What infection control practices should be implemented when performing tracheostomy care and tracheostomy suctioning?

Invited Review| November 01 2020

Vinciya Pandian, PhD, MBA, MSN, APN, RN, ACNP-BC;

Vinciya Pandian, PhD, MBA, MSN, APN, RN, ACNP-BC

Vinciya Pandian is associate professor, Department of Nursing Faculty, and Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland.

Corresponding author: Vinciya Pandian, PhD, MBA, MSN, RN, ACNP-BC, Johns Hopkins School of Nursing, 525 N Wolfe St, Baltimore, MD 21205. (email: .)

Search for other works by this author on:

Linda L. Morris, PhD, APN, CCNS;

Linda L. Morris, PhD, APN, CCNS

Linda L. Morris is associate professor, Northwestern University Feinberg School of Medicine; Shirley Ryan AbilityLab, Chicago, Illinois.

Search for other works by this author on:

Martin B. Brodsky, PhD, ScM, CCC-SLP;

Martin B. Brodsky, PhD, ScM, CCC-SLP

Martin B. Brodsky is associate professor, Department of Physical and Rehabilitation, Division of Critical Care and Pulmonary and OACIS Research Group, Johns Hopkins University.

Search for other works by this author on:

James Lynch, MSc Nursing;

James Lynch is advanced critical care practitioner, Acute Intensive Care Unit, Manchester University National Health Services Foundation Trust, and National Tracheostomy Safety Project, Manchester, United Kingdom.

Search for other works by this author on:

Brian Walsh, PhD, RRT;

Brian Walsh is professor, Department of Health Sciences, Liberty University, Lynchburg, Virginia.

Search for other works by this author on:

Cynda Rushton, PhD, MSN, RN;

Cynda Rushton, PhD, MSN, RN

Cynda Rushton is professor, Johns Hopkins University Anne and George L. Bunting Berman Institute of Bioethics, Department of Nursing Faculty, Johns Hopkins School of Nursing, and Department of Pediatrics, Johns Hopkins School of Medicine; and adjunct professor, University of Technology of Sydney, Sydney, New South Wales, Australia.

Search for other works by this author on:

Jane Phillips, PhD, RN;

Jane Phillips is professor of Palliative Nursing, and director IMPACCT, University of Technology Sydney.

Search for other works by this author on:

Alphonsa Rahman, DNP, APRN, CNS;

Alphonsa Rahman, DNP, APRN, CNS

Alphonsa Rahman is critical care clinical nurse specialist, The Johns Hopkins Hospital, Baltimore, Maryland.

Search for other works by this author on:

Troy DeRose, MSN, CRNP, RNFA, CORLN;

Troy DeRose, MSN, CRNP, RNFA, CORLN

Troy DeRose is nurse practitioner, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Search for other works by this author on:

Leah Lambe, BSN, RN, CEN;

Leah Lambe is nursing clinical coordinator, Rapid Response Team, Hospital of the University of Pennsylvania, Phila-delphia, Pennsylvania.

Search for other works by this author on:

... Show more

Am J Crit Care (2020) 29 (6): e116–e127.

• Standard View
• Views Icon Views
  • Article contents
  • Figures & tables
  • Video
  • Audio
  • Supplementary Data
  • Peer Review
• PDF
• Tools Icon Tools

Citation

Vinciya Pandian, Linda L. Morris, Martin B. Brodsky, James Lynch, Brian Walsh, Cynda Rushton, Jane Phillips, Alphonsa Rahman, Troy DeRose, Leah Lambe, Lionel Lami, Sarah Pui Man Wu, Francisco Paredes Garza, Simona Maiani, Andrea Zavalis, Kafilat Ajoke Okusanya, Patrick A. Palmieri, Brendan A. McGrath, Paolo Pelosi, Mary Lou Sole, Patricia Davidson, Michael J. Brenner; Critical Care Guidance for Tracheostomy Care During the COVID-19 Pandemic: A Global, Multidisciplinary Approach. Am J Crit Care 1 November 2020; 29 (6): e116–e127. doi: https://doi.org/10.4037/ajcc2020561

Download citation file:

• Ris (Zotero)
• Reference Manager
• EasyBib
• Bookends
• Mendeley
• Papers
• EndNote
• RefWorks
• BibTex

The coronavirus disease 2019 (COVID-19) pandemic coincides with the culmination of the World Health Organization Nursing Now Campaign1  and the bicentennial of Florence Nightingale’s birth.2–5  The timing is significant because critical care nurses at the forefront of life-saving efforts are also at risk for infection with SARS-CoV-2 during tracheostomy care.6,7  High risks of viral aerosolization attend both the tracheotomy procedure in patients receiving invasive mechanical ventilation and the subsequent tracheostomy management during weaning and after liberation from the ventilator.8,9  Therefore, it is important for nurses and other providers caring for patients to protect themselves from harm.10  In this article, we summarize current evidence on caring for patients with a tracheostomy, outlining state-of-the-art consensus guidance while also acknowledging the challenges inherent in providing such care in low-resource health systems.11 

“Critical care nurses at the forefront of life-saving efforts are also at risk for infection with SARS-CoV-2 during tracheostomy care.”

Methods

A search for relevant studies was conducted in the PubMed, CINAHL Plus, Embase, PsycINFO, and Scopus databases. Keywords included coronavirus, COVID-19, SARS-CoV-2, SARS, MERS, tracheostomy, tracheotomy, nursing, ventilator, and critical care. Studies were included if they assessed aerosol-generating procedures or tracheostomy and were published in English between January 1 and May 31, 2020, to coincide with the COVID-19 pandemic. The inter-net (Google and Google Scholar search engines) and gray literature were also searched for recent evidence and expert opinions in the forms of national and global guidance. Content experts in tracheostomy from various disciplines, including nursing, anesthesia and critical care, surgery, respiratory therapy, and speech-language pathology from different continents, were identified, with increased representation from nursing in the areas of critical care and otolaryngology. Contributors reviewed content and quality of the studies independently; discrepancies were adjudicated through iterative discussion via email, phone, and video conference until consensus was reached. Key concepts related to tracheostomy included timing and location for procedure, tracheostomy tube sizing and type, cuff management, humidification, tracheostomy tube and stoma care, suctioning, nebulization, positioning, tube changes, transportation, speech, rehabilitation, decannulation, resuscitation, and ethical considerations.

Transmission, Pathogenesis, and Clinical Course of COVID-19

The high infectivity of SARS-CoV-2 is evident in the global spread of infection.12,13  SARS-CoV-2 is primarily transmitted through droplets generated by speech, coughing, and sneezing but may be found in blood, feces, urine, and semen.13–16  The pathogenesis of severe COVID-19 involves several steps. SARS-CoV-2 enters the respiratory tract, causes respiratory cells to lyse, and infects nearby cells, initiating a cytokine storm. Activated neutrophils release inter leukins (namely, interleukin-2, -7, and -10), leuko trienes, platelet-activating factors, oxidants, proteases, and tumor necrosis factor-α.17  These factors, in turn, increase alveolar-capillary membrane permeability, allowing fluid to leak into alveolar sacs and preventing gas exchange, resulting in hypoxemia and bilateral infiltrates (ie, interstitial pneumonitis). Patients typically present with fever, shortness of breath, cough, and fatigue. When patients’ illness progresses to acute respiratory distress syndrome, mechanical ventilation is required, sometimes necessitating tracheostomy, and some patients will experience ensuing progressive multiple organ dysfunction.17–20 

“Nurses and others assisting in the procedure should wear a fit-tested N95 mask, powered air-purifying respirator, or equivalent (filtering facepiece 3 [FFP3]) with or without a surgical mask and face shield.”

