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"Vicepresidenta de la Comisión Nacional de Anestesiologia, Reanimación y Terapéutica del Dolor; Presidenta de la Sociedad Catalana de Anestesiología, Reanimación y Terapéutica del Dolor (SCARTD), Spain" "etiqueta" => "t" "identificador" => "aff0100" ] 20 => array:3 [ "entidad" => "Servicio Medicina Intensiva, Hospital Universitario de Torrejón, Universidad Francisco de Vitoria, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "u" "identificador" => "aff0105" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tracheotomy is a common procedure in intensive care units (ICU) in patients with respiratory failure requiring mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The recent COVID-19 pandemic, in its most severe form, presents with a picture of acute respiratory failure that can evolve into acute respiratory distress syndrome (ARDS), which in many patients requires initiation of mechanical ventilation. In the different series, between 9.8% and 15.2% of these patients have required mechanical ventilation.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> Surgical tracheotomy is the most common surgical procedure among critically ill COVID-19 patients.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The mortality of COVID-19 patients on mechanical ventilation is high, up to 50%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> These patients require ventilatory strategies that in the initial stages involve deep analgesia and even relaxation, protective ventilation, recruitment manoeuvre and prone position.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> All this means that many patients will remain on mechanical ventilation for days, with a high risk of developing ICU- acquired weakness, making weaning them from mechanical ventilation difficult. The use of specific antiviral drugs may interact with sedatives and analgesics, prolonging their effects.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The onset of delirium, frequent in this type of patient, may also influence successful withdrawal of mechanical ventilation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">SARS-CoV-2 has a demonstrated high rate of transmissibility, especially via the respiratory tract and droplet dispersion. Specific recommendations have been established on personal protective equipment (PPE), as well as on airway management related to intubation and mechanical ventilation. Undertaking procedures that generate aerosols involves a high risk of infection and intubation, fibrobronchoscopy and tracheotomy are among the highest risk procedures.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There are different recommendations as to the technical procedure for tracheotomy in patients with COVID-19, but there is insufficient evidence as to the optimal timing of the procedure, the type of procedure (surgical versus percutaneous tracheotomy) or the subsequent treatment of these patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">At present, although there are case series describing the experience of tracheotomy in COVID-19 patients, there is insufficient evidence to support firm recommendations, and therefore expert consensus and a literature review in the context of routine practice could help establish guidelines for this procedure in this disease.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The following recommendations are made by the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) and the Spanish Society of Anaesthesiology and Resuscitation (SEDAR). These recommendations are subject to changes in the scientific evidence and can be adapted to existing resources at any time.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology of the Recommendations</span><p id="par0040" class="elsevierStylePara elsevierViewall">SEMICYUC, SORRL-CCC and SEDAR formed an ad hoc group in light of the COVID-19 pandemic and the need to establish recommendations to help professionals make decisions regarding certain clinical procedures, in this case tracheotomy. A literature search was conducted, and recommendations based on it were drafted by consensus.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The relative indications and contraindications for tracheotomy are described in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Timing of Tracheotomy in the COVID-19 Patient</span><p id="par0050" class="elsevierStylePara elsevierViewall">In routine practice, outside the context of COVID-19, there are no conclusive findings as to the optimal time to perform a tracheotomy in critically ill patients. This is due to the heterogeneity of the patients included in the studies, the different definitions used of early and late tracheotomy, and even defects in the randomisation of patients in the clinical trials conducted. All of this means that the impact on the results of performing tracheotomy in critically ill patients cannot be definitively established. It could be appropriate in the context of COVID-19 patients to define early tracheotomy as that performed in the first 10 days, and late tracheotomy as that performed after that time.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Post-intubation laryngo-tracheal stenosis is a well-known risk of prolonged orotracheal intubation but has not been shown in systematic reviews to significantly reduce in patients treated with early tracheotomy.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">It could be that early tracheotomy does not provide benefits in variables such as mechanical ventilation-associated pneumonia or mortality, but it seems reasonable to perform it in patients with a high probability of prolonged mechanical ventilation, because of its benefits over intubation in terms of well-being, ICU stay and time on mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> A recent meta-analysis only showed results in reduction of sedative use in relation to the timing of tracheotomy.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Early tracheotomy may increase the risk of infection in COVID-19 patients and positive PCR with higher viral load. Although the rate of viral clearance is not known exactly, in critical patients it may persist for 2–3 weeks.