Journal Pre-proof
Practical insights for paediatric otolaryngology surgical cases and performing
microlaryngobronchoscopy during the COVID-19 pandemic
Claire Frauenfelder, Colin Butler, Ben Hartley, Lesley Cochrane, Chris Jephson,
Robert Nash, Richard Hewitt, David Albert, Michelle Wyatt, Andrew Hall
PII:

S0165-5876(20)30173-7

DOI:

https://doi.org/10.1016/j.ijporl.2020.110030

Reference:

PEDOT 110030

To appear in:International Journal of Pediatric Otorhinolaryngology

Please cite this article as: C. Frauenfelder, C. Butler, B. Hartley, L. Cochrane, C. Jephson, R. Nash, R.
Hewitt, D. Albert, M. Wyatt, A. Hall, Practical insights for paediatric otolaryngology surgical cases andperforming microlaryngobronchoscopy during the COVID-19 pandemic, International Journal of PediatricOtorhinolaryngology, https://doi.org/10.1016/j.ijporl.2020.110030.
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Practical insights for paediatric otolaryngology surgical cases andperforming microlaryngobronchoscopy during the COVID-19
pandemic

Authors
Claire Frauenfelder1, Colin Butler1,2, Ben Hartley1, Lesley Cochrane1, Chris Jephson1, Robert
Nash1, Richard Hewitt1, David Albert1, Michelle Wyatt1, Andrew Hall1

1

Great Ormond Street Hospital for Children

2

UCL Institute of Child Health, London, UK

Corresponding Author
Mr Andrew Christopher HallGreat Ormond Street Hospital
Great Ormond Street
Holborn
LondonWC1N 3JH
020704059200
andrew.hall@gosh.nhs.uk
Word Count: 2719

Key words:

COVID-19; SARS CoV2; coronavirus; paediatric airway; microlaryngobronchoscopy

1Introduction

The current COVID-19 pandemic requires paediatric otolaryngologists to carefully selectoperative procedures undertaken during this time. However, the nature of many conditions
treated by this group means that urgent operative evaluation and intervention in the
airway, oral, and nasal cavities is still required. This paper produced by the Otolaryngology
team at Great Ormond Street Hospital, London, UK aims to provide guidance for operative
modifications to these necessary paediatric procedures at the time of the COVID-19
pandemic. Additionally, we share our experience performing microlaryngobronchoscopy in
COVID-19 positive patients. It is recommended this paper be read in conjunction withsupporting guidance from local otolaryngological societies and further literature as it
becomes available.

Patient assessment for risk of COVID-19

Children have been infected from the early stages of the current pandemic, and those thatare symptomatic have had a less-severe clinical illness than most adults admitted fortreatment. Current data suggests that 15% paediatric COVID positive cases are
asymptomatic and 25% present with features of an upper respiratory tract infection.[1]There are also concerns regarding the high viral load of asymptomatic paediatric patients.[2]A disproportionately high number of health care workers (otolaryngologists in particular)
have been infected during the course of their recent clinical work.[3–5] The current risk of2

transmission from asymptomatic patients with COVID-19 to clinicians is difficult to gage
based on clinical patient assessment.

Patient COVID-19 status is being formally confirmed via testing, however not all patientsrequiring urgent surgical treatment of the oral cavity and respiratory tract will have beentested.

A key difficulty in paediatric otolaryngology practice is examining and operating in
anatomical locations with high possibility of aerosol generation within a potentiallyasymptomatic population affected by COVID-19.[2] Asymptomatic patients are at risk ofviral shedding during examination and procedural work involving these areas should also
recognize the risk of transmission across adjacent surfaces.[6] Our current recommendationis all paediatric patients undergoing urgent otolaryngology procedures should be treated assuspected COVID-19 cases until proven otherwise due to the higher proportion of
asymptomatic children carrying COVID-19. This is in keeping with guidance emerging fromsurgical societies and professional organisations.[7] While universal screening of patientsprior to surgery would be ideal, few institutions around the world are currently equipped to
do so due to restricted availability of testing resources. False negative test results remain anarea of concern. As such, specific recommendations about which patients to test is currently
evolving day by day and is beyond the scope of our discussion.

