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Title: Airway Management for Endoscopic Laryngotracheal Stenosis Surgery During COVID-1
19 2
Authors: Andrew D.P. Prince, BA1, Benjamin H. Cloyd, MD, MIPH2, Norman D. Hogikyan, 3
MD3,4, Samuel A. Schechtman MD2, Robbi A. Kupfer, MD3 4
5
Affiliations 6
1 University of Michigan Medical School, Ann Arbor, MI, USA 7
2Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan, 8
USA 9
3Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, 10
Ann Arbor, Michigan, USA 11
4Center for Bioethics & Social Sciences in Medicine, University of Michigan, Ann Arbor, 12
Michigan, USA 13
14
Corresponding Author: 15
Robbi A. Kupfer, MD 16
Department of Otolaryngology—Head & Neck Surgery, University of Michigan Medical School 17
1904 Taubman Center, 1500 E. Medical Center Dr., SPC 5312 18
Ann Arbor, MI 48109-5312 19
Phone: 734-936-7633, Fax: 734-936-9625, Email: [email protected] 20
21
Keywords: Otolaryngology; COVID-19; laryngotracheal stenosis; subglottic stenosis; laryngeal 22
stenosis; tracheal stenosis; airway management 23
Complete Manuscript Click here to access/download;Complete Manuscript;Stenosisairway management during COVID-19.docx
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
2
Authorship Contributions: 24
Robbi Kupfer Conceptual design, drafting and review of the manuscript, final approval, 25
and agreement to be accountable 26
Andrew Prince Conceptual design, drafting and review of the manuscript, final approval, 27
and agreement to be accountable 28
Benjamin Cloyd Conceptual design, drafting and review of the manuscript, final approval, 29
and agreement to be accountable 30
Norman Hogikyan Conceptual design, drafting and review of the manuscript, final approval, 31
and agreement to be accountable 32
Samuel Schechtman Conceptual design, drafting and review of the manuscript, final approval, 33
and agreement to be accountable 34
Funding: None 35
COI: None 36
37
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
3
Abstract 38
The novel coronavirus disease 2019 (COVID-19) pandemic presents unique challenges for 39
surgical management of laryngotracheal stenosis. High viral concentrations in the upper 40
aerodigestive tract, the ability of the virus to be transmitted by asymptomatic carriers and 41
through aerosols, and the need for open airway access during laryngotracheal surgery create a 42
high-risk situation for airway surgeons, anesthesiologists, and operating room personnel. While 43
some surgical cases of laryngotracheal stenosis may be deferred, patients with significant airway 44
obstruction or progressing symptoms often require urgent surgical intervention. We present best 45
practices from our institutional experience for surgical management of laryngotracheal stenosis 46
during this pandemic including preoperative triage, intraoperative airway management, and 47
personal protective measures. 48
49
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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Introduction 50
The novel coronavirus disease 2019 (COVID-19) outbreak was designated a pandemic by the 51
World Health Organization on March 11, 2020.1 Global spread has occurred at an alarming rate. 52
High viral concentration in the upper aerodigestive tract, the possibility of transmission by 53
asymptomatic carriers, and aerosolization during airway procedures contribute to a high risk of 54
occupational exposure among otolaryngologists.2 55
Efforts to reduce non-essential procedures to minimize patient and provider risk have heightened 56
the need for procedure prioritization and management protocols for patients with time-sensitive 57
conditions. While surgical treatment of severe laryngotracheal stenosis (LTS) is essential to 58
prevent devastating consequences including respiratory failure and death, published guidance for 59
management during the COVID-19 crisis does not exist. 60
Treatment of LTS commonly includes endoscopic surgery to dilate the airway. Intraoperative 61
management requires open access to the airway, often utilizing techniques implicated in viral 62
transmission including jet ventilation, spontaneous ventilation, trans-nasal humidified rapid-63
insufflation ventilatory exchange (THRIVE), and/or laser excision.3,4 Operations employing 64
standard airway management techniques for LTS are thus highly aerosolizing and should be 65
avoided at this time. We present alternative airway management techniques to minimize 66
aerosolization and discuss patient triage and safety measures. 67
68
Preoperative Evaluation and Triage 69
During COVID-19, LTS surgery should be performed when delay poses significant risk to the 70
patient. Evaluation during COVID-19 may involve initial phone or video triage to ascertain 71
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
5
severity of LTS symptoms including dyspnea or stridor. Patients who have had prior procedures 72
can often provide insights into the acuity of their symptoms. When circumstances require 73
visualization of the larynx, office visits with laryngoscopy should be conducted with appropriate 74
airborne precautions.5 Given current public health mandated mobility restrictions, scheduling 75
surgery without in-person examination can be considered for patients with known history of 76
