Tracheostomy During COVID-19 Pandemic—In Search of Lost Timing—Reply

In Reply We thank Cazzador et al for their appreciation of the Viewpoint “Surgical Considerations for Tracheostomy During the COVID-19 Pandemic: Lessons Learned From the Severe Acute Respiratory Syndrome Outbreak.”¹ Since the publication, several other groups have also developed guidelines for tracheostomy in the context of coronavirus disease 2019 (COVID-19), with similar goals of minimizing perioperative aerosolization risks.²

We agree with Cazzador et al that an optimal timing for tracheostomy in patients with COVID-19 has not been clearly established. Given that open tracheostomy performed with the necessary personal protective equipment has proven to be safe during SARS (severe acute respiratory syndrome) and COVID-19,¹ in general, we would consider tracheostomy in a patient approaching 14 days of intubation without the possibility of imminent successful extubation.

We have thus far not advocated early tracheostomy in patients with COVID-19 in the absence of any compelling evidence to do so. Evaluating benefit from early tracheostomy in patients with COVID-19 is a challenging task, given the variable clinical severity of COVID-19 among patients and the multiple risk factors that are associated with disease severity.

In a multicenter cohort study of 53 patients with COVID-19 who underwent tracheostomy, Chao et al³ reported that 56.6% of patients were liberated from the ventilator at a mean (SD) of 11.8 (6.9) days after tracheostomy. The authors observed a weak positive correlation between time to tracheostomy and posttracheostomy ventilator dependence, suggesting some support for earlier tracheostomy. Nonetheless, the authors also acknowledged the possibility of selection bias of healthier patients for earlier tracheostomy and delayed tracheostomy in patients with questionable prognoses.

A randomized clinical trial with specific patient selection criteria would be ideal to address this question. However, it has been our experience, and also the experience of others,⁴ that most patients with COVID-19 who require intubation can be successfully extubated within the first 14 days. Therefore, careful selection of patients who will benefit from tracheostomy is required for such a clinical trial.

In relation to percutaneous tracheostomy techniques, there have been reports of percutaneous tracheostomy being safely performed in patients with COVID-19, with special emphasis on minimizing aerosolization, including complete paralysis of the patient and pausing ventilation during instrumentation of the airway.³ A technique involving placement of the bronchoscope alongside the endotracheal tube (rather than inside of it) to minimize aerosolization has been described.^5,6 Nonetheless, one should be cognizant of the aerosolization risks involved, especially during a difficult percutaneous tracheostomy procedure or one in which a complication occurs. If these risks are unacceptable, then an open tracheostomy with direct surgical control of the airway would be the safest approach.

We once again thank Cazzador et al for their thoughtful comments and the opportunity to discuss these issues.

Corresponding Author: Woei Shyang Loh, MBBS, Department of Otolaryngology–Head & Neck Surgery, National University Hospital, Singapore, 1E Kent Ridge Rd, Level 7, Singapore 119228 (entlws@nus.edu.sg).

Published Online: September 3, 2020. doi:10.1001/jamaoto.2020.2633

Conflict of Interest Disclosures: None reported.