Considerations While Caring for a Patient With a Tracheostomy

Timing of a Tracheostomy

Patients critically ill with COVID-19 often require prolonged ventilatory support and are at risk of critical illness myopathy and neuropathy, requiring prolonged weaning and rehabilitation via tracheostomy.17–19,21,22  The timing of tracheostomy is controversial because the virus, even when inert and unable to grow in culture, may be amplified beyond 30 days (range, 8-37 days; median, 20 days; interquartile range, 17-24 days).22,23  Waiting until viral loads decrease may reduce risk to health care workers24 ; however, such delays also present challenges. Prolonged deferral of tracheostomy when clinically indicated limits pulmonary hygiene, impedes efforts to decrease sedation, and may predispose to cognitive impairments or nosocomial complications, in addition to exacerbating the strain on intensive care unit bed capacity.25  Prolonged intubation also interferes with normal voice and swallowing functions, as well as predisposing to laryngeal injuries, such as posterior glottis injury or subglottic stenosis.26  Early in the pandemic, Takhar et al27  observed that many patients positive for COVID-19 were extubated within 5 to 10 days after intubation. Building on this observation and integrating subsequent evidence, a multinational work group with expertise in nursing critical care, pulmonary, anesthesiology, intensive care medicine, otolaryngology, virology, and infectious disease partnered with medical ethicists and patient and family stakeholders. After evaluating clinical data and the timeline of SARS-CoV-2 viral load and immune response, this broad-based team arrived at a recommendation of 10 to 21 days postintubation for tracheostomy.28 

Setting Where Procedure Performed

Tracheostomy for patients requiring prolonged mechanical ventilation is performed in the operating room or at the bedside in intensive care units. The safety risk of transmission while transporting patients positive for COVID-19 to operating rooms must be considered.29,30  Procedures are ideally performed by experienced specialists in negative- pressure rooms equipped with high-efficiency particulate air filter using time-out and checklists ( Appendix).31–37  For patients negative for COVID-19, considerations of acuity and presence of a difficult airway may influence location. Experience from the 2003 era of severe acute respiratory syndrome favored an open surgical technique out of concern for aerosolization during bronchoscopy; however, percutaneous techniques have progressed significantly, and there currently are no data indicating superior safety profile with open versus percutaneous techniques.28,38 

Preparing for a Tracheostomy

Regardless of the procedure technique or location, tracheostomy is a high-risk, aerosol-generating procedure; therefore, nurses and others assisting in the procedure should wear a fit-tested N95 mask, powered air-purifying respirator, or equivalent (filtering facepiece 3 [FFP3]) with or without a surgical mask and face shield.24,36,39,40  A trained health care professional should monitor donning and doffing for quality assurance.41  Meticulous collection of equipment ( Appendix) is crucial to avoid multiple re-entries into procedure areas and unnecessary donning and doffing of personal protective equipment (PPE) (see Table).42  A dry run with the operating team before the procedure (using simulation centers,43  if available) clarifies all team members’ roles, responsibilities, and technique, with a senior operator performing the procedure to ensure efficiency and minimize exposure.24,44–47 

Size and Type of Initial Tracheostomy Tube

The size of the initial tracheostomy tube is chosen on the basis of several factors: the patient’s airway anatomy, the need to facilitate early phonation, and the risk for development of granulation tissue. Selection of a tube of the appropriate size is particularly important during COVID-19 to create a smaller stoma to reduce aerosolization,44  facilitate bronchial hygiene,27  reduce tracheostomy tube changes, and minimize ventilator leak around the cuff. A computed tomographic scan of the neck or chest provides measurement distance from skin to cricoid cartilage, aiding tube selection. If distance from skin to cricoid cartilage is greater than 4 cm, an extended-length tracheostomy tube may decrease need for additional tracheostomy tube changes.48  Ultrasound can also aid evaluation of anatomy and be useful during the procedure.49  Disposable inner-cannula tubes allow easier maintenance and decrease prolonged exposure to viral particles.28 

“A closed suction-circuit system reduces expulsion of aerosolized viral particles from positive-pressure ventilation.”

Tracheostomy Tube Cuff Management

Tracheostomy tube cuff pressures are typically maintained between 20 and 30 cm H2O but may be slightly increased to obtain a better seal,28,50  bearing in mind that daily duties such as in-bed bathing and raising the head of the bed to 30° may alter pressures.51  Low pressure increases the risk of microaspiration of upper airway secretions, leading to ventilator-associated pneumonia as well as aerosol- generating ventilation leak. Risk of tracheal stenosis, tracheomalacia, or tracheal necrosis developing increases with higher cuff pressures.52  Therefore, cuff pressure should be checked at least once per shift. Using minimum occlusion volume or minimal leak techniques, which are often used in low-resource settings, is discouraged because of aerosol generation. If these techniques are used in the absence of a manometer, then the clinician should wear an N95 (FFP3) mask or equivalent, gloves, goggles, and a face shield, and the patient should wear a surgical mask.

“A surgical mask is placed on the face and over the tracheostomy tube to reduce the potential for viral spread via respiratory droplets.”

Humidification

Because the tracheostomy bypasses the upper airway’s humidification, the standard of care is to ensure humidification. In patients with COVID-19, certain humidification devices should be used with caution, however. To minimize risk of viral particles being sprayed, use of pressurized cooled or heated aerosols is discouraged.28,53  Humidification is best provided by either an active (heated) pass-over humidifier with a bacterial and viral filter on the exhaust limb or port or a heat and moisture exchanger (HME) with built-in filter, if available.54–57  Most HMEs are not equipped with filters to prevent transmission of viral particles. Therefore, when caring for patients with a tracheostomy, health care workers should be alerted to this common limitation and take precautions to minimize risk of viral exposure.58  The patient’s hydration status and need for enteral mucolytic agents should also be assessed to minimize risk of occlusion from tenacious secretions.

Tracheostomy Tube Care

Cleaning stomas, dressing changes, cleaning or changing the inner cannula, and changing tracheos-tomy ties may all expose nurses to aerosolized particles. Therefore, performing these procedures on the basis of patient need is preferable to performing them at routine, scheduled intervals.53,54  Secretions of patients infected with COVID-19 may be of high volume, however, thus contributing to stomal inflammation and overall viral load if not carefully monitored. Careful assessment of the stoma site using an interdisciplinary care protocol, therefore, is imperative.59  Patency of tracheostomy tubes is confirmed by passing inline suction through a closed circuit, ensuring that the suction catheter passes freely beyond the distal tip of the tracheostomy tube without sticking or blockage.

Tracheostomy Suctioning: Closed Versus Open Circuit

For patients receiving mechanical ventilatory support, a closed suction-circuit system (Figure 1A) reduces expulsion of aerosolized viral particles from positive-pressure ventilation.54,55,60  If the patient does not require mechanical ventilation, a T-piece using an HME with expiratory filter may be used to maintain a closed system (Figure 1B).61,62  Suctioning requirements are usually increased during the first 48 hours after tracheostomy.63  Saline instillation is used sparingly or even avoided to prevent aerosolization and water-logging of the HME in the ventilator circuit.64,65  Nurses need to assess suctioning needs and communicate with physicians or advanced prac-tice providers to ensure appropriate orders for safe treatment of patients.

Inhaled Medication Administration

Administering medications via nebulizer through tracheostomy collars generates even more aerosol than most other aerosol-generating procedures (Figure 2).67–69  Nebulized medication delivery is discouraged because it causes sideways leakage of exhaled air, and dispersion distance increases with lung injury. Dispersion distance is 45 cm in the normal lung, 54 cm in mild lung injury, and 80 cm in severe lung injury.70  Vibrating mesh nebulizers that do not require disconnection of ventilator circuits are preferred for administering medications.71  Metered-dose inhalation is best administered via a spacer attached directly to the tra-cheostomy tube in patients not receiving mechanical ventilatory support or via ventilator circuit in those who are (Figure 2).66,71–81 

Managing the Tracheostomy During Proning

COVID-19 acute respiratory distress syndrome involves a vascular injury; disrupted vasoregulation may influence critical care strategy. Prone ventilation82  improves oxygenation and reduces lung atelectasis83  but introduces unique new challenges.84  Prone positioning is an effective intervention for acute respiratory distress syndrome in COVID-19 during noninvasive85  and invasive mechanical ventilation.86  An increasing number of patients with acute respiratory distress syndrome related to COVID-19 required prone positioning, which posed a challenge to the nurses. A rehabilitation-based prone team has been suggested to assist with prone positioning of patients.87  Prone position has been suggested for use in the early phase of severe hypoxemia in patients without a tracheostomy but has been necessary for patients with COVID-19 who have been admitted with a tracheostomy from a skilled-nursing facility or long-term acute care facility. In this case, particular attention has to be given to the those with a tracheostomy, because it is not easy to identify tracheostomy tube displacement. The patient’s head should be aligned properly with padding around the tracheostomy tube, and extra tubing may be needed to ensure airway patency and access for suctioning. Suturing the tracheostomy tube may also need be considered to decrease tracheostomy tube displacement. Thus, specific challenges have to be considered and monitored when proning a patient with a tracheostomy.

“Lack of PPE, rationing of ventilators, inability to isolate patients, and fear of contracting COVID-19 all may render nurses susceptible to moral distress or injury.”

Tracheostomy Tube Changes

The frequency of elective tracheostomy tube changes varies by institution.88  Some centers perform weekly or biweekly tracheostomy changes in patients with resistant infections, to assist in decreasing bacterial or viral load. Others may perform less frequent changes to avoid risking loss of airway or airway injury. Institutions that practice tracheostomy tube changes more regularly may consider decreasing frequency to reduce nurses’ exposure to aerosolized particles.50  Waiting 29 days is suggested, on the basis of manufacturing guidelines, unless earlier change of the tube is clinically warranted.65,89  This standard may impede timely transition to skilled nursing homes and long-term acute care hospitals that expect the first tracheostomy tube change to be performed by health care providers in acute care hospitals. Communication with the receiving institution is crucial for timely and safe transitioning, especially amid limited hospital-bed capacity.

