Methods
Open surgical sub-isthmic bedside tracheotomies were performed, following most of the suggestions of already published guidelines for tracheotomy in Covid-19 1-4 with some technical refinements.
Proper use of personal protective equipment (PPE) is mandatory5. Some authors1 recommend a powered air-purifying respirator (PAPR), being it not available we used FFP3 masks. For eyes we use closed surgical goggles, misting up for sweating must be prevented by anti-fog spray or simply by soap and water6.
The patient is fully paralyzed in supine position with hyper-extended head. To minimize airflow between the tracheal wall and the tube, with ETT always connected, the ventilation is hold at the end of expiration until cuff is deflated, advanced distal to the tracheotomy site to the level of the carina, then fully reinflated.
After a horizontal 1.5-3cm skin incision 0.5cm cranial to the jugular suprasternal notch, a blunt dissection along the midline is carried out, until the exposure of 3 rings and 2 inter-cartilaginous spaces. The most cranial inter-cartilaginous space visible under the isthmus is weakened by low-power monopolar coagulation so that, through palpation, it is possible to verify the position of the cuff and to push further down the cuff as described above if it is close to the tracheotomy site. There is no reason to transect the isthmus as described elsewhere7, as it is always possible in our experience to retract it cranially and comfortably tailor a sub-isthmic tracheostomy. The most cranial inter-cartilaginous space under the isthmus is weakened by low-power monopolar coagulation so that, through palpation, it is possible to verify the position of the cuff and to push further down the cuff as described above if it is close to the tracheotomy site. Then the trachea is opened without any damage to cartilage and to the cuff itself. With the ETT tube always inflated and in place, the opening is widened so that the suture of the caudal rings to the skin with Ethilon 0 tailors a stable tracheostomy, large enough to loosely place a n.8.5 cuffed cannula (RuschTracheoFix TFC), without any damage to the cartilage nor need for a Bjork flap.
The crucial phase is the exchange between ETT and cannula, with a time frame from ETT cuff deflation to cannula cuff inflation without a seal from the alveolar space to the environment (“no-seal” time). When the surgeon is ready the intensivist holds MV at the end of the expiration, clamps the tube with an ECMO clamp (Landangerinc., Paris, France), disconnects the tube itself connecting the cannula with already the inner tube in place (no obturator is needed with the previously tailored large opening) and puts it within easy reach of the first operator. Subsequently, the ETT cuff is deflated and pulled up by the intensivist, the already connected cannula is placed into the trachea under direct vision immediately below the ascending end of the tube by the otolaryngologist and cannula cuff, previously connected to the syringe, is inflated by the nurse. Then the ventilation is resumed, and correct positioning is confirmed by checking End Tidal CO2 values as usual 4.
We recorded clinical and surgical variables, including potential transmission (i.e. if any team member was recorded positive or showed symptoms of Covid-19 in the following days/weeks).