Personal Protective Equipment (PPE)3

Appropriate PPE must be utilized to protect staff and local guidelines should reflect theincreased risk of aerosol generating procedures (AGP), as described by the World HealthOrganization.[8] The following are the current guidelines published by ENT-UK:

Minimum PPE for urgent ENT procedures[9]-FFP3 or Powered Air Purifying Respirator (PAPR) if fit test not achievable-

Long sleeved gowns-

Gloves-

Disposable eye protection

General Principles of paediatric patient treatment during COVID-19 pandemic-

Protection of staff, patient and future patients-

Only most urgent procedures should be performed-

Appropriate use of Personal Protective Equipment (PPE) at all times-

Where no appropriate PPE available, no oral cavity and invasive respiratory tract
examination or procedure should be undertaken

Specific Airway & Procedural Principles

Intubation of the airway is widely recognized as a high-risk intervention for respiratory virustransmission to healthcare workers.[10] Procedural work undertaken in oral cavity andrespiratory tract is also recognized to generate high volume of viral-laden aerosols.[11]4Only the most urgent procedures should be performed. Management of the airway during
urgent paediatric otolaryngology procedures should aim to keep aerosol generation and gas
escape from the airway to a minimum. Airway circuits should be closed for as long as
possible and minimal airway or mucosal instrumentation should be performed.[12]Procedures should be restricted to urgent components only and any suitable modifications
or abbreviations to usual procedure should be employed, with the goal of limiting staff
exposure to operating time and aerosol generation. No powered instrumentation should be
used for soft tissue (e.g. microdebrider or laser). Minimal power should be used where drills
or burrs are required for bone, however this work should be deferred wherever possible.
Allow significantly more time for the procedure than it would usually take, especially whileteams are adjusting to the operating conditions.

COVID-19 positive Microlaryngobronchoscopy: Practical Insights

Within our institution we have performed urgent microlaryngobronchoscopies in a COVID19 positive paediatric patient in order to secure and evaluate a known difficult airway. We
share our experience to assist other providers prepare to operate in this situation. Many of
the general considerations for care of patients with COVID-19 have been explored in early
literature, however there are a number of specific operative insights that may be useful.

MLB and rigid bronchoscopy should be considered very high-risk in terms of exposure tostaff for the entirety of the procedure due to a combination of aerosol-generation andprolonged gas flow. The requirement for an open circuit delivery of gas/oxygen via the5nasopharynx or oropharynx combined with the manipulation of mucosa distributes a very
high aerosol volume. Every effort should be made to shorten the procedure time before,
during and after the case to minimize the exposure to viral aerosol by staff.[11,13]

As these procedures routinely involve oxygenating the patient via a nasopharyngeal or
oropharyngeal airway, without any containment of aerosols, the follow advice applies:o Only urgent cases should be performedo All patients should be treated as infectiveo Procedural time should be kept to a bare minimum with an expert provider
performing the caseo Consider minimal 2 person operators given additional challenges of operatingin additional PPEa) Pre-operative considerations-Time

All cases performed under these conditions are taking significantly longer time and patience
with all team members during preparation is important. Especially with the addition of staff
upskilling with donning and doffing of PPE, allow for up to double the usual time required
for a case from brief to transfer of the patient back to intensive care or their ward
environment. This should be taken into account in discussion with relatives and ward staff.

-

Team preparation

Pre-operative briefing prior to patient arriving in theatre allows for targeted planning andoptimized equipment preparation. A modified WHO checklist was utilized to adequately

6prepare all staff as to their roles and responsibilities. Where time permits and while teams
are learning about how to operate under these conditions, we found that short rehearsal of
the procedure with the team beneficial. Our overnight theatre teams have begun their shift
with a quick simulation to familiarize themselves with who will be performing what role andchecking PPE stocking in the relevant theatres to ensure things are ready for an emergent
case involving a COVID patient.

The role of simulation and its principles in preparation for scenarios such as this has also
been recommended by the Royal College of Anesthetists in the UK with supporting
documents available to assist with local planning prior to an emergency event. This include
activities such as rehearsal of donning and doffing in PPE or use of physical action cards totalk/walk through likely scenarios and how this may be planned for.[14] Any opportunities
to practice ‘in situ’ as a team were felt to be invaluable at our subsequent debriefs.