Transporting Patients

The tracheostomy tube cuff should be inflated to maintain a closed system when transporting patients receiving mechanical ventilatory support with a tracheostomy within or between hospitals. For patients not receiving mechanical ventilatory support, an HME with viral filter may be placed on the tracheostomy tube, and a surgical mask is placed on the face and over the tracheostomy tube to reduce the potential for viral spread via respiratory droplets. Preplanning, collecting equipment, and effective communication ensure patient and staff safety.90–93 

Speech and Augmentative Communication

Restoring ability to communicate greatly decreases anxiety and improves patient and family experience. Augmentative and alternative communication devices, smartphones, and tablets are first-line methods of communication for patients with COVID-19. Cuff deflation for insertion of an inline, one-way speaking valve in patients receiving mechanical ventilatory support results in aerosol generation; therefore, it is generally discouraged. If cuff deflation is necessary to perform cognitive assessments or to facilitate end-of-life discussions, transient cuff deflation may be considered.94  During cuff deflation, the patient should wear a face mask to reduce the distances that aerosols can travel. Because patients not receiving mechanical ventilatory support have an open-circuit system, the cuff may be deflated to facilitate speech by either digital occlusion or a one-way speaking valve. Nevertheless, speech can generate aerosols. Nurses should wear surgical masks while communicating with patients with deflated cuffs and should maintain social distancing to minimize viral exposure.95,96 

Rehabilitation of Patients With COVID-19

Even after patients recover from COVID-19 critical illness, residual multisystem sequelae often persist. Rehabilitation aims to improve respiration, swallowing, mobility, cognition, emotional adjustment, and overall quality of life while reducing complications and disability.97  During acute hospitalization, early respiratory rehabilitation is highly recommended. Strategies include noninvasive ventilation, frequent changes in position, and passive range of motion. It is important to gradually increase patients’ anti-gravity position until an upright position can be maintained.97  Staff protection with an N95 mask or equivalent with or without surgical masks, gloves, and goggles or a face shield should continue en route to the rehabilitation environment until the patient is confirmed noninfectious.

Tracheostomy Decannulation

When the underlying reason for a tracheostomy tube has resolved, capping trials and decannulation should be approached conservatively in patients with COVID-19.28  Often, lung injury is severe in COVID-19; therefore, the patient should be monitored in an outpatient setting with tracheostomy in situ until healing of lung injury is confirmed. Viral polymerase chain reaction assay or antibody testing may guide downsizing, capping, and decannulating of tracheostomy tubes.98–101  When a patient is ready for downsizing and decannulation, appropriate PPE ensures protection from aerosolized particles (see Table).

Cardiopulmonary Resuscitation of Patients With a Tracheostomy

Data from Wuhan, China, on patients who experienced cardiac arrest (n = 136) showed that 87.5% of cardiac arrests had an underlying respiratory cause; for most (89.7%), the initial rhythm for cardiac arrest was asystole. Return of spontaneous circulation was achieved in 13.2% of patients (n = 18), with few alive at 30 days.102  The appropriateness of initiating and continuing cardiopulmonary resuscitation (CPR) should be considered early in patients’ care, in line with patients’ values and goals,103,104  and if the critical care team deems that CPR does not offer physiologic benefit, it may be withheld.105 

If a prone-positioned patient with a tracheostomy requires CPR, the prone position is maintained to prevent loss of airway.104,106–108  Conducting CPR in patients with COVID-19 is an intermediate- risk exposure event for clinicians.105  The cause of acute deterioration in condition may be a readily reversible airway occlusion, such as a mucous plug or malposition of the tracheostomy tube in patients with a tracheostomy; therefore, an urgent assessment of mechanical airway obstruction is warranted. Nurses should provide CPR even when some personal risk is present103,105,109  but only after donning appropriate PPE to ensure safety.104  A bag-mask valve should be used with a filter to decrease exposure during resuscitation.

Ethical Considerations

Few subjects are more fraught with fear than allocation of scarce resources amid a pandemic and duty to serve in instances that harbor risk for health care workers. The overarching principle of primum non nocere, “First, do no harm,” must consider the safety of patients and health care workers and societal needs. Opinions differ on how prevailing standards of care may be modified in the setting of a pandemic or other crisis; these issues have immediate relevance to care of patients with tracheostomy, whether in timing of the procedure or whether to perform CPR in a patient with progressive decline. Reconciling the benefits and countervailing risks of invasive care for patients and health care workers is an ongoing process.110  In the United Kingdom, clinicians were advised not to resuscitate patients with COVID-19 who had cardiac arrest in the hospital outside the emergency department, noting the poor prognosis and the aerosol-generating risk of CPR.111  Nurses and clinicians should identify reversible causes of arrest, such as an occluded tracheostomy tube.

Lack of PPE, rationing of ventilators, inability to isolate patients, and fear of contracting COVID-19 all may render nurses susceptible to moral distress or injury. Inability to allow family to visit patients, particularly when communication is limited by restrictions on cuff deflation, also amplifies distress. The strain of bearing witness to critically ill patients is not new to intensive care unit nurses, but the suffering of patients with COVID-19, many of whom undergo tracheostomy, is increased during surges. These clinical realities are superimposed on providers’ exhaustion from wearing PPE for prolonged periods, difficulty connecting with patients through protective gear, and fatigue from increased demands amid staff shortages.112  Organizational efforts are needed to mitigate moral distress and foster resilience.

Considerations for Low-Resource Health Systems

Challenges in safely treating patients with tracheostomy in low-resource settings include staff training, inadequate PPE, insufficient functioning ventilators or repairs, lack of medical oxygen, short supply of suction devices, and reliance on nonsterile suction catheters that are washed and reused between patients.113–118  Despite these constraints, remarkable ingenuity by critical care nurses and hospitals allows most evidence-based recommendations presented herein to be tailored for implementation within local protocols,119  with notable caveats in conventional sterilization techniques, limited testing, and lack of isolation rooms.120–122  Examples of ingenuity include gloves made from plastic materials melted in home-made heated molds, cutting 5-gallon water bottles into vented full-coverage face shields, and evidence-based substitution for infection control (eg, soaking used gloves in special available detergents).123 

Conclusion

Nurses have a critical role during the COVID-19 pandemic, especially when caring for patients with a tracheostomy. These guidelines address gaps in the literature and carefully ensure patient and staff safety. Aerosol generation and exposure risk can be minimized through use of closed systems, appropriate PPE, and other mindful practices. For low-resource countries, international recommendations, including protocols, may need to be adapted to the local context. Nurses and other health care team members need to care for themselves to optimize their physical and emotional health amidst a distressing and demanding environment. By working collaboratively to optimize care and by adhering to best practice in COVID-19 management, the dual goals of patient-centered care and health care worker safety can be ensured.

ACKNOWLEDGMENTS

The following people contributed to the multidisciplinary collaborative success of this manuscript: Sébastien Vergez, MD, PhD, ORL et Chirurgie Cervico-Faciale & Institut Univer-sitaire du Cancer de Toulouse - CHU Rangueil-Larrey & Oncopôle, Toulouse, France; Wong Wai Yeung Eddy, MBChB, chief, Division of Head and Neck Surgery, clinical associate professor, Department of Otorhinolaryngology, Head and Neck Surgery, Chinese University of Hong Kong, Hong Kong; Jose Manuel Añon, MD, PhD, jefe de sección, Servi-cio de Medicina Intensiva, Hospital Universitario La Paz-Carlos III, IdiPAZ, Madrid, Spain; and Joseph Forrester, MD, MSc, associate trauma medical director, assistant professor of surgery, Stanford University, Stanford, California.

Equipment Needed for Bedside Tracheostomy Procedure

Collect the following supplies:

• Sterile gownsa

• Sterile glovesa

• Bouffant caps

• N95 masks or equivalent

• Goggles or face shield

• Shoulder roll

• Free-flowing intravenous tubing and normal saline

• Central-catheter drape

• Sterile scissors

• Percutaneous tracheostomy kit or open tracheostomy tray for surgical technique

• Tracheostomy tubes (2 sizes)

• Cuff manometer

• 10-mL syringe

• Bronchoscope

• Curved hemostat

• Cricoid kit

• Sterile sutures

• Tracheal dilator

• Cricoid hook

• Electrocauteryb

• Medications per anesthesiologist

Ensure that the following supplies are available in the patient’s room:

• 2 working suction setups with suction tubing and suction catheters

• 500-mL bottle of sterile watera

• Infusion pump

• Manual resuscitation bag and mask

• Intubation supplies

• 4 × 4 gauze pads

• Limb restraints

REFERENCES

1

Munro

CL

Empowering nurses in 2020, the Year of the Nurse

.

Am J Crit Care

.

2020

;

29

(

3

):

165

–

167

.

