Critical Care Guidance for Tracheostomy Care During the COVID-19 Pandemic

A Global, Multidisciplinary Approach

Vinciya Pandian, PhD, MBA, MSN, APN, RN, ACNP-BC; Linda L. Morris, PhD, APN, CCNS; Martin B. Brodsky, PhD, ScM, CCC-SLP; James Lynch, MSc Nursing; Brian Walsh, PhD, RRT; Cynda Rushton, PhD, MSN, RN; Jane Phillips, PhD, RN; Alphonsa Rahman, DNP, APRN, CNS; Troy DeRose, MSN, CRNP, RNFA, CORLN; Leah Lambe, BSN, RN, CEN; Lionel Lami, RN; Sarah Pui Man Wu, MN, RN; Francisco Paredes Garza, RN; Simona Maiani, RN; Andrea Zavalis, RN; Kafilat Ajoke Okusanya, NRN, NRM, NRICN, BSc Nursing; Patrick A. Palmieri, DHSc, DPhil(Hon.), EdS, PGDip(Oxon), MBA, MSN, ACNP, RN, CPHRM, CPHQ; Brendan A. McGrath, MBChB, PhD; Paolo Pelosi, MD; Mary Lou Sole, PhD, CCNS, CNL, RN; Patricia Davidson, PhD, MEd, RN; Michael J. Brenner, MD


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

In This Article

Abstract and Introduction


Purpose: Critical care nurses caring for patients with a tracheostomy are at high risk because of the predilection of SARS-CoV-2 for respiratory and mucosal surfaces. This review identifies patient-centered practices that ensure safety and reduce risk of infection transmission to health care workers during the coronavirus disease 2019 (COVID-19) pandemic.

Methods: Consensus statements, guidelines, institutional recommendations, and scientific literature on COVID-19 and previous outbreaks were reviewed. A global interdisciplinary team analyzed and prioritized findings via electronic communications and video conferences to develop consensus recommendations.

Results: Aerosol-generating procedures are commonly performed by nurses and other health care workers, most notably during suctioning, tracheostomy tube changes, and stoma care. Patient repositioning, readjusting circuits, administering nebulized medications, and patient transport also present risks. Standard personal protective equipment includes an N95/FFP3 mask with or without surgical masks, gloves, goggles, and gown when performing aerosol-generating procedures for patients with known or suspected COVID-19. Viral testing of bronchial aspirate via tracheostomy may inform care providers when determining the protective equipment required. The need for protocols to reduce risk of transmission of infection to nurses and other health care workers is evident.

Conclusion: Critical care nurses and multidisciplinary teams often care for patients with a tracheostomy who are known or suspected to have COVID-19. Appropriate care of these patients relies on safeguarding the health care team. The practices described in this review may greatly reduce risk of infectious transmission.


The coronavirus disease 2019 (COVID-19) pandemic coincides with the culmination of the World Health Organization Nursing Now Campaign[1] 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]