Measuring Tracheotomy Risk in Patients With COVID-19: Time to Look Beyond Surgery and Surgeons | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Comment & Response
April 22, 2021

Measuring Tracheotomy Risk in Patients With COVID-19: Time to Look Beyond Surgery and Surgeons

Author Affiliations
  • 1Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Wythenshawe, Manchester, United Kingdom
  • 2Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
  • 3Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
  • 4Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
  • 5Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan
  • 6Global Tracheostomy Collaborative, Raleigh, North Carolina
JAMA Otolaryngol Head Neck Surg. 2021;147(7):678-679. doi:10.1001/jamaoto.2021.0554

To the Editor Avilés-Jurado and colleagues1 add another piece to the coronavirus 2019 (COVID-19) jigsaw puzzle with their investigation of 50 patients undergoing surgical tracheostomy for respiratory failure. The study affords insights on timing and reassurances regarding surgeon safety during bedside open tracheostomy in the intensive care unit. A lingering question remains, however, concerning safety of the rest of the health care team during surgery and afterwards.

Avilés-Jurado and colleagues1 reported that no surgeons contracted COVID-19 disease during the study period, but they do not report on other indispensable members of the team. Nurses, speech-language pathologists, and respiratory care clinicians bear a substantial burden of COVID-19 exposure risk. Surgical opening of the airway during tracheotomy is brief in duration, and this critical step is typically performed with apnea—greatly reducing aerosol generation. In contrast, this margin of safety from apnea is seldom available to nurses and other allied health professionals. Notably, the investigation reports median time to tracheostomy of 9 days (interquartile range, 2-24 days), suggesting that many tracheotomies were performed before infectivity waned.2

Both the number of airway manipulations performed following tracheotomy and the duration of such exposures greatly exceeds that attributable to the index procedure. Examples of aerosolizing maneuvers, often accompanied by cough, include tracheostomy suctioning and stomal care, flexible endoscopic or videofluoroscopic evaluation of swallowing, cuff deflation, speaking valve evaluation, administration of nebulizers, high-resolution manometry, expiratory muscle strength training, and Iowa Oral Performance Instrument tongue strength diagnostics.

In this cohort,1 the timing of tracheostomy was primarily determined by intensivists, based on clinical condition, prognosis, and predicted tolerance to weaning; however, judging when patients will safely tolerate tracheostomy is difficult. Multidisciplinary collaboration enhances decision making, particularly amidst intensive care unit capacity strain. Such decisions should engage the relevant stakeholders bearing risk of aerosol generation during and after the procedure. A preprocedural apnea test in conjunction with the multidisciplinary team may help assess physiological reserve to tolerate tracheotomy and minimize complications.2

Long before the COVID-19 pandemic swept across countries and continents, the World Health Organization declared 2020 the Year of the Nurse and Midwife, the culmination of a global campaign to improve health by raising the profile of nursing worldwide. All frontline workers should be given due consideration not only in practice, but in reporting safety provisions and outcomes. High-quality tracheostomy care is predicated on purposeful interprofessional collaboration. We commend Avilés-Jurado and colleagues1 for their study, which adds to growing knowledge on assessment of safety, timing, and outcomes of tracheostomy.3-5

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Article Information

Corresponding Author: Michael J. Brenner, MD, Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, 1500 E Medical Center Dr, 1903 Taubman Center, SPC 5312, Ann Arbor, MI 48104 (

Published Online: April 22, 2021. doi:10.1001/jamaoto.2021.0554

Conflict of Interest Disclosures: None reported.

Avilés-Jurado  FX, Prieto-Alhambra  D, González-Sánchez  N,  et al.  Timing, complications, and safety of tracheotomy in critically ill patients with COVID-19.   JAMA Otolaryngol Head Neck Surg. 2020;147(1):41-48. doi:10.1001/jamaoto.2020.3641PubMedGoogle ScholarCrossref
McGrath  BA, Brenner  MJ, Warrillow  SJ,  et al.  Tracheostomy in the COVID-19 era: global and multidisciplinary guidance.   Lancet Respir Med. 2020;8(7):717-725. doi:10.1016/S2213-2600(20)30230-7PubMedGoogle ScholarCrossref
Schultz  MJ, Teng  MS, Brenner  MJ.  Timing of tracheostomy for patients with COVID-19 in the ICU-Setting precedent in unprecedented times.   JAMA Otolaryngol Head Neck Surg. 2020;146(10):887-888. doi:10.1001/jamaoto.2020.2630PubMedGoogle ScholarCrossref
Fiacchini  G, Tricò  D, Ribechini  A,  et al.  Evaluation of the incidence and potential mechanisms of tracheal complications in patients with COVID-19.   JAMA Otolaryngol Head Neck Surg. 2021;147(1):70-76. doi:10.1001/jamaoto.2020.4148PubMedGoogle ScholarCrossref
Kwak  PE, Connors  JR, Benedict  PA,  et al.  Early outcomes from early tracheostomy for patients with COVID-19.   JAMA Otolaryngol Head Neck Surg. 2021;147(3):239-244. doi:10.1001/jamaoto.2020.4837PubMedGoogle ScholarCrossref
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