What is the best method for collecting a viral panel from a patient with a tracheostomy (trach)?

From the Guidelines

The best method for collecting a viral panel from a patient with a tracheostomy is to perform a tracheal aspirate using a sterile suction catheter. This method is preferred because it directly samples the lower respiratory tract where viral replication may be occurring, potentially increasing diagnostic yield 1. First, pre-oxygenate the patient to prevent hypoxemia during the procedure. Then, using aseptic technique, insert an appropriate-sized suction catheter (typically 10-14 French for adults) through the tracheostomy tube until resistance is met, and withdraw slightly. Apply suction while slowly withdrawing the catheter, collecting secretions in a sterile specimen trap. Typically, 1-2 mL of secretions is sufficient for viral testing. The specimen should be immediately labeled and sent to the laboratory in a viral transport medium.

Key Considerations

• The procedure should be performed carefully to minimize trauma to the tracheal mucosa and to prevent contamination of the specimen.
• Enhanced personal protective equipment (PPE) should be used to mitigate the risk of health care worker (HCW) related infection during the procedure 1.
• The use of a closed circuit while on mechanical ventilation with a tracheostomy tube and with in-line suction is recommended to minimize aerosolization 1.

Benefits of Tracheal Aspirate

• Directly samples the lower respiratory tract where viral replication may be occurring
• Avoids anatomical barriers that might make nasopharyngeal sampling difficult or impossible in patients with altered upper airway anatomy
• Potentially increases diagnostic yield compared to nasopharyngeal swabs in tracheostomy patients 1

From the Research

Collecting Viral Panel from a Patient with Tracheostomy

To collect a viral panel from a patient with a tracheostomy, it is essential to follow proper protocols to minimize the risk of transmission to healthcare workers. The following steps can be taken:

• Use personal protective equipment (PPE) such as gloves, gowns, and face shields to prevent exposure to droplets and aerosols 2, 3.
• Perform the procedure at the bedside to limit exposure time and the number of exposed personnel 3.
• Use a percutaneous approach with limited bronchoscopy to decrease viral exposure 3.
• Employ a clear and sterile plastic drape as an additional physical barrier against droplets and aerosols 2.
• Ensure thorough preprocedural planning, use of experienced personnel, and a thoughtful anesthesia approach to maximize positive patient outcomes while protecting healthcare personnel 3.

Reducing Contamination Risks

To reduce contamination risks for healthcare staff, the following measures can be taken:

• Use temporary balloon over-inflation, pre-operative adjustment of endotracheal tube position, and attachment of a transparent film dressing to the surgical field without stopping the ventilator while following routine safety measures 4.
• Use a suction catheter to mobilize secretions effectively, and ensure that each bedside is equipped with a functional suctioning system, an oxygen source, a manual resuscitation bag, and a complete tracheostomy kit 5.
• Document operative diagnosis, droplet count, and distribution on plastic sheets and face shields to monitor contamination 2.

Tracheostomy Care and Complications

Proper tracheostomy care is crucial to prevent complications, including:

• Infection
• Tracheomalacia
• Skin breakdown
• Tracheoesophageal fistula 5. Tracheostomy emergencies, such as hemorrhage, tube dislodgement, and tube obstruction, should be managed effectively with readily available supplies at the bedside 5.