2

McCarthy

C

State of the World’s Nursing 2020: Investing in Education, Jobs, and Leadership

.

World Health Organization

;

2020

.

3

Hetland

B

2020 – The year that needed the nurse: considerations for critical care nursing research and practice emerging in the midst of COVID-19

.

Heart Lung

.

2020

;

49

(

4

):

342

–

343

.

4

Treston

C

COVID-19 in the Year of the Nurse

.

J Assoc Nurses AIDS Care

.

2020

;

31

(

3

):

359

–

360

.

5

Munro

CL

The “lady with the lamp” illuminates critical care today

.

Am J Crit Care

.

2010

;

19

(

4

):

315

–

317

.

6

Schultz

MJ

Walking the line between benefit and harm from tracheostomy in COVID-19

.

Lancet Respir Med

.

2020

;

8

(

7

):

656

–

657

.

7

Zheng

L

Analysis of the infection status of the health care workers in Wuhan during the COVID-19 outbreak: a cross-sectional study

.

Clin Infect Dis

.

2020

;

ciaa588

.

8

McGrath

BA

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

.

Anaesthesia

.

Published online May 12, 2020

. doi:

9

Miles

BA

Tracheostomy during SARS-CoV-2 pandemic: recommendations from the New York Head and Neck Society

.

Head Neck

.

2020

;

42

(

6

):

1282

–

1290

.

10

Manning

HL

Pathophysiology of dyspnea

.

N Engl J Med

.

1995

;

333

(

23

):

1547

–

1553

.

11

Bong

CL

The COVID-19 pandemic: effects on low and middle-income countries

.

Anesth Analg

.

2020

;

131

(

2

):

86

–

92

.

12

Pillay

TS

Gene of the month: the 2019-nCoV/SARS-CoV-2 novel coronavirus spike protein

.

J Clin Pathol

.

2020

;

73

(

7

):

366

–

369

.

13

Wolfel

R

Virological assessment of hospitalized patients with COVID-2019

.

Nature

.

2020

;

581

(

7809

):

465

–

469

.

14

Asadi

S

Aerosol emission and superemission during human speech increase with voice loudness

.

Sci Rep

.

2019

;

9

(

1

):

2348

.

15

Cheng

PK

Viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome

.

Lancet

.

2004

;

363

(

9422

):

1699

–

1700

.

16

Xia

J

Does immune privilege result in recovered patients testing positive for COVID-19 again?

Biosci Trends

.

2020

;

14

(

3

):

209

–

211

.

17

Huang

C

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

.

Lancet

.

2020

;

395

(

10223

):

497

–

506

.

18

Lovato

A

Clinical presentation of COVID-19: a systematic review focusing on upper airway symptoms

.

Ear Nose Throat J

.

2020

:

145561320920762

.

19

Richardson

S

Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area

.

JAMA

.

2020

;

323

(

20

):

2052

–

2059

.

20

Ciceri

F

Microvascular COVID-19 lung vessels obstructive thromboinflammatory syndrome (MicroCLOTS): an atypical acute respiratory distress syndrome working hypothesis

.

Crit Care Resusc

.

2020

;

22

(

2

):

95

–

97

.

21

Bhatraju

PK

Covid-19 in critically ill patients in the Seattle region - case series

.

N Engl J Med

.

2020

;

382

(

21

):

2012

–

2022

.

22

Zhou

F

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

.

Lancet

.

2020

;

395

(

10229

):

1054

–

1062

.

23

Ferri

E

Indications and timing for tracheostomy in patients with SARS CoV2-related

.

Eur Arch Otorhinolaryngol

.

2020

;

277

(

8

):

2403

–

2404

.

24

Sommer

DD

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic

.

J Otolaryngol Head Neck Surg

.

2020

;

49

(

1

):

23

.

25

Pandharipande

PP

Long-term cognitive impairment after critical illness

.

N Engl J Med

.

2013

;

369

(

14

):

1306

–

1316

.

26

Brodsky

MB

Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: a systematic review

.

Crit Care Med

.

2018

;

46

(

12

):

2010

–

2017

.

27

Takhar

A

Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic

.

Eur Arch Otorhinolaryngol

.

2020

;

277

(

8

):

2173

–

2184

.

28

McGrath

BA

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance

.

Lancet Respir Med

.

2020

;

8

(

7

):

717

–

725

.

29

Tay

JK

Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak

.

JAMA Otolaryngol Head Neck Surg

.

Published online March 31, 2020

. doi:

30

Shiba

T

Tracheostomy considerations during the COVID-19 pandemic

.

OTO Open

.

2020

;

4

(

2

):

2473974X20922528

.

31

Ku

PK

Management of dysphagia in the head and neck cancer patient during COVID-19 pandemic: a practical strategy

.

Head Neck

.

2020

;

42

(

7

):

1491

–

1496

.

32

Heyd

CP

Tracheostomy protocols during COVID-19 pandemic

.

Head Neck

.

2020

;

42

(

6

):

1297

–

1302

.

33

Mecham

JC

Utility of tracheostomy in patients with COVID-19 and other special considerations

.

Laryngoscope

.

Published online May 5, 2020

. doi:

34

Dharmarajan

H

Tracheostomy time-out: new safety tool in the setting of COVID-19

.

Head Neck

.

2020

;

42

(

7

):

1397

–

1402

.

35

Soma

M

Operative team checklist for aerosol generating procedures to minimise exposure of healthcare workers to SARS-CoV-2

.

Int J Pediatr Otorhinolaryngol

.

2020

;

134

:

110075

.

36

Alhazzani

W

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19)

.

Crit Care Med

.

2020

;

48

(

6

):

e440

–

e469

.

37

Bertroche

JT

Negative-pressure aerosol cover for COVID-19 tracheostomy

.

JAMA Otolaryngol Head Neck Surg

.

2020

;

146

(

7

):

672

–

674

.

38

Angel

L

Novel percutaneous tracheostomy for critically ill patients with COVID-19

.

Ann Thorac Surg

.

2020

;

110

(

3

):

1006

–

1011

.

39

Bartoszko

JJ

Medical masks vs N95 respirators for preventing COVID-19 in health-care workers: a systematic review and meta-analysis of randomized trials

.

Influenza Other Respir Viruses

.

2020

;

14

(

4

):

365

–

373

.

40

Howard

BE

High-risk aerosol-generating procedures in COVID-19: respiratory protective equipment considerations

.

Otolaryngol Head Neck Surg

.

2020

;

163

(

1

):

98

–

103

.

41

Centers for Disease Control and Prevention

Interim U.S. guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease 2019 (COVID-19)

.

2020

. Accessed May 9, 2020.

42

Cordier

PY

Health workers’ safety during tracheostomy in COVID-19 patients: homemade protective screen

.

Head Neck

.

2020

;

42

(

7

):

1361

–

1362

.

43

Cook

TM

Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists

.

Anaesthesia

.

2020

;

75

(

6

):

785

–

799

.

44

Givi

B

Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic

.

JAMA Otolaryngol Head Neck Surg

.

Published online March 31, 2020

. doi:

45

Airway and Swallowing Committee of the American Academy of Otolaryngology-Head and Neck Surgery

Tracheotomy recommendations during the COVID-19 pandemic

.

2020

. Accessed May 20, 2020.

46

Bedwell

JR

Multidisciplinary tracheostomy care: how collaboratives drive quality improvement

.

Otolaryngol Clin North Am

.

2019

;

52

(

1

):

135

–

147

.

47

Brenner

MJ

Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardization, education and patient partnership

.

Br J Anesth

.

2020

;

121

(

1

):

e104

–

e118

.

48

Pandian

V

Predicting the need for nonstandard tracheostomy tubes in critically ill patients

.

J Crit Care

.

2017

;

37

:

173

–

178

.

49

Gobatto

ALN

Ultrasound-guided percutaneous dilational tracheostomy: a systematic review of randomized controlled trials and meta-analysis

.

J Intensive Care Med

.

2020

;

35

(

5

):

445

–

452

.

50

David

AP

Tracheostomy guidelines developed at a large academic medical center during the COVID-19 pandemic

.

Head Neck

.

2020

;

42

(

6

):

1291

–

1296

.

51

Beccaria

LM

Tracheal cuff pressure change before and after the performance of nursing care

.

Rev Bras Enferm

.

2017

;

70

(

6

):

1145

–

1150

.

52

Cooper

JD

Tracheal injuries complicating prolonged intubation and tracheostomy

.

Thorac Surg Clin

.

2018

;

28

(

2

):

139

–

144

.

53

Yaneza

M

ENTUK guidelines for changes in ENT during COVID-19 pandemic

.

2020

. Accessed July 31, 2020.

54

Australia and New Zealand Intensive Care Society

The Aus-tralian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines

.

Version 1. 2020

. Accessed July 31, 2020.

55

National Tracheostomy Safety Project

.