recurrent stenosis. 77
Shared decision making between the patient and surgeon about whether to proceed with surgery 78
is paramount. Triage discussions must also involve departmental and operating room leadership 79
in the setting of pandemic-related resource limitations. Appropriate timing should be considered, 80
as a controlled LTS surgery may save emergency resources and possibly pose less viral 81
transmission risk to health care providers and patients than an emergent procedure. 82
83
Preoperative Testing and Personal Protective Equipment (PPE) 84
Preoperative testing for asymptomatic patients has the potential to provide reassurance to 85
proceed with surgery if negative; however, testing resources are limited and may not be 86
available. Furthermore, a single negative test may be misleading.6 Current guidelines at our 87
institution are therefore to wear full airborne precautions PPE and mitigate occupational 88
exposures (Table 1) during high risk aerosol generating procedures without requirement for 89
preoperative COVID-19 testing. 90
91
Laryngotracheal Stenosis Endoscopic Surgical Protocol During COVID-19 92
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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Development of an airway management plan for LTS surgery always mandates close 93
coordination of care amongst surgeon and anesthesiologist, and this need is amplified during the 94
COVID-19 pandemic due to recommended modifications in standard techniques. Individual 95
patient factors must also be considered, including comorbidities, degree and nature of stenosis, 96
and surgical access via direct laryngoscopy. The protocol outlined in Table 2 for patients 97
requiring subglottic stenosis surgical intervention at our institution during the COVID-19 crisis 98
was developed collaboratively by otolaryngology along with head and neck anesthesiology 99
colleagues. 100
The key principle guiding pandemic-related modifications in airway management is mitigation 101
of viral aerosolization, which is achieved by using closed systems when possible, rapid sequence 102
induction (RSI), neuromuscular blockade, and avoiding bag-mask ventilation.7 Prolonged awake 103
preoxygenation for five minutes can extend apnea time and reduce need for bag masking. Direct 104
laryngoscopy, telescopic bronchoscopy, dilation, and intubation are performed by the surgeon 105
immediately following RSI. Patients selected through triage are likely to have severe stenosis, 106
requiring immediate dilation to allow for safe intubation. Our protocol utilizes intubation with 107
5.0 cuffed microlaryngeal tracheal tube (Medtronic, Minneapolis, MN) with an outer diameter of 108
6.9 mm; therefore, dilation is performed prior to intubation if the stenosis is narrower than this 109
diameter. 110
Once intubation is accomplished, surgery proceeds with intermittent apnea using closed-loop 111
communication between the surgeon and anesthesiologist to ensure ventilation is held any time 112
the cuff is deflated, circuit is disconnected, or tube is removed. Neuromuscular blockade is 113
maintained throughout the case to minimize upper respiratory response. Laser is avoided due to 114
risk of virus aerosolization. 115
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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Extubation can also lead to aerosolization due to coughing, gagging, and endotracheal tube 116
removal. Similar to the rest of the procedure, we recommend minimizing the number of 117
personnel present and continuing to utilize full airborne precautions PPE. Use of glycopyrrolate 118
may help to minimize secretions, while intravenous lidocaine, opioids, sedatives, and topical 119
lidocaine applied to the larynx and trachea at the conclusion of the surgical procedure may 120
attenuate laryngeal and cough reflex at extubation.8 Aerosolization barriers may also be 121
considered, although we are not currently using these devices at our institution.9 122
123
Laryngeal Mask Airway (LMA) Considerations 124
For patients with inadequate direct laryngoscopy access or known difficult laryngoscopy, airway 125
dilation can be accomplished over a guidewire using flexible bronchoscopy through a 126
supraglottic airway (i.e. LMA). While this technique is an invaluable tool in select cases, risk of 127
aerosolization is thought to be higher with LMA than with endotracheal intubation10 and 128
therefore we recommend using this technique with caution during the COVID-19 pandemic. 129
130
Conclusion 131
Surgical management of LTS presents unique challenges during the COVID-19 pandemic 132
requiring careful consideration of patient triage and protocols that minimize patient and provider 133
risk. Close collaboration between otolaryngology and anesthesiology teams is essential to safely 134
navigate these difficult airways while mitigating risk of viral aerosolization. 135
136
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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137
Acknowledgments: None 138
References 139
1. Rolling updates on coronavirus disease (COVID-19). World Health Organization. 140
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-141