-

Team members

While the principle of keeping the number of team members within the theatre isimportant, overall the team may need to be larger and we have increased allocation ofnursing staff, operating department practitioners for a COVID case, and changed our on-calltheatre staff arrangements and numbers. We have also included the security team inbriefing for the patient as they are key for safe transfer of the patient to and from theoperating theatre, keeping contamination of doors, lifts etc. to a minimum as they walk withthe clinical team while moving a COVID positive patient around the hospital.
During the case an additional nurse remained clean but with PPE donned in the preparation
area with supply of anticipated extra equipment and disposables after different possible

7

outcomes of the procedure was discussed. This minimized delays while waiting forequipment. Also, a second operating department practitioner (ODP) was in the anesthetic
room performing the same role: remaining clean but able to liaise with a runner allocatedoutside of the theatre for communication and to facilitate access to additional medication
or equipment without contaminating other parts of the operating suite.

-

Communication within the team is challenging

PPE required by involved staff can affect intra-operative communication owing to loss ofvisual cues and sound attenuation. As such particular attention should be given to minimize
background noise and precise closed loop communication. Communication between teammembers in the theatre is more challenging and requires patience at a time of alreadyincreased stress. Good briefing prior to the case helps with this as team members have an
idea of what should be happening at each step. Speaker phones or walkie-talkies can bechallenging due to PPE, however additional staff members and satellite members of theteam with appropriate PPE donned were very helpful.

-

Theatre Environment

Within our institution no negative pressure theatre environment is available and as such anormal pressure room with closed doors was used yet if present would be preferable.[12]Currently a group of nominated theatres for COVID cases have been allocated andstock/equipment within them has been modified.

-

Transfer to theatre

8

The patient should be sent for once the team is ready with all equipment. PPE needs to bedonned and checked prior to receiving the patient and time should be allocated even in
emergent cases.

b) Anesthesia and airway management during MLB
Anesthetic rooms should not be used and induction of anesthesia should be in the operating
theatre itself. Where the patient is being transferred from intensive care, minimal
manipulation of airway adjuncts or suctioning should be minimized until all staff andequipment for the procedure is ready to begin immediately.
Insertion of an LMA at induction of anesthesia and prior to commencement of MLB/rigid
bronchoscopy should also be considered. This decreases distribution of aerosols comparedto open airway.[10,11] It allows a short but additional time period for preparation ofequipment, clinician positioning, WHO surgical safety checklist etc while minimizing timewith an open airway. Caution should employed though as the LMA does not provide
protection from spread of viral spread so should be used for the shortest possible period oftime. There are many other guidelines being published by our anesthetic colleagues andthese are beyond the scope of this discussion.

c) Intra-operative-

Equipment

Familiarity with the procedure and equipment is important and team members should beselected accordingly. Reassurance of anxious team members that in fact these procedures
are well executed by your team on a regular basis is helpful. A brief but detailed discussionof how the procedure is expected to ‘play-out’ is important and allows nursing staff to9

prepare a stockpile of equipment for all eventualities in close proximity to the theatre
without contaminating other areas or risking staff by rushed doffing of PPE to leave theroom. As mentioned, a PPE-protected clean member of nursing staff allocated to thisequipment stockpile streamlined the time taken for the case. All equipment including lightleads, cameras, suction should all be set up and checked prior to arrival of patient in the
room.

-

Anticipate and verbalize potential difficulties

Attention should be paid to possible anatomical abnormalities or patient factors that willaffect equipment selection (e.g. cleft palates with sumps of thick secretions, ex-prematureinfants with small airways that have been previously intubated with possible stenoses).
Suction attachments and laryngoscope blades set up should reflect these to streamline timeand aerosol generation while manipulating the airway.