Considerations for tracheostomy in the COVID-19 outbreak

.

2020

. Accessed July 31, 2020.

56

De Seta

D

Management of tracheostomy during COVID-19 outbreak: heat and moisture exchanger filter and closed suctioning system

.

Oral Oncol

.

2020

;

106

:

104777

.

57

Kelley

J

The Kelley Circuit: a solution for the management of in-hospital self-ventilating tracheostomy patietns, providing humidification and filtration, with closed circuit suctioning

.

2020

.

The Wellington Hospital

. Accessed May 31, 2020.

58

Brusasco

C

In vitro evaluation of heat and moisture exchangers designed for spontaneously breathing tracheostomized patients

.

Respir Care

.

2013

;

58

(

11

):

1878

–

1885

.

59

Carroll

DJ

Implementation of an interdisciplinary tracheostomy care protocol to decrease rates of tracheostomy-related pressure ulcers and injuries

.

Am J Otolaryngol

.

2020

;

41

(

4

):

102480

.

60

Balakrishnan

K

COVID-19 pandemic: what every otolaryngologist-head and neck surgeon needs to know for safe airway management

.

Otolaryngol Head Neck Surg

.

2020

;

162

(

6

):

804

–

808

.

61

Kligerman

MP

Managing head and neck cancer patients with tracheostomy or laryngectomy during the COVID-19 pandemic

.

Head Neck

.

2020

;

42

(

6

):

1209

–

1213

.

62

Goldman

RA

Tracheostomy management during the COVID-19 pandemic

.

Otolaryngol Head Neck Surg

.

2020

;

163

(

1

):

67

–

69

.

63

Intensive Care National Audit & Research Centre

ICNARC report on COVID-19 in critical care

.

2020

. Accessed July 31, 2020.

64

Wang

CH

Normal saline instillation before suctioning: a meta-analysis of randomized controlled trials

.

Aust Crit Care

.

2017

;

30

(

5

):

260

–

265

.

65

Ng

J

Tracheostomy tube change

.

StatPearls [Internet]

.

StatPearls Publishing

;

2020

.

66

Hui

DS

Aerosol dispersion during various respiratory therapies: a risk assessment model of nos-ocomial infection to health care workers

.

Hong Kong Med J

.

2014

;

20

(

suppl 4

):

9

–

13

.

67

Li

J

Defining aerosol generating procedures and pathogen transmission risks in healthcare settings

.

Open Forum Infect Dis

.

2017

;

4

(

suppl 1

):

S34

–

S35

.

68

Tran

K

Aerosol-Generating Procedures and Risk of Transmission of Acute Respiratory Infections: A Systematic Review

.

Canadian Agency for Drugs and Technologies in Health

;

2011

.

69

Tran

K

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

.

PLoS One

.

2012

;

7

(

4

):

e35797

.

70

Ferioli

M

Protecting healthcare workers from SARS-CoV-2 infection: practical indications

.

Eur Respir Rev

.

2020

;

29

(

155

):

200068

.

71

Respiratory Care Committee of Chinese Thoracic Society

Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia

].

Zhonghua Jie He He Hu Xi Za Zhi

.

2020

;

43

(

4

):

288

–

296

.

72

Chan

MT

Mask ventilation and dispersion of exhaled air

.

Am J Respir Crit Care Med

.

2013

;

187

(

7

):

e12

–

14

.

73

Chan

MTV

Exhaled air dispersion during bag-mask ventilation and sputum suctioning – implications for infection control

.

Sci Rep

.

2018

;

8

(

1

):

198

.

74

Hui

DS

Exhaled air dispersion and removal is influenced by isolation room size and ventilation settings during oxygen delivery via nasal cannula

.

Respirology

.

2011

;

16

(

6

):

1005

–

1013

.

75

Hui

DS

Exhaled air dispersion during coughing with and without wearing a surgical or N95 mask

.

PLoS One

.

2012

;

7

(

12

):

e50845

.

76

Hui

DS

Exhaled air and aerosolized droplet dispersion during application of a jet nebulizer

.

Chest

.

2009

;

135

(

3

):

648

–

654

.

77

Hui

DS

Exhaled air dispersion during noninvasive ventilation via helmets and a total facemask

.

Chest

.

2015

;

147

(

5

):

1336

–

1343

.

78

Hui

DS

Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks

.

Eur Respir J

.

2019

;

53

(

4

).

79

Hui

DS

Exhaled air dispersion distances during noninvasive ventilation via different Respironics face masks

.

Chest

.

2009

;

136

(

4

):

998

–

1005

.

80

Hui

DS

Exhaled air dispersion during oxygen delivery via a simple oxygen mask

.

Chest

.

2007

;

132

(

2

):

540

–

546

.

81

Hui

DS

Impact of severe acute respiratory syndrome (SARS) on pulmonary function, functional capacity and quality of life in a cohort of survivors

.

Thorax

.

2005

;

60

(

5

):

401

–

409

.

82

Marini

JJ

Management of COVID-19 respiratory distress

.

JAMA

.

Published online ahead of print April 24, 2020

. doi:

83

Guerin

C

Prone positioning in severe acute respiratory distress syndrome

.

N Engl J Med

.

2013

;

368

(

23

):

2159

–

2168

.

84

National COVID-19 Evidence Taskforce

Australian guidelines for the clinical care of people with COVID-19

.

2020

. Accessed May 25, 2020.

85

Bower

G

Protocol for awake prone positioning in COVID-19 patients: to do it earlier, easier, and longer

.

Crit Care

.

2020

;

24

(

1

):

371

.

86

Shang

Y

Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China

.

Ann Intensive Care

.

2020

;

10

(

1

):

73

.

87

Ng

JA

Prone positioning of patients with acute respiratory distress syndrome related to COVID-19: a rehabilitation-based prone team

.

Phys Ther

.

Published online July 16, 2020

. doi:

88

Global Tracheostomy Collaborative

Global Tracheostomy Collaborative Database

.

CAPQA Boston Children’s Hospital

;

2020

.

89

Food and Drug Administration

Smith Medicals Portex Trache-ostomy Tubes [letter]

.

2018

. Accessed May 30, 2020.

90

Albrecht

R

Transport of COVID-19 and other highly contagious patients by helicopter and fixed-wing air ambulance: a narrative review and experience of the Swiss air rescue Rega

.

Scand J Trauma Resusc Emerg Med

.

2020

;

28

(

1

):

40

.

91

Liew

MF

Safe patient transport for COVID-19

.

Crit Care

.

2020

;

24

(

1

):

94

.

92

Tien

H

Critical care transport in the time of COVID-19

.

CJEM

.

Published online May 13, 2020

. doi:

93

Yousuf

B

Transport of critically ill COVID-19 patients

.

Intensive Care Med

.

2020

;

64

(

8

):

1663

–

1664

.

94

Zaga

CJ

Speech-language pathology guidance for trachesotomy during the COVID-19 pandemic: an international multidisciplinary perspective

.

Am J Speech Lang Pathol

.

2020

;

29

(

3

):

1320

–

1334

.

95

Anfinrud

P

Visualizing speech-generated oral fluid droplets with laser light scattering

.

N Engl J Med

.

2020

;

382

(

21

):

2061

–

2063

.

96

Stadnytskyi

V

The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission

.

Proc Natl Acad Sci USA

.

2020

;

117

(

22

):

11875

–

11877

.

97

Brugliera

L

Rehabilitation of COVID-19 patients

.

J Rehabil Med

.

2020

;

52

(

4

):

jrm00046

.

98

Wang

Y

Combination of RT-qPCR testing and clinical features for diagnosis of COVID-19 facilitates management of SARS-CoV-2 outbreak

.

J Med Virol

.

2020

;

92

(

6

):

538

–

539

.

99

Ai

T

Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases

.

Radiology

.

2020

:

200642

.

100

Yang

W

Patients with RT-PCR-confirmed COVID-19 and normal chest CT

.

Radiology

.

2020

;

296

(

2

):

e32

–

e40

.

101

Li

Y

Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19

.

J Med Virol

.

2020

;

92

(

7

):

903

–

908

.

102

Shao

F

In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China

.

Resuscitation

.

2020

;

151

:

18

–

23

.

103

Curtis

JR

The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19)

.

JAMA

.

Published online March 27, 2020

. doi:

104

Edelson

DP

Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines((R))-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians

.

Circulation

.

2020

;

141

(

25

):

e933

–

e943

.

105

Fischkoff

K

Society of Critical Care Medicine crisis standard of care recommendations for triaging critical resources during the COVID-19 pandemic

2020

. Accessed May 20, 2020.

106

Bhatnagar

V

Cardiopulmonary resuscitation: unusual techniques for unusual situations

.

J Emerg Trauma Shock

.

2018

;

11

(

1

):

31

–

37

.

107

Medrzycka-Dabrowska

W

Prone ventilation of critically ill adults with COVID-19: how to perform CPR in cardiac arrest?