happen. Accessed April 17, 2020. 142
2. Cheng X, Liu J, Li N, et al. Otolaryngology Providers Must Be Alert for Patients with 143
Mild and Asymptomatic COVID-19. Otolaryngol Head Neck Surg. 144
2020:194599820920649. 145
3. Hui DS. Severe acute respiratory syndrome (SARS): lessons learnt in Hong Kong. J 146
Thorac Dis. 2013;5 Suppl 2:S122-126. 147
4. Garden JM, O'Banion MK, Bakus AD, Olson C. Viral disease transmitted by laser-148
generated plume (aerosol). Arch Dermatol. 2002;138(10):1303-1307. 149
5. Rameau A, Young VN, Amin MR, Sulica L. Flexible Laryngoscopy and COVID-19. 150
Otolaryngol Head Neck Surg. 2020:194599820921395. 151
6. Beeching NJ, Fletcher TE, Beadsworth MBJ. Covid-19: testing times. Bmj. 152
2020;369:m1403. 153
7. Balakrishnan K, Schechtman S, Hogikyan ND, Teoh AYB, McGrath B, Brenner MJ. 154
COVID-19 Pandemic: What Every Otolaryngologist-Head and Neck Surgeon Needs to 155
Know for Safe Airway Management. Otolaryngol Head Neck Surg. 156
2020:194599820919751. 157
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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8. Clivio S, Putzu A, Tramer MR. Intravenous Lidocaine for the Prevention of Cough: 158
Systematic Review and Meta-analysis of Randomized Controlled Trials. Anesth Analg. 159
2019;129(5):1249-1255. 160
9. Brown S, Patrao F, Verma S, Lean A, Flack S, Polaner D. Barrier System for Airway 161
Management of COVID-19 Patients. Anesthesia & Analgesia. 9000;Publish Ahead of 162
Print. 163
10. COVID-19 and Anesthesia FAQ. Anesthesia Patient Safety Foundation. 164
https://www.apsf.org/covid-19-and-anesthesia-faq/. Published 2020. Accessed April 23, 165
2020. 166
167
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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Table 1. Mitigation of Occupational Exposures During Airway Surgery 168
Principle Implementation
Airborne precautions PPE
All personnel in OR should wear gown, gloves, and PAPR or fit-tested N95
mask and full face shield (eye protection)
Providers should be trained in appropriate donning and doffing procedures
Optimize personnel Procedures should be performed expeditiously by experienced providers with the
fewest assistants and trainees possible
Room air clearance Room air clearance times should be followed to ensure aerosolized virus has
cleared prior to room entry by OR turnover personnel
Minimize virus
aerosolization
Airway management should include closed circuits when possible utilizing
intermittent apnea and avoiding bag-mask ventilation
Use of laser should be avoided
Cough should be mitigated upon emergence from anesthesia
Abbreviation: PPE, personal protective equipment; PAPR, powered air-purifying respirator
169
170
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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Table 2. Laryngotracheal Stenosis Surgical Protocol in COVID-19 171
Protocol Step Implementation
Rapid Sequence Induction
Awake preoxygenation with 100% FiO2 for 5 minutes followed by rapid
sequence induction
Avoid bag-mask and laryngeal mask ventilation
Direct Laryngoscopya Assess degree of laryngotracheal stenosis with rigid telescope
Initial Dilation
Dilate stenosis with balloon or rigid dilators prior to intubation if airway
diameter less than outer diameter of ETTb
Surgeon should be familiar with relative diameters of: lumen of chosen
laryngoscope, available dilators, and outer diameter of ETTc
Initial Closed System with
ETT Intubation
Tracheal intubation with small cuffed ETT
ETT loaded over rigid telescope may mitigate risk of false passage
Once intubated ventilate with 100% FiO2 to preoxygenate before apneic
interventions
Laryngoscope Suspension
Hold ventilation before disconnecting ETT and removing laryngoscope if closed
laryngoscope used for intubation
Reconnect circuit before reinserting and suspending laryngoscope
Intermittent Apnea
Proceed with procedures that can be done while intubated, e.g. steroid
injection/mitomycin application
Intermittently extubate for balloon dilation/biopsy/excision
Stop ventilation during end expiration prior to extubation
Maintain neuromuscular blockade throughout the surgery
ETT can be replaced directly through the operative laryngoscope between apneic
interventions
Extubation Administer glycopyrrolate during procedure to minimize secretions
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
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Apply topical lidocaine to larynx and trachea upon completion of surgical
procedure
Intravenous lidocaine, opioids, sedatives at time of extubation to attenuate
laryngeal and cough reflexes
a May use closed operating laryngoscope or anesthesia laryngoscope blade
b Outer diameter of 5.0 cuffed microlaryngeal tracheal tube is 6.9 mm
c A 28-French Jackson laryngeal dilator (Pilling/Teleflex, Morrisville, NC) has an outer diameter 9.3 mm and can be
passed through a standard (male) Ossoff-Pilling laryngoscope (Pilling/Teleflex, Morrisville, NC)
Abbreviation: FiO2, fraction of inspired oxygen; ETT, endotracheal tube; THRIVE, trans-nasal humidified rapid-
insufflation ventilatory exchanges
172
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.
This manuscript has been accepted for publication in Otolaryngology-Head and Neck Surgery.