d) Post-operative-

Pause at the end of the case for safety

Doffing of PPE is high risk for transmission of aerosolized material and poor technique has
been associated with increased COVID infection rates in healthcare workers.[10,11] Where
the temptation is to remove PPE quickly at the end of the case, additional time should beallocated for this. As team members doff, team members need to supervise each other as
they doff (especially while staff are new to PPE) to prompt the steps of doffing with proper
hand hygiene to be performed between steps. Laminated guides on the wall in these areas
are also helpful. This is especially important given the high level of contamination of thetheatre and onto staff’s PPE during MLB. Aerosol settling time of 20 minutes is allocated at10

our institution between the patient leaving at the end of the case prior to any cleaning by
nursing staff.
-

Debrief

A short team debrief at the end of the case, especially during early experience of COVID
cases being performed in the operating suite, allows for identification of steps tostreamline, any system or equipment issues that should be addressed and to allow
peripheral team members to learn from those involved in the case.

Other procedures

Flexible bronchoscopy via airway-adjunct or ETT

Flexible bronchoscopy should continue to be performed via an LMA or ETT with minimal
opening or disconnection of the ventilatory circuit to prevent spread of aerosol.

Paediatric Tracheostomy

Tracheostomy is a high-risk procedure because of aerosol-generation and any elective
paediatric tracheostomy should be delayed until active COVID-19 disease has passed in
keeping with current guidance.[15] Any essential paediatric tracheostomy should proceedwith PPE as for an AGP in suspected COVID-19 patients:-

Non-fenestrated cuffed tracheostomy should be used to minimise aerosol

11-

Initial advancement of the endotracheal tube should be performed prior totracheostomy being made-Ventilation to cease prior to tracheostomy tube insertion where possible and ensureswift and accurate placement of tracheostomy tube with prompt inflation of the cuff-

Ensure there is no leak from the cuff and the tube is secured in position-

Post-operative tube changes should only be limited to the initial tube change. Tube
exchange should be deferred until the patient has ceased being contagious where
possible

Humidification via tracheostomy tube following new paediatric tracheostomy should
continue to be utilised to avoid crusting within the tube differing from adult guidance.[16]Careful clinical judgment is required when selecting the appropriate method of
humidification and a heat moisture exchanger (HME) represents an alternative to wet circuitand may decrease aerosol generation. Nebulisers should be avoided and spacers with ametered dose inhaler provide an alternative method of medication delivery to the airway.
Caution should be used as unlike adult patients, paediatric tracheostomy tubes classicallyhave no inner cannula for removal and without humidification, are more likely to occlude.
An occluded tube would necessitate disruption of the circuit in as an emergency, increasing
likelihood of aerosol spread.

Paediatric Tracheostomy Tube Changes

Tracheostomy changes by staff should be minimized during the current COVID pandemic.
Where possible the time to the next tracheostomy tube change should be extended or

12avoided until no active COVID disease present, or negative status is confirmed. If essential,
any tracheostomy change should proceed with PPE as for an AGP.

Paediatric Nasal and sinus surgery & Peri-orbital cellulitis

Non-urgent nasal or sinus surgery should not be undertaken during the COVID-19 pandemic.
In peri-orbital cellulitis, the British Association of Paediatric Otolaryngology haverecommended only considering operating on patients whose infection threatens vision or
has developed an intracranial complication.[17] An external approach should be used where
possible. Throat packs should be used with caution as insertion risks aerosol generation,
however debris and secretions in the pharynx are likely to stimulate coughing on emergencefrom anaesthesia.

Paediatric nasal bone fracture reduction is not recommended at the present time unlessthere is a presence of a nasal septal haematoma. [17]Other procedures-

Other urgent paediatric ENT procedures should be performed with a cuffed or microcuff ETT where possible-