Crit Care

.

2020

;

24

(

1

):

258

.

108

Barker

J

A need for prone position CPR guidance for intubated and non-intubated patients during the COVID-19 pandemic

.

Resuscitation

.

2020

;

151

:

135

–

136

.

109

Cohen

IG

Potential legal liability for withdrawing or withholding ventilators during COVID-19: assessing the risks and identifying needed reforms

.

JAMA

.

Published online April 1, 2020

. doi:

110

Fritz

Z

Cardiopulmonary resuscitation after hospital admission with Covid-19

.

BMJ

.

2020

;

369

:

m1387

.

111

Mahase

E

Covid-19: doctors are told not to perform CPR on patients in cardiac arrest

.

BMJ

.

2020

;

368

:

m1282

.

112

Rushton

CH

Burnout and resilience among nurses practicing in high-intensity settings

.

Am J Crit Care

.

2015

;

24

(

5

):

412

–

420

.

113

Inglis

R

Optimizing respiratory management in resource-limited settings

.

Curr Opin Crit Care

.

2019

;

25

(

1

):

45

–

53

.

114

Lone

SA

COVID-19 pandemic – an African perspective

.

Emerg Microbes Infect

.

2020

;

9

(

1

):

1300

–

1308

.

115

McMahon

DE

Global resource shortages during COVID-19: bad news for low-income countries

.

PLoS Negl Trop Dis

.

2020

;

14

(

7

):

e0008412

.

116

Sutton

L

Barriers to improving tracheostomy care in low- and middle-income countries: our experience of a 23 patient closed loop audit cycle

.

Clin Otolaryngol

.

2018

;

43

(

5

):

1392

–

1395

.

117

Khan

MM

Safety guidelines for sterility of face shields during COVID 19 pandemic

.

Indian J Otolaryngol Head Neck Surg

.

2020

:

1

–

2

.

118

Tabah

A

Personal protective equipment and intensive care unit healthcare worker safety in the COVID-19 era (PPE-SAFE): an international survey

.

J Crit Care

.

2020

;

59

:

70

–

75

.

119

Ayebare

RR

Adoption of COVID-19 triage strategies for low-income settings

.

Lancet Respir Med

.

2020

;

8

(

4

):

e22

.

120

Desai

AN

Global infection prevention gaps, needs, and utilization of educational resources: a cross-sectional assessment by the International Society for Infectious Diseases

.

Int J Infect Dis

.

2019

;

82

:

54

–

60

.

121

Dondorp

AM

Respiratory support in COVID-19 patients, with a focus on resource-limited settings

.

Am J Trop Med Hyg

.

2020

;

102

(

6

):

1191

–

1197

.

122

Fast

O

Limited sterile processing capabilities for safe surgery in low-income and middle-income countries: experience in the Republic of Congo, Madagascar and Benin

.

BMJ Glob Health

.

2017

;

2

(

suppl 4

):

e000428

.

123

Pecchia

L

The inadequacy of regulatory frameworks in time of crisis and in low-resource settings: personal protective equipment and COVID-19

.

Health Technol (Berl)

.

2020

:

1

–

9

.

©2020 American Association of Critical-Care Nurses

2020

Footnotes

aLow-resource health systems should consider using equipment (eg, available gowns; boiled, distilled water) available in their settings.

bPrecautions must be taken with use around oxygen (inflammable); a grounding pad is required for monopolar cautery.

FINANCIAL DISCLOSURES

None of the authors received any funding for this work. Vinciya Pandian is a consultant for Medtronic.

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, .

Data & Figures

Figure 1

Suctioning of patients receiving mechanical ventilatory support. (A) This cross-sectional view displays the placement of the tracheostomy tube within the trachea and the attachments necessary to create a closed circuit when suctioning a patient who is receiving mechanical ventilatory support. A heat and moisture exchanger (HME) filter is recommended between the tracheostomy tube and the ventilator tubing. (B) This cross-sectional view displays the placement of the tracheostomy within the trachea and how an inline suction catheter with a sleeve and an HME filter could be used to imitate a closed-circuit system and minimize the aerosolization of viral particles.

Figure 1

Suctioning of patients receiving mechanical ventilatory support. (A) This cross-sectional view displays the placement of the tracheostomy tube within the trachea and the attachments necessary to create a closed circuit when suctioning a patient who is receiving mechanical ventilatory support. A heat and moisture exchanger (HME) filter is recommended between the tracheostomy tube and the ventilator tubing. (B) This cross-sectional view displays the placement of the tracheostomy within the trachea and how an inline suction catheter with a sleeve and an HME filter could be used to imitate a closed-circuit system and minimize the aerosolization of viral particles.

Close modal

Figure 2

Exhaled air dispersion distance. This figure provides a diagrammatic representation of the distance (in centimeters) of exhaled air dispersion for each procedure based on findings from the Hui et al66  studies in simulated models. The distance increases in a counterclockwise direction.

Figure 2

Exhaled air dispersion distance. This figure provides a diagrammatic representation of the distance (in centimeters) of exhaled air dispersion for each procedure based on findings from the Hui et al66  studies in simulated models. The distance increases in a counterclockwise direction.

Close modal

Table

Personal protective equipment and clinical considerations for tracheostomy care

Supplements

References

1

Munro

CL

Empowering nurses in 2020, the Year of the Nurse

.

Am J Crit Care

.

2020

;

29

(

3

):

165

–

167

.

2

McCarthy

C

State of the World’s Nursing 2020: Investing in Education, Jobs, and Leadership

.

World Health Organization

;

2020

.

3

Hetland

B

2020 – The year that needed the nurse: considerations for critical care nursing research and practice emerging in the midst of COVID-19

.

Heart Lung

.

2020

;

49

(

4

):

342

–

343

.

4

Treston

C

COVID-19 in the Year of the Nurse

.

J Assoc Nurses AIDS Care

.

2020

;

31

(

3

):

359

–

360

.

5

Munro

CL

The “lady with the lamp” illuminates critical care today

.

Am J Crit Care

.

2010

;

19

(

4

):

315

–

317

.

6

Schultz

MJ

Walking the line between benefit and harm from tracheostomy in COVID-19

.

Lancet Respir Med

.

2020

;

8

(

7

):

656

–

657

.

7

Zheng

L

Analysis of the infection status of the health care workers in Wuhan during the COVID-19 outbreak: a cross-sectional study

.

Clin Infect Dis

.

2020

;

ciaa588

.

8

McGrath

BA

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

.

Anaesthesia

.

Published online May 12, 2020

. doi:

9

Miles

BA

Tracheostomy during SARS-CoV-2 pandemic: recommendations from the New York Head and Neck Society

.

Head Neck

.

2020

;

42

(

6

):

1282

–

1290

.

10

Manning

HL

Pathophysiology of dyspnea

.

N Engl J Med

.

1995

;

333

(

23

):

1547

–

1553

.

11

Bong

CL

The COVID-19 pandemic: effects on low and middle-income countries

.

Anesth Analg

.

2020

;

131

(

2

):

86

–

92

.

12

Pillay

TS

Gene of the month: the 2019-nCoV/SARS-CoV-2 novel coronavirus spike protein

.

J Clin Pathol

.

2020

;

73

(

7

):

366

–

369

.

13

Wolfel

R

Virological assessment of hospitalized patients with COVID-2019

.

Nature

.

2020

;

581

(

7809

):

465

–

469

.

14

Asadi

S

Aerosol emission and superemission during human speech increase with voice loudness

.

Sci Rep

.

2019

;

9

(

1

):

2348

.

15

Cheng

PK

Viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome

.

Lancet

.

2004

;

363

(

9422

):

1699

–

1700

.

16

Xia

J

Does immune privilege result in recovered patients testing positive for COVID-19 again?

Biosci Trends

.

2020

;

14

(

3

):

209

–

211

.

17

Huang

C

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

.

Lancet

.

2020

;

395

(

10223

):

497

–

506

.

18

Lovato

A

Clinical presentation of COVID-19: a systematic review focusing on upper airway symptoms

.

Ear Nose Throat J

.

2020

:

145561320920762

.

19

Richardson

S

Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area

.

JAMA

.

2020

;

323

(

20

):

2052

–

2059

.

20

Ciceri

F

Microvascular COVID-19 lung vessels obstructive thromboinflammatory syndrome (MicroCLOTS): an atypical acute respiratory distress syndrome working hypothesis

.

Crit Care Resusc

.

2020

;

22

(

2

):

95

–

97

.

21

Bhatraju

PK

Covid-19 in critically ill patients in the Seattle region - case series

.

N Engl J Med

.

2020

;

382

(

21

):

2012

–

2022

.

22

Zhou

F

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

.

Lancet

.

2020

;

395

(

10229

):

1054

–

1062

.