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Therefore, there are recommendations from scientific societies that establish negative PCR criteria for the procedure, considering as an exception those patients whose orotracheal intubation does not secure the airway.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> In situations where there may be a shortage of certain equipment, such as ventilators, early tracheotomy could increase the availability of these, by reducing days of mechanical ventilation, which would facilitate access to a greater number of patients with an indication for mechanical ventilation. In these circumstances, early tracheotomy may facilitate treatment and nursing care.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In a recent study (data pending publication), tracheotomy has enabled removal of mechanical ventilation an average of 4 days later, in both early (<10 days) and late tracheotomies.</p><p id="par0075" class="elsevierStylePara elsevierViewall">At the other extreme, late tracheotomy can better select patients in whom the procedure is not useful due to subsequent complications, such as dysfunction of other organs that increase the risk of death, or patients with a better prognosis who will progress equally favourably and can be extubated. It appears that patients who do not show clinical or radiological remission within 10 days may be more likely to require continuous ventilation and have a more severe disease course, even death.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">It is recommended that tracheotomy should be performed in patients with a positive PCR for COVID-19 from day 14 of orotracheal intubation, and that early tracheotomy is considered only for stable patients with low oxygen demand, where prolonged mechanical ventilation is planned for other reasons. Early tracheotomy could be considered to optimise intensive care resources.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Surgical Tracheotomy Versus Percutaneous Tracheotomy (PT)</span><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to the type of procedure outside the context of COVID-19, it is considered that at the present time there is no evidence to establish recommendations for one tracheotomy method over others. The selection of one or another method can only be made on the basis of clinical criteria, experience and availability. In the current situation of high care burden, where intensive care resources are scarce, surgical tracheotomy performed by specific surgical teams may favour the procedure and avoid unnecessary delays. We recommend considering open tracheotomy or percutaneous tracheotomy (PT) at the discretion of the multidisciplinary team, according to the experience of the centre and the availability of the various resources. In the event that PT is chosen, based on experience and in a multidisciplinary team, the considerations already known should be considered.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Although the use of fibrobronchoscopy could reduce the risks related to PT,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> it would be inadvisable for COVID-19 patients, since it increases the number of participants and is a high-risk procedure for generating aerosols. If it is considered, it is recommended to use parts that produce a seal at the tube inlet and to evaluate the use of disposable fiberscopes.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In these cases, although there is insufficient evidence to recommend its use, in order to reduce complications associated with the procedure, ultrasound may be useful to improve accuracy at the puncture site in patients who present difficulty in identifying anatomical structures.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In both cases, care should be taken to clean the equipment used according to the established recommendations.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In necks without significant anatomical abnormalities, percutaneous tracheotomy may be considered the technique of choice taking previous recommendations into account and the availability of trained professionals to perform it. The surgical technique, as opposed to percutaneous, would provide a more controlled and rapid approach to the airway in a patient at high risk of complications.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> It could be considered in the phases of the pandemic where there is the greatest burden on intensive care professionals.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Where the Tracheotomy Procedure Should Be Performed</span><p id="par0110" class="elsevierStylePara elsevierViewall">Bed-side PT reduces the need to move and disconnect mechanical ventilation if it can be performed in individual or negative pressure rooms.</p><p id="par0115" class="elsevierStylePara elsevierViewall">It is recommended that the tracheotomy be performed in an ICU cubicle or nearby location (such as the operating theatre) that has an isolation and negative pressure system, with appropriate equipment for the procedure. It is not recommended that tracheotomy be performed in COVID-19 cohort spaces without isolation cubicles. If performed in the operating theatre, specific considerations should be made, with areas marked for circulation of patients and for carrying out the procedure.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Surgical Technique<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25–28</span></a></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">General Recommendations</span><p id="par0120" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Use of standard surgical tracheotomy material.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">As far as possible, limit the use of electrical, ultrasound or any other cutting and coagulation systems that can spread airborne macroparticles. Preferably use cold material and conventional haemostasis systems, unless it is considered that this will entail excessive delay in performing the technique.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">Use closed circuit suction systems with anti-viral filters.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">The number of personnel required for the technique must be kept to a minimum.