Negative-Pressure Aerosol Cover for COVID-19 Tracheostomy | Critical Care Medicine | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure 1.  View of the Operative Field With Aerosol Reduction Cover in Place
View of the Operative Field With Aerosol Reduction Cover in Place

The patient’s head is right. Visible is the position of the smoke evacuator, which creates negative pressure around the surgical field.

Figure 2.  Aerosol Reduction Cover in Place
Aerosol Reduction Cover in Place

Note position of the laryngoscope suspension arm at the head of the bed, allowing the aerosol cover to remain suspended over the surgical field.

1.
Zou  L, Ruan  F, Huang  M,  et al.  SARS-CoV-2 viral load in upper respiratory specimens of infected patients.   N Engl J Med. 2020;382(12):1177-1179. doi:10.1056/NEJMc2001737PubMedGoogle ScholarCrossref
2.
van Doremalen  N, Bushmaker  T, Morris  DH,  et al.  Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.   N Engl J Med. 2020;382(16):1564-1567. doi:10.1056/NEJMc2004973PubMedGoogle ScholarCrossref
3.
Givi  B, Schiff  BA, Chinn  SB,  et al.  Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic  [published online March 31, 2020].  JAMA Otolaryngol Head Neck Surg. 2020. doi:10.1001/jamaoto.2020.0780PubMedGoogle Scholar
4.
Parker  N, Schiff  B, Fritz  M,  et al; Airway and Swallowing Committee of the American Academy of Otolaryngology–Head and Neck Surgery. Tracheotomy recommendations during the COVID-19 pandemic. Accessed April 20, 2020. https://www.entnet.org/content/tracheotomy-recommendations-during-covid-19-pandemic
5.
Tay  JK, Khoo  ML, Loh  WS.  Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak  [published online March 31, 2020].  JAMA Otolaryngol Head Neck Surg. 2020. doi:10.1001/jamaoto.2020.0764PubMedGoogle Scholar
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Research Letter
April 28, 2020

Negative-Pressure Aerosol Cover for COVID-19 Tracheostomy

Author Affiliations
  • 1Department of Otolaryngology–Head & Neck Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
JAMA Otolaryngol Head Neck Surg. 2020;146(7):672-674. doi:10.1001/jamaoto.2020.1081

Because of the high virulence of the novel coronavirus responsible for causing COVID-19, many patients infected with the virus become critically ill, requiring prolonged intubation, and may ultimately require tracheostomy. Mucosal surfaces have been shown to be reservoirs for high concentrations of the virus, which can become aerosolized for up to 3 hours following manipulation.1,2 Surgeons performing tracheostomies are at high risk for exposure, and recently published guidelines recommend against elective, non–time-sensitive procedures.3 In the event that a tracheostomy is indicated in a patient with confirmed or suspected COVID-19, interventions that limit the spread of aerosols are critical to reducing exposure.4,5 Here we present the creation of a novel negative-pressure aerosol cover made out of readily available operating room materials as an additional barrier to limit the spread of aerosols during tracheostomy.

Methods

A patient was admitted to the hospital and required time-sensitive tracheostomy. The patient was negative for COVID-19 symptoms, and preoperative testing results for coronavirus were also negative. Written informed consent was obtained for the tracheostomy; however, we did not specifically obtain consent for the use of the cover because it was considered an extension of personal protective equipment. As a quality improvement safety initiative, formal institutional review board review was not required per our institution’s human research protection office guidelines.

Following intubation, the patient was prepared and draped in the standard manner. The laryngoscope suspension apparatus was placed at the head of the bed and was covered using an x-ray cassette drape. A sterile C-arm drape was cut along one seam and draped over the suspension arm and patient. A smoke evacuator and high-efficiency particulate air filtration unit was secured near the surgical field to create a negative-pressure environment. “Hand ports” for the surgeon and assistant were created by making 8-cm vertical cuts on each side of the tented drape in an ergonomic position for optimal movement during the procedure. An additional 20-cm horizontal “chest port” was cut into the drape to allow for passage of instruments to the surgeons. A flap was created over the chest port by applying an adhesive drape to cover the opening to limit aerosol spread while passing instruments. The tracheostomy was then performed using the standard surgical technique without complications (Figures 1 and 2). To allow safe removal of the drape, the high-efficiency smoke evacuator remained in effect while the cover was systematically folded starting from the center in a manner that continually kept the contaminated undersurface of the drape sequestered from contact. This was performed by 1 person to limit possible exposure to other members of the team.