23

Ferri

E

Indications and timing for tracheostomy in patients with SARS CoV2-related

.

Eur Arch Otorhinolaryngol

.

2020

;

277

(

8

):

2403

–

2404

.

24

Sommer

DD

Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic

.

J Otolaryngol Head Neck Surg

.

2020

;

49

(

1

):

23

.

25

Pandharipande

PP

Long-term cognitive impairment after critical illness

.

N Engl J Med

.

2013

;

369

(

14

):

1306

–

1316

.

26

Brodsky

MB

Laryngeal injury and upper airway symptoms after oral endotracheal intubation with mechanical ventilation during critical care: a systematic review

.

Crit Care Med

.

2018

;

46

(

12

):

2010

–

2017

.

27

Takhar

A

Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic

.

Eur Arch Otorhinolaryngol

.

2020

;

277

(

8

):

2173

–

2184

.

28

McGrath

BA

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance

.

Lancet Respir Med

.

2020

;

8

(

7

):

717

–

725

.

29

Tay

JK

Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak

.

JAMA Otolaryngol Head Neck Surg

.

Published online March 31, 2020

. doi:

30

Shiba

T

Tracheostomy considerations during the COVID-19 pandemic

.

OTO Open

.

2020

;

4

(

2

):

2473974X20922528

.

31

Ku

PK

Management of dysphagia in the head and neck cancer patient during COVID-19 pandemic: a practical strategy

.

Head Neck

.

2020

;

42

(

7

):

1491

–

1496

.

32

Heyd

CP

Tracheostomy protocols during COVID-19 pandemic

.

Head Neck

.

2020

;

42

(

6

):

1297

–

1302

.

33

Mecham

JC

Utility of tracheostomy in patients with COVID-19 and other special considerations

.

Laryngoscope

.

Published online May 5, 2020

. doi:

34

Dharmarajan

H

Tracheostomy time-out: new safety tool in the setting of COVID-19

.

Head Neck

.

2020

;

42

(

7

):

1397

–

1402

.

35

Soma

M

Operative team checklist for aerosol generating procedures to minimise exposure of healthcare workers to SARS-CoV-2

.

Int J Pediatr Otorhinolaryngol

.

2020

;

134

:

110075

.

36

Alhazzani

W

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19)

.

Crit Care Med

.

2020

;

48

(

6

):

e440

–

e469

.

37

Bertroche

JT

Negative-pressure aerosol cover for COVID-19 tracheostomy

.

JAMA Otolaryngol Head Neck Surg

.

2020

;

146

(

7

):

672

–

674

.

38

Angel

L

Novel percutaneous tracheostomy for critically ill patients with COVID-19

.

Ann Thorac Surg

.

2020

;

110

(

3

):

1006

–

1011

.

39

Bartoszko

JJ

Medical masks vs N95 respirators for preventing COVID-19 in health-care workers: a systematic review and meta-analysis of randomized trials

.

Influenza Other Respir Viruses

.

2020

;

14

(

4

):

365

–

373

.

40

Howard

BE

High-risk aerosol-generating procedures in COVID-19: respiratory protective equipment considerations

.

Otolaryngol Head Neck Surg

.

2020

;

163

(

1

):

98

–

103

.

41

Centers for Disease Control and Prevention

Interim U.S. guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease 2019 (COVID-19)

.

2020

. Accessed May 9, 2020.

42

Cordier

PY

Health workers’ safety during tracheostomy in COVID-19 patients: homemade protective screen

.

Head Neck

.

2020

;

42

(

7

):

1361

–

1362

.

43

Cook

TM

Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists

.

Anaesthesia

.

2020

;

75

(

6

):

785

–

799

.

44

Givi

B

Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic

.

JAMA Otolaryngol Head Neck Surg

.

Published online March 31, 2020

. doi:

45

Airway and Swallowing Committee of the American Academy of Otolaryngology-Head and Neck Surgery

Tracheotomy recommendations during the COVID-19 pandemic

.

2020

. Accessed May 20, 2020.

46

Bedwell

JR

Multidisciplinary tracheostomy care: how collaboratives drive quality improvement

.

Otolaryngol Clin North Am

.

2019

;

52

(

1

):

135

–

147

.

47

Brenner

MJ

Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardization, education and patient partnership

.

Br J Anesth

.

2020

;

121

(

1

):

e104

–

e118

.

48

Pandian

V

Predicting the need for nonstandard tracheostomy tubes in critically ill patients

.

J Crit Care

.

2017

;

37

:

173

–

178

.

49

Gobatto

ALN

Ultrasound-guided percutaneous dilational tracheostomy: a systematic review of randomized controlled trials and meta-analysis

.

J Intensive Care Med

.

2020

;

35

(

5

):

445

–

452

.

50

David

AP

Tracheostomy guidelines developed at a large academic medical center during the COVID-19 pandemic

.

Head Neck

.

2020

;

42

(

6

):

1291

–

1296

.

51

Beccaria

LM

Tracheal cuff pressure change before and after the performance of nursing care

.

Rev Bras Enferm

.

2017

;

70

(

6

):

1145

–

1150

.

52

Cooper

JD

Tracheal injuries complicating prolonged intubation and tracheostomy

.

Thorac Surg Clin

.

2018

;

28

(

2

):

139

–

144

.

53

Yaneza

M

ENTUK guidelines for changes in ENT during COVID-19 pandemic

.

2020

. Accessed July 31, 2020.

54

Australia and New Zealand Intensive Care Society

The Aus-tralian and New Zealand Intensive Care Society (ANZICS) COVID-19 Guidelines

.

Version 1. 2020

. Accessed July 31, 2020.

55

National Tracheostomy Safety Project

.

Considerations for tracheostomy in the COVID-19 outbreak

.

2020

. Accessed July 31, 2020.

56

De Seta

D

Management of tracheostomy during COVID-19 outbreak: heat and moisture exchanger filter and closed suctioning system

.

Oral Oncol

.

2020

;

106

:

104777

.

57

Kelley

J

The Kelley Circuit: a solution for the management of in-hospital self-ventilating tracheostomy patietns, providing humidification and filtration, with closed circuit suctioning

.

2020

.

The Wellington Hospital

. Accessed May 31, 2020.

58

Brusasco

C

In vitro evaluation of heat and moisture exchangers designed for spontaneously breathing tracheostomized patients

.

Respir Care

.

2013

;

58

(

11

):

1878

–

1885

.

59

Carroll

DJ

Implementation of an interdisciplinary tracheostomy care protocol to decrease rates of tracheostomy-related pressure ulcers and injuries

.

Am J Otolaryngol

.

2020

;

41

(

4

):

102480

.

60

Balakrishnan

K

COVID-19 pandemic: what every otolaryngologist-head and neck surgeon needs to know for safe airway management

.

Otolaryngol Head Neck Surg

.

2020

;

162

(

6

):

804

–

808

.

61

Kligerman

MP

Managing head and neck cancer patients with tracheostomy or laryngectomy during the COVID-19 pandemic

.

Head Neck

.

2020

;

42

(

6

):

1209

–

1213

.

62

Goldman

RA

Tracheostomy management during the COVID-19 pandemic

.

Otolaryngol Head Neck Surg

.

2020

;

163

(

1

):

67

–

69

.

63

Intensive Care National Audit & Research Centre

ICNARC report on COVID-19 in critical care

.

2020

. Accessed July 31, 2020.

64

Wang

CH

Normal saline instillation before suctioning: a meta-analysis of randomized controlled trials

.

Aust Crit Care

.

2017

;

30

(

5

):

260

–

265

.

65

Ng

J

Tracheostomy tube change

.

StatPearls [Internet]

.

StatPearls Publishing

;

2020

.

66

Hui

DS

Aerosol dispersion during various respiratory therapies: a risk assessment model of nos-ocomial infection to health care workers

.

Hong Kong Med J

.

2014

;

20

(

suppl 4

):

9

–

13

.

67

Li

J

Defining aerosol generating procedures and pathogen transmission risks in healthcare settings

.

Open Forum Infect Dis

.

2017

;

4

(

suppl 1

):

S34

–

S35

.

68

Tran

K

Aerosol-Generating Procedures and Risk of Transmission of Acute Respiratory Infections: A Systematic Review

.

Canadian Agency for Drugs and Technologies in Health

;

2011

.

69

Tran

K

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

.

PLoS One

.

2012

;

7

(

4

):

e35797

.

70

Ferioli

M

Protecting healthcare workers from SARS-CoV-2 infection: practical indications

.

Eur Respir Rev

.

2020

;

29

(

155

):

200068

.

71

Respiratory Care Committee of Chinese Thoracic Society

Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia

].

Zhonghua Jie He He Hu Xi Za Zhi

.

2020

;

43

(

4

):

288

–

296

.

72

Chan

MT

Mask ventilation and dispersion of exhaled air

.

Am J Respir Crit Care Med

.