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0145" class="elsevierStylePara elsevierViewall">Tracheotomy should be performed by the most experienced personnel available in the minimum time possible.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">Use appropriate protective measures. PPE: disposable, waterproof gown, cap and footwear; disposable, plastic, full-face, waterproof eye and face shield; FFP2 or FFP3 or equivalent (N95) protective mask and surgical mask overlay. Preferably use double surgical gloves.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Goggles, coveralls and similar are usually waterproof systems. It is advisable to use anti-fogging or similar.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">Choose between percutaneous or standard surgical tracheotomy principally depending on the centre’s usual protocol.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Recommendations in Elective Tracheotomy (Intubated Patient)</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">1</span><p id="par0170" class="elsevierStylePara elsevierViewall">Before opening the trachea:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Establish adequate pre-oxygenation of the patient (100% oxygen, 5 min).</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0180" class="elsevierStylePara elsevierViewall">Complete muscle relaxation of the patient during the entire procedure and especially at the time of withdrawal from intubation and decannulation, to prevent coughing and aerosolization.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0185" class="elsevierStylePara elsevierViewall">Before tracheal opening, mechanical ventilation should be removed.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2</span><p id="par0190" class="elsevierStylePara elsevierViewall">Perform the tracheotomy, withdraw the endotracheal intubation tube until the balloon cannula can be placed without removing it completely; inflate the cannula balloon.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">3</span><p id="par0195" class="elsevierStylePara elsevierViewall">Connect the ventilator and, when correct ventilation has been checked (preferably by capnography), withdraw the endotracheal tube and fix the tracheotomy cannula with tape and silk stitches. Never deflate the tracheotomy tube balloon once mechanical ventilation has begun.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">4</span><p id="par0200" class="elsevierStylePara elsevierViewall">Collect all the tracheotomy material.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">5</span><p id="par0205" class="elsevierStylePara elsevierViewall">Remove the protective equipment from the surgeon in the operating theatre or room according to current regulations.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">6</span><p id="par0210" class="elsevierStylePara elsevierViewall">Leave the operating theatre or room according to the regulations.</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Recommendations in Emergency Tracheotomy (Non-intubated Patient)</span><p id="par0215" class="elsevierStylePara elsevierViewall">On occasion, as determined by the patient's ventilatory deterioration, tracheotomy may be required in emergency situations in previously unintubated patients. In these cases, a cricothyrotomy may be necessary by means of a set pre-designed for this purpose.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Emergency tracheotomy should be avoided as far as possible because it is performed under conditions that are not ideal. Good communication with the intensive care, anaesthesia and emergency services is recommended, and offer help with intubations expected to be difficult.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">1</span><p id="par0225" class="elsevierStylePara elsevierViewall">Establish appropriate pre-oxygenation of the patient (oxygen at 100%, 5 min).</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">2</span><p id="par0230" class="elsevierStylePara elsevierViewall">Full muscle relaxation to prevent patient movement, as well as coughing.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">3</span><p id="par0235" class="elsevierStylePara elsevierViewall">Place the tracheotomy cannula and inflate the balloon.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">4</span><p id="par0240" class="elsevierStylePara elsevierViewall">Switch on the mechanical ventilator and stabilise the patient.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">5</span><p id="par0245" class="elsevierStylePara elsevierViewall">Attach the cannula.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">6</span><p id="par0250" class="elsevierStylePara elsevierViewall">If tracheotomy is not possible, a cricothyrotomy will be performed according to the standard technique.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">7</span><p id="par0255" class="elsevierStylePara elsevierViewall">If a cricothyrotomy has been performed, once the patient has been stabilised and the airway secured, a surgical tracheotomy will be performed using a different incision. The cricothyrotomy incision will be closed after removal of the previous cannula and placement of the cannula in the tracheotomy.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">8</span><p id="par0260" class="elsevierStylePara elsevierViewall">Same as points 4–6 above (elective tracheotomy).</p></li></ul></p></span></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Recommendations for Tracheotomy Care</span><p id="par0265" class="elsevierStylePara elsevierViewall">The care of tracheostomised COVID-19 patients may increase exposure of healthcare workers to infection and the spread of infection.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">•</span><p id="par0270" class="elsevierStylePara elsevierViewall">Place patients in cohort areas according to COVID-19 and the risk of contagion.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">•</span><p id="par0275" class="elsevierStylePara elsevierViewall">Preferably in single and negative pressure rooms, if available.</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">•</span><p id="par0280" class="elsevierStylePara elsevierViewall">The appropriate use of PPE during care of tracheotomy patients should always be indicated for procedures with a risk of generating aerosols, especially in those who remain PCR positive; this includes the use of a waterproof gown, respiratory protection with FPP2 or FFP3 mask, splash protection and the use of gloves. Correct hand hygiene is essential before putting on and removing PPE.