be considered in patients with Covid-19,1 and each institution should select the method most appropriate for its resources and experience.
Daniel A. Hashimoto, M.D.
Andrea L. Axtell, M.D., M.P.H.
Hugh G. Auchincloss, M.D., M.P.H.
Massachusetts General Hospital, Boston, MA
[email protected]
Since publication of their article, the authors report no further potential conflict of interest.
This letter was published on February 3, 2021, at NEJM.org.
-
1. McGrath BA, Brenner MJ, Warrillow SJ, et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. Lancet Respir Med 2020;8:717–725.
-
2. Lamb CR, Desai NR, Angel L, et al. 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.
-
3. Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev 2016;7:CD008045–CD008045.
Les téléphones mobiles Samsung ont toujours été l’une des marques les plus populaires sur le marché avec une variété de fonctionnalités, l’enregistrement vocal étant l’une d’entre elles.