2013

;

187

(

7

):

e12

–

14

.

73

Chan

MTV

Exhaled air dispersion during bag-mask ventilation and sputum suctioning – implications for infection control

.

Sci Rep

.

2018

;

8

(

1

):

198

.

74

Hui

DS

Exhaled air dispersion and removal is influenced by isolation room size and ventilation settings during oxygen delivery via nasal cannula

.

Respirology

.

2011

;

16

(

6

):

1005

–

1013

.

75

Hui

DS

Exhaled air dispersion during coughing with and without wearing a surgical or N95 mask

.

PLoS One

.

2012

;

7

(

12

):

e50845

.

76

Hui

DS

Exhaled air and aerosolized droplet dispersion during application of a jet nebulizer

.

Chest

.

2009

;

135

(

3

):

648

–

654

.

77

Hui

DS

Exhaled air dispersion during noninvasive ventilation via helmets and a total facemask

.

Chest

.

2015

;

147

(

5

):

1336

–

1343

.

78

Hui

DS

Exhaled air dispersion during high-flow nasal cannula therapy versus CPAP via different masks

.

Eur Respir J

.

2019

;

53

(

4

).

79

Hui

DS

Exhaled air dispersion distances during noninvasive ventilation via different Respironics face masks

.

Chest

.

2009

;

136

(

4

):

998

–

1005

.

80

Hui

DS

Exhaled air dispersion during oxygen delivery via a simple oxygen mask

.

Chest

.

2007

;

132

(

2

):

540

–

546

.

81

Hui

DS

Impact of severe acute respiratory syndrome (SARS) on pulmonary function, functional capacity and quality of life in a cohort of survivors

.

Thorax

.

2005

;

60

(

5

):

401

–

409

.

82

Marini

JJ

Management of COVID-19 respiratory distress

.

JAMA

.

Published online ahead of print April 24, 2020

. doi:

83

Guerin

C

Prone positioning in severe acute respiratory distress syndrome

.

N Engl J Med

.

2013

;

368

(

23

):

2159

–

2168

.

84

National COVID-19 Evidence Taskforce

Australian guidelines for the clinical care of people with COVID-19

.

2020

. Accessed May 25, 2020.

85

Bower

G

Protocol for awake prone positioning in COVID-19 patients: to do it earlier, easier, and longer

.

Crit Care

.

2020

;

24

(

1

):

371

.

86

Shang

Y

Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China

.

Ann Intensive Care

.

2020

;

10

(

1

):

73

.

87

Ng

JA

Prone positioning of patients with acute respiratory distress syndrome related to COVID-19: a rehabilitation-based prone team

.

Phys Ther

.

Published online July 16, 2020

. doi:

88

Global Tracheostomy Collaborative

Global Tracheostomy Collaborative Database

.

CAPQA Boston Children’s Hospital

;

2020

.

89

Food and Drug Administration

Smith Medicals Portex Trache-ostomy Tubes [letter]

.

2018

. Accessed May 30, 2020.

90

Albrecht

R

Transport of COVID-19 and other highly contagious patients by helicopter and fixed-wing air ambulance: a narrative review and experience of the Swiss air rescue Rega

.

Scand J Trauma Resusc Emerg Med

.

2020

;

28

(

1

):

40

.

91

Liew

MF

Safe patient transport for COVID-19

.

Crit Care

.

2020

;

24

(

1

):

94

.

92

Tien

H

Critical care transport in the time of COVID-19

.

CJEM

.

Published online May 13, 2020

. doi:

93

Yousuf

B

Transport of critically ill COVID-19 patients

.

Intensive Care Med

.

2020

;

64

(

8

):

1663

–

1664

.

94

Zaga

CJ

Speech-language pathology guidance for trachesotomy during the COVID-19 pandemic: an international multidisciplinary perspective

.

Am J Speech Lang Pathol

.

2020

;

29

(

3

):

1320

–

1334

.

95

Anfinrud

P

Visualizing speech-generated oral fluid droplets with laser light scattering

.

N Engl J Med

.

2020

;

382

(

21

):

2061

–

2063

.

96

Stadnytskyi

V

The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission

.

Proc Natl Acad Sci USA

.

2020

;

117

(

22

):

11875

–

11877

.

97

Brugliera

L

Rehabilitation of COVID-19 patients

.

J Rehabil Med

.

2020

;

52

(

4

):

jrm00046

.

98

Wang

Y

Combination of RT-qPCR testing and clinical features for diagnosis of COVID-19 facilitates management of SARS-CoV-2 outbreak

.

J Med Virol

.

2020

;

92

(

6

):

538

–

539

.

99

Ai

T

Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases

.

Radiology

.

2020

:

200642

.

100

Yang

W

Patients with RT-PCR-confirmed COVID-19 and normal chest CT

.

Radiology

.

2020

;

296

(

2

):

e32

–

e40

.

101

Li

Y

Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19

.

J Med Virol

.

2020

;

92

(

7

):

903

–

908

.

102

Shao

F

In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China

.

Resuscitation

.

2020

;

151

:

18

–

23

.

103

Curtis

JR

The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19)

.

JAMA

.

Published online March 27, 2020

. doi:

104

Edelson

DP

Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines((R))-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians

.

Circulation

.

2020

;

141

(

25

):

e933

–

e943

.

105

Fischkoff

K

Society of Critical Care Medicine crisis standard of care recommendations for triaging critical resources during the COVID-19 pandemic

2020

. Accessed May 20, 2020.

106

Bhatnagar

V

Cardiopulmonary resuscitation: unusual techniques for unusual situations

.

J Emerg Trauma Shock

.

2018

;

11

(

1

):

31

–

37

.

107

Medrzycka-Dabrowska

W

Prone ventilation of critically ill adults with COVID-19: how to perform CPR in cardiac arrest?

Crit Care

.

2020

;

24

(

1

):

258

.

108

Barker

J

A need for prone position CPR guidance for intubated and non-intubated patients during the COVID-19 pandemic

.

Resuscitation

.

2020

;

151

:

135

–

136

.

109

Cohen

IG

Potential legal liability for withdrawing or withholding ventilators during COVID-19: assessing the risks and identifying needed reforms

.

JAMA

.

Published online April 1, 2020

. doi:

110

Fritz

Z

Cardiopulmonary resuscitation after hospital admission with Covid-19

.

BMJ

.

2020

;

369

:

m1387

.

111

Mahase

E

Covid-19: doctors are told not to perform CPR on patients in cardiac arrest

.

BMJ

.

2020

;

368

:

m1282

.

112

Rushton

CH

Burnout and resilience among nurses practicing in high-intensity settings

.

Am J Crit Care

.

2015

;

24

(

5

):

412

–

420

.

113

Inglis

R

Optimizing respiratory management in resource-limited settings

.

Curr Opin Crit Care

.

2019

;

25

(

1

):

45

–

53

.

114

Lone

SA

COVID-19 pandemic – an African perspective

.

Emerg Microbes Infect

.

2020

;

9

(

1

):

1300

–

1308

.

115

McMahon

DE

Global resource shortages during COVID-19: bad news for low-income countries

.

PLoS Negl Trop Dis

.

2020

;

14

(

7

):

e0008412

.

116

Sutton

L

Barriers to improving tracheostomy care in low- and middle-income countries: our experience of a 23 patient closed loop audit cycle

.

Clin Otolaryngol

.

2018

;

43

(

5

):

1392

–

1395

.

117

Khan

MM

Safety guidelines for sterility of face shields during COVID 19 pandemic

.

Indian J Otolaryngol Head Neck Surg

.

2020

:

1

–

2

.

118

Tabah

A

Personal protective equipment and intensive care unit healthcare worker safety in the COVID-19 era (PPE-SAFE): an international survey

.

J Crit Care

.

2020

;

59

:

70

–

75

.

119

Ayebare

RR

Adoption of COVID-19 triage strategies for low-income settings

.

Lancet Respir Med

.

2020

;

8

(

4

):

e22

.

120

Desai

AN

Global infection prevention gaps, needs, and utilization of educational resources: a cross-sectional assessment by the International Society for Infectious Diseases

.

Int J Infect Dis

.

2019

;

82

:

54

–

60

.

121

Dondorp

AM

Respiratory support in COVID-19 patients, with a focus on resource-limited settings

.

Am J Trop Med Hyg

.

2020

;

102

(

6

):

1191

–

1197

.

122

Fast

O

Limited sterile processing capabilities for safe surgery in low-income and middle-income countries: experience in the Republic of Congo, Madagascar and Benin

.

BMJ Glob Health

.

2017

;

2

(

suppl 4

):

e000428

.

123

Pecchia

L

The inadequacy of regulatory frameworks in time of crisis and in low-resource settings: personal protective equipment and COVID-19

.

Health Technol (Berl)

.

2020

:

1

–

9

.

Related

Cited By

Email alerts