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">•</span><p id="par0285" class="elsevierStylePara elsevierViewall">In tracheostomised patients a surgical mask will be placed over the tracheostoma or over nasal goggles or oxygen mask if the tracheotomy is closed.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">•</span><p id="par0290" class="elsevierStylePara elsevierViewall">In life-threatening emergencies, priorities should be given to placement of PPE and seeking help.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">•</span><p id="par0295" class="elsevierStylePara elsevierViewall">Extra PPE should be available in tracheostomised patient areas.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">•</span><p id="par0300" class="elsevierStylePara elsevierViewall">Minimise handling of the tracheotomy and the number of professionals involved.</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">•</span><p id="par0305" class="elsevierStylePara elsevierViewall">Consider delaying the first change of tracheotomy tube and make subsequent changes after the virus detection test is negative.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">•</span><p id="par0310" class="elsevierStylePara elsevierViewall">The use of internal cannulas should always be considered.</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">•</span><p id="par0315" class="elsevierStylePara elsevierViewall">Always keep the balloon inflated.</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">•</span><p id="par0320" class="elsevierStylePara elsevierViewall">Use closed suction systems.</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">•</span><p id="par0325" class="elsevierStylePara elsevierViewall">Adjust the frequency of liner change or cleaning the tracheostoma, assessing risks and benefits.</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">•</span><p id="par0330" class="elsevierStylePara elsevierViewall">Avoid active humidification and assess the risks and benefits in relation to obstruction of the cannula.</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">•</span><p id="par0335" class="elsevierStylePara elsevierViewall">Use high-efficiency antimicrobial filters and heat exchangers to disconnect mechanical ventilation.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">•</span><p id="par0340" class="elsevierStylePara elsevierViewall">Preferably avoid T-tubes, fenestrated cannulas and deflating the balloon until the virus detection test is negative.</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">•</span><p id="par0345" class="elsevierStylePara elsevierViewall">Multidisciplinary teams trained in the handling of tracheostomas are recommended for the care of these patients.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">•</span><p id="par0350" class="elsevierStylePara elsevierViewall">Specific equipment should be available to redo the tracheotomy in case of decannulation failure.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">•</span><p id="par0355" class="elsevierStylePara elsevierViewall">There must be an alarm system to the ENT department.</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">•</span><p id="par0360" class="elsevierStylePara elsevierViewall">PPE can make vision and communication between the team difficult. Tracheostomy procedures should be anticipated, and short briefing sessions should be held.</p></li></ul></p><p id="par0365" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarises the main conclusions of the consensus on tracheotomy in COVID-19 patients.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0370" class="elsevierStylePara elsevierViewall">All these recommendations are based on evidence and the current knowledge of the specialists involved regarding acute respiratory failure secondary to COVID-19 pneumonia, and some indications are likely to change or need to be adapted to the resources available in care centres during the course of the pandemic.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of Interests</span><p id="par0375" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1414162" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1294153" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1414161" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1294154" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology of the Recommendations" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Timing of Tracheotomy in the COVID-19 Patient" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgical Tracheotomy Versus Percutaneous Tracheotomy (PT)" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Where the Tracheotomy Procedure Should Be Performed" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0035" "titulo" => "Surgical Technique" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "General Recommendations" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Recommendations in Elective Tracheotomy (Intubated Patient)" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Recommendations in Emergency Tracheotomy (Non-intubated Patient)" ] ] ] ] ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Recommendations for Tracheotomy Care" ] 11 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of Interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-29" "fechaAceptado" => "2020-04-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1294153" "palabras" => array:4 [ 0 => "Mechanical ventilation" 1 => "Tracheotomy" 2 => "COVID-19" 3 => "Pandemic" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1294154" "palabras" => array:4 [ 0 => "Ventilación mecánica" 1 => "Traqueotomía" 2 => "COVID-19" 3 => "Pandemia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The current COVID-19 pandemic has rendered up to 15% of patients under mechanical ventilation. Because the subsequent tracheotomy is a frequent procedure, the three societies mostly involved (SEMICYUC, SEDAR and SEORL-CCC) have setup a consensus paper that offers an overview about indications and contraindications of tracheotomy, be it by puncture or open, clarifying its respective advantages and enumerating the ideal conditions under which they should be performed, as well as the necessary steps. Regular and emergency situations are displayed together with the postoperative measures.