Tube-selection should be targeted to minimising a leak around the tube-

Operating time should be kept to a minimum

13

Optimal management in the era of COVID-19 necessitates careful consideration of staff
safety while continuing to ensure best possible care of the paediatric otolaryngology
patient. As further evidence develops as to COVID-19 the recommendations of this paper
may be subject to change. In addition, we recognise the availability of PPE worldwide
remains variable and resource restriction may result in necessary variance.[8]References:[1] X. Lu, L. Zhang, H. Du, J. Zhang, Y.Y. Li, J. Qu, W. Zhang, Y. Wang, S. Bao, Y. Li, C. Wu, H.
Liu, D. Liu, J. Shao, X. Peng, Y. Yang, Z. Liu, Y. Xiang, F. Zhang, R.M. Silva, K.E. Pinkerton, K.
Shen, H. Xiao, S. Xu, G.W.K. Wong, C.P.N.C.S. Team, SARS-CoV-2 Infection in Children., New
England Journal of Medicine. (2020). doi:10.1056/nejmc2005073.
[2] K.-Q. Kam, C.F. Yung, L. Cui, R.L.T. Pin, T.M. Mak, M. Maiwald, J. Li, C.Y. Chong, K. Nadua,
N.W.H. Tan, K.C. Thoon, A Well Infant with Coronavirus Disease 2019 (COVID-19) with High
Viral Load., Clinical Infectious Diseases : An Official Publication of the Infectious Diseases
Society of America. 361 (2020) 1701. doi:10.1093/cid/ciaa201.
[3] P.Z. PH, N. JV, Fernandez, M. JD, S. H, J. RK, Statement From: Stanford University Schoolof Medicine Departments of Otolaryngology-H&N Surgery and Neurosurgery, Neurosurgery.
(2020).
[4] D. Lu, H. Wang, R. Yu, H. Yang, Y. Zhao, Integrated infection control strategy to minimize
nosocomial infection of coronavirus disease 2019 among ENT healthcare workers, Journal of
Hospital Infection. (2020). doi:10.1016/j.jhin.2020.02.018.
[5] D. Wang, B. Hu, C. Hu, F. Zhu, X. Liu, J. Zhang, B. Wang, H. Xiang, Z. Cheng, Y. Xiong, Y.
Zhao, Y. Li, X. Wang, Z. Peng, Clinical Characteristics of 138 Hospitalized Patients With 2019
Novel Coronavirus-Infected Pneumonia in Wuhan, China., JAMA. 323 (2020) 1061.
doi:10.1001/jama.2020.1585.
[6] N.V. Doremalen, T. Bushmaker, D.H. Morris, Aerosol and surface stability of HCoV-19(SARS-CoV-2) compared to SARS-CoV-1, (n.d.).
[7] Magennis P, Kumar N, British Association of Oral & Maxilofacial Surgeons & ENT-UK:
Guidance PPE for patients with emergency oropharyngeal and nasopharyngeal conditions
whose COVID Status is unknown, (2020).
[8] World Health Organisation, Rational use of personal protective equipment (PPE) for
coronavirus disease (COVID-19), (2020).

14[9] ENT-UK, Guidance for ENT during the COVID-19 pandemic, (24 March 2020)
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-ofpossible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novelcoronavirus-wn-cov-infection#criteria[10] K. Tran, K. Cimon, M. Severn, C.L. Pessoa-Silva, J. Conly, Aerosol generating procedures
and risk of transmission of acute respiratory infections to healthcare workers: a systematic
review., PloS One. 7 (2012) e35797. doi:10.1371/journal.pone.0035797.
[11] J.C.-H. Cheung, L.T. Ho, J.V. Cheng, E.Y.K. Cham, K.N. Lam, Staff safety during
emergency airway management for COVID-19 in Hong Kong, Lancet Respir Medicine. (2020).
doi:10.1016/s2213-2600(20)30084-9.
[12] Safe Airway Society, Consensus statement: Safe Airway Society principles of airway
management and tracheal intubation specific to the COVID-19 adult patient group, Medical
Journal of Australia. (n.d.).
[13] Public Health England, When to use a surgical face mask or FFP3 respirator, (2020).
[14] Faculty of Intensive Care Medicine, ‘Think SIM’ for your COVID Preparations. Accessed
March 24. https://icmanaesthesiacovid-19.org/covid-19-airway-management-principles[15] ENT-UK, ENT-UK Guidelines: Framework for open tracheostomy in COVID-19 patients,(2020).
[16] Royal College of Anaesthetists. UK, COVID-19 airway management principles. (March
2020)[17] Kuo M. Otolaryngology, British Association of Paediatric Otolaryngology. BAPO
statement on SARS Cov2 and Paediatric Otolaryngology Provision, (2020).

15