It wasn’t supposed to go this way.
According to a case report in BMJ, a 51 year old patient in the U.K. was being tested for Covid-19 via a swab placed into an opening in her neck (tracheostomy) that allows her to breathe. The swab broke off, and subsequently became embedded in one of the airway passages in her lung.
The patient had recently undergone brain surgery along with placement of a tracheostomy tube—a device inserted into a hole made in the neck and windpipe (trachea) that is designed to help a person breathe.
After the procedure, and as part of the normal protocol at University Hospitals of Leicester (NHS), she was required to get a Covid-19 test before she was discharged to a nursing home.
The hospital staff obtained a Covid-19 swab through the tracheostomy tube because she was breathing through the tube in her neck and could potentially have acquired the virus in this manner.
As the patient was being swabbed, the nurse performing the procedure stated that she felt part of the swab break off, with one part of the swab dropping into her trachea (and subsequently migrating into her lower airways).
Authors of the report state that the patient became “momentarily unsettled” then developed an increase in her breathing rate for a short period of time before her vital signs normalized.
A CT scan of her chest did not clearly reveal the presence of the swab, but they did notice signs of inflammation (or swelling) in the tissue of her right lower lung. The scan suggested the presence of a foreign body, but a bronchoscopy—a procedure performed in which a flexible scope is placed into the airway’s breathing passages (bronchus)—was able to locate the swab so that it could be removed.
Under normal (non-pandemic) conditions, a bronchoscopy is considered a low risk procedure for medical providers. But it’s not the case in the era of Covid-19 due to the risk of aerosolizing the viral particles during such a procedure.
This was quite fortunate for the patient, since inability to locate and remove this swab could have led to development of pneumonia, a lung abscess, sepsis and even death.
So the question is this: in the era of Covid-19, what’s the safest, most efficient and evidence-based approach for testing a patient with a tracheostomy?
Studies have demonstrated that the most optimal approach for testing for SARS-CoV-2, the virus responsible for Covid-19, is via sampling the nasopharynx, as opposed to just the nasal cavity or throat itself. The virus seems to remain at higher concentrations in this area, increasing the chance for a positive result. But, it’s also important to realize that in patients with a tracheostomy, the area around the site can become contaminated from regular use—by standard respiratory care, involving handling of the site/ daily activities—so it can be a portal of entry for the virus. That said, it may also just be “colonized” with viruses or bacteria, without causing an overt infection leading to fever or illness.
“The nasopharynx, nose, and oral cavity may still be colonized with Covid-19, even in patients who have indwelling tracheotomy tubes or after laryngectomy. (voice box removal), said Nina L. Shapiro, MD, FACS, FAAP, Director, Pediatric Otolaryngology, Professor of Head and Neck Surgery, UCLA School of Medicine.
But having adequate training to perform a swab is also critical as well. “Many underestimate the technique and precision needed when performing Covid-19 swabs,” Shapiro emphasized. “Risks, while rare, include nasal trauma, epistaxis (nosebleeds), and, in one other rare case, brain injury and cerebrospinal fluid leak, as she detailed in her recent Forbes piece.”
CDC guidelines currently recommend a nasopharyngeal swab for patients with a tracheostomy, but also consideration for sampling secretions from the tracheostomy if available.
A practice policy posted by the American Head and Neck Society gives a bit more discretion to medical providers, stating that “criteria for testing will vary by local supply and practices and is outside the scope of this policy.” Even so, their stated recommendation is for sampling both the upper airway or nasopharynx and the lower respiratory tract with a tracheal swab, when the patient qualifies per testing protocols.
“I would recommend performing a nasopharyngeal swab in these patients, as their nasopharynx remains a potential source of Covid-19 viral load,” with priority over the tracheal site, according to Shapiro.
Dennis H. Kraus, MD, FACS, Director for Head and Neck Oncology, Northwell Health Cancer Institute, Professor and Vice Chairman of Otolaryngology, Department of Otolaryngology, Zucker School of Medicine at Hoftra/Northwell agreed, offering we will need to look at longer term data to see which approach makes more sense.
“Both swabs of the nasopharynx and tracheostomy site have been employed, but it’s not clear if one is superior over the other, said Kraus. “The nose is considered the primary source of entry of Covid-19 into the body, but it is unclear if that is true in tracheostomy patients. There may be a role in performing both types of test in tracheostomy patients.”
As for sampling only the nasopharyngeal cavity, instead of the tracheostomy site, Kraus explains that it’s unclear which approach is more ideal at this time. “We will need to track this patient population in an effort to determine which test offers the most effective outcome.”
Whether collecting tracheal or nasopharyngeal samples, it’s recommended to adhere to standard protocols using nasopharyngeal swabs with full PPE (gown, gloves, N-95, face shield, goggles, head and show covers) due to risk of aerosolization associated if a patient were to cough.
In addition, the American Head and Neck Society states that the depth of sampling required in patients with a tracheostomy tube (without an inner cannula) may be quite deep, 5 to 7 cm, in order to obtain adequate mucous for sampling.
As for the risk of the swab “breaking off”, the question is whether a modification in the tensile strength of the stem of the swab might prevent the “break-away” complication seen in this patient. (The swab is actually designed to be broken or snapped when bent, as it placed into the sampling tube sent to the lab for analysis.) Aside from required and additional training to perform specimen collection, this may be worth investigating in this special patient population.
“Covid-19 testing does require some training and precision,” offered Shapiro. “Understanding basic nasal and nasopharyngeal anatomy is key in accessing the nasopharynx—as well as risks to the tracheobronchial airway when accessing the trachea needs to also be recognized.”
Kraus concludes that it’s “critical that individuals performing tests have adequate training and oversight, as “this largely appears to be a preventable complication,” emphasizing that “this would be considered a rare complication in any tracheostomy patient.”