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September 3, 2020

Timing of Tracheostomy for Patients With COVID-19 in the ICU—Setting Precedent in Unprecedented Times

Author Affiliations
  • 1Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, the Netherlands
  • 2Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
  • 3Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
  • 4Department of Otolaryngology–Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
  • 5Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, Ann Arbor
JAMA Otolaryngol Head Neck Surg. Published online September 3, 2020. doi:10.1001/jamaoto.2020.2630

“Uncontrolled variation is the enemy of quality.”

W. Edwards Deming, Basic Statistical Tools for Improving Quality

Navigating the uncharted has been a pervasive theme during the coronavirus disease 2019 (COVID-19) pandemic, and lack of data to guide decisions has been the most evident regarding the timing of tracheostomy. Tracheostomy, an aerosol-generating procedure with risk of infectious transmission for health care workers,1 also has important implications for patient care and stewardship of critical resources.2,3 Emerging data concerning infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the course of patients with COVID-19, and clinical experience may alter practice, even preempting publication. For example, Chao et al4 originally recommended deferring tracheostomy beyond 21 days of intubation and recommended open surgical tracheostomy over percutaneous dilatational tracheostomy; however, updated practices at the authors’ institution reflect outcomes of tracheostomy performed at 10 to 14 days after intubation, with percutaneous technique performed regularly. Similarly, shortly after the New York Head and Neck Society advocated a 14-day standard,5 the New York University thoracic group published a series of 98 COVID-19 tracheostomy procedures, with surgical procedures at a mean (SD) of 10.6. (5) days of intubation,6 indicating that many patients underwent tracheostomy well before day 10 of intubation. When COVID-19 overwhelms capacity in intensive care units (ICUs), early timing of tracheostomy may accelerate ventilator weaning and free up critical equipment, staff, and units. Guidelines now recommend that timing of tracheostomy consider scarcity of ventilators and other ICU resources.3

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