Discussion

We present the creation of a negative-pressure aerosol reduction cover made out of readily available materials. We were able to perform a complete open tracheostomy procedure while operating entirely under this cover; however, as the highest risk for aerosolization begins when the airway is entered, it is reasonable to deploy the cover immediately prior to this portion of the procedure. The cover setup was generally easy to perform and able to be completed in less than 5 minutes. The plastic cover allows for generally good mobility of the surgeon’s hands; however, there is some limitation in forearm movement. Surgical instruments were able to be passed from the scrub technician to the surgeon with use of this cover. Although the drape used was translucent as a monolayer, there was some degree of glare if it became overlapped. This was overcome by changing one’s forearm position within the drape.

In patients with COVID-19 who require tracheostomy, limiting aerosol spread during the procedure is critical to reducing viral exposure of the health care team. We present the use of a novel negative-pressure aerosol reduction cover for use during tracheostomy. This cover was easy to create and deploy using readily available materials found in operating centers.

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Article Information

Accepted for Publication: April 14, 2020.

Published Online: April 28, 2020. doi:10.1001/jamaoto.2020.1081

Correction: This article was corrected on June 11, 2020, to add missing funding information.

Corresponding Author: J. Tyler Bertroche, MD, Department of Otolaryngology–Head & Neck Surgery, Washington University in St Louis School of Medicine, 1 Barnes-Jewish Plaza, St Louis, MO 63108 (jtbertroche@wustl.edu).

Author Contributions: Drs Bertroche, Pipkorn, and Zevallos had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Bertroche, Buchman, Zevallos.

Acquisition, analysis, or interpretation of data: Bertroche, Pipkorn, Zolkind, Zevallos.

Drafting of the manuscript: Bertroche, Buchman.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Zolkind, Zevallos.

Study supervision: Pipkorn, Buchman, Zevallos.

Conflict of Interest Disclosures: Dr Buchman reported receiving grants from the US Department of Defense and consulting fees from Cochlear Limited, Advanced Bionics, Envoy, and IotaMotion outside the submitted work; in addition, Dr Buchman had a patent to US9,072,468B2 licensed. No other disclosures were reported.

Funding/Support: Research reported in this publication was supported by the Foundation for Barnes-Jewish Hospital Otolaryngology Surgical Outcomes and Quality Improvement Unit (SOQIU) at Barnes-Jewish Hospital (grant 4090).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Zou  L, Ruan  F, Huang  M,  et al.  SARS-CoV-2 viral load in upper respiratory specimens of infected patients.   N Engl J Med. 2020;382(12):1177-1179. doi:10.1056/NEJMc2001737PubMedGoogle ScholarCrossref
2.
van Doremalen  N, Bushmaker  T, Morris  DH,  et al.  Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1.   N Engl J Med. 2020;382(16):1564-1567. doi:10.1056/NEJMc2004973PubMedGoogle ScholarCrossref
3.
Givi  B, Schiff  BA, Chinn  SB,  et al.  Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic  [published online March 31, 2020].  JAMA Otolaryngol Head Neck Surg. 2020. doi:10.1001/jamaoto.2020.0780PubMedGoogle Scholar
4.
Parker  N, Schiff  B, Fritz  M,  et al; Airway and Swallowing Committee of the American Academy of Otolaryngology–Head and Neck Surgery. Tracheotomy recommendations during the COVID-19 pandemic. Accessed April 20, 2020. https://www.entnet.org/content/tracheotomy-recommendations-during-covid-19-pandemic
5.
Tay  JK, Khoo  ML, Loh  WS.  Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak  [published online March 31, 2020].  JAMA Otolaryngol Head Neck Surg. 2020. doi:10.1001/jamaoto.2020.0764PubMedGoogle Scholar
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