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La alta incidencia de insuficiencia respiratoria aguda en el contexto de la pandemia por COVID-19 ha conllevado el uso de ventilación mecánica hasta en un 15%. Dado que la traqueotomía es un procedimiento quirúrgico frecuente, este documento de consenso, elaborado por tres Sociedades Científicas, la SEMICYUC, la SEDAR y la SEORL-CCC, tiene como objetivo ofrecer una revisión de las indicaciones y contraindicaciones de traqueotomía, ya sea por punción o abierta, esclarecer las posibles ventajas y exponer las condiciones ideales en que deben realizarse y los pasos que considerar en su ejecución. Se abordan situaciones regladas y urgentes, así como los cuidados posoperatorios.</p></span>" ] ] "NotaPie" => array:3 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Rosa Villalonga Vadell and María Cruz Martín Delgado have contributed equally as senior authors.</p>" "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bernal-Sprekelsen M, Avilés-Jurado FX, Álvarez Escudero J, Aldecoa Álvarez-Santuyano C, de Haro López C, Díaz de Cerio Canduela P, et al. Documento de consenso de la Sociedad Española de Medicina Intensiva, Crítica, y Unidades Coronarias (SEMICYUC), la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) y la Sociedad Española de Anestesiología y Reanimación (SEDAR) sobre la traqueotomía en pacientes con COVID-19. Acta Otorrinolaringol Esp. 2020. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.otorri.2020.04.002">https://doi.org/10.1016/j.otorri.2020.04.002</span></p>" ] 2 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is published simultaneously in <span class="elsevierStyleItalic">Medicina Intensiva</span> (<span class="elsevierStyleInterRef" id="intr0010" href="https://doi.org/10.1016/j.medin.2020.05.001">https://doi.org/10.1016/j.medin.2020.05.001</span>), in <span class="elsevierStyleItalic">Acta Otorrinolaringologica Espanola</span> (<span class="elsevierStyleInterRef" id="intr0015" href="https://doi.org/10.1016/j.otorri.2020.04.002">https://doi.org/10.1016/j.otorri.2020.04.002</span>) and in <span class="elsevierStyleItalic">Revista Española de Anestesiología y Reanimación</span> (<span class="elsevierStyleInterRef" id="intr0020" href="https://doi.org/10.1016/j.redar.2020.05.001">https://doi.org/10.1016/j.redar.2020.05.001</span>), with the consent of the authors and editors.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Prevention of laryngeal and upper airway damage by intubation in patients undergoing prolonged mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Enable easy access to the airway for removal of secretions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Reduction of dead space \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Airway obstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Impossibility of orotracheal intubation in patients with difficult airway after emergency cricothyrotomy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Expedite disconnection of mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2426145.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Indications for Tracheotomy in the Intensive Care Unit.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Known advance directives refusing the procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• End-of-life situation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Uncontrolled septic shock and multi-organ dysfunction with high risk of death \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• It is considered that the procedure should be delayed, or high risk taken into account in certain circumstances: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>-Very high respiratory requirement: FiO<span class="elsevierStyleInf">2</span> > 70% and/or PEEP > 12 cmH<span class="elsevierStyleInf">2</span>O \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>-Need for proning in previous 48 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>-Haemodynamic instability with the need for vasoactive support \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>-Coagulopathy with high bleeding risk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>-Inability to obtain informed consent \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2426144.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Contraindications for Tracheotomy.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Indicate tracheotomy for patients with prolonged mechanical ventilation after 14 days of orotracheal intubation in the absence of contraindications and with clinical stability. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Early tracheotomy can be considered for stable patients with prolonged mechanical ventilation for other reasons \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percutaneous tracheotomy remains the technique of choice for critical patients with no contraindications. Percutaneous surgical tracheotomy should be considered in situations of high healthcare overload in intensive care professionals \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use non-fenestrated balloon cannulas with interchangeable internal cannulas and keep the balloon inflated by using closed suction systems \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Delay the first cannula change as long as possible \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consider the frequency of liner changes or tracheotomy cleaning according to risk-benefit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Take extreme care and use PPE according to the recommendations once weaning with balloon deflation has started \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If T-tube parts are used, use high-efficiency antimicrobial filters and heat exchangers \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2426146.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Tracheostomy Recommendations for COVID-19 Patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tracheotomy: historical review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.W. 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