Tracheotomy in patients COVID-19: A necessary high risk procedure. Two center experience.

To the Editor,

Coronavirus disease 2019 (Covid-19) caused by SARS-CoV-2 is now a pandemic, as defined by the World Health Organization, that has caused a health emergency and social alarm (Royal Decree 463/2020, of 14 March). It is an infection that is normally asymptomatic, but in 14%–20% of patients it can be complicated by pneumonia with bilateral infiltrates. Five percent of these cases may develop acute respiratory distress syndrome (ARDS), sepsis, septic shock and multiorgan failure requiring admission to an intensive care unit (ICU), orotracheal intubation, and invasive mechanical ventilation (IMV).2, 3

SARS-CoV-2 is transmitted from person to person by the respiratory route in Flügge droplets (>5 microns) and aerosols originating from infected individuals.4, 5 This poses a threat of contagion to all healthcare personnel involved in the care of these patients, especially those responsible for patients who require ventilatory support.

Tracheotomy in ARDS patients is considered necessary after prolonged orotracheal intubation or when long, difficult weaning is anticipated. Tracheostomy after 7–10 days of IMV is associated with a potential reduction in the duration of ventilation and length of ICU stay, especially in patients with severe or moderate muscle weakness, failed attempt to wean, limited respiratory reserve, and abundant thick secretions.

All aspects of tracheotomy in patients affected by SARS-CoV-2 infection have been discussed extensively due to the high risk of transmission to medical personnel from aerosol generation during manipulation and opening of the airway. In this regard, various consensus documents and recommendations which must be followed during procedures have been published, addressing not only the indication but also the safety and protection of the personnel who carry out the procedure, the technique, and the ideal conditions for its implementation.8, 9, 10

The aim of our study was to analyze tracheotomies performed in intubated patients in the setting of SARS-CoV-2 pneumonia, and to describe the steps taken when performing these procedures, and outcomes in terms of days on ventilation, days with tracheotomy, and surgical complications.

This is a descriptive, retrospective study of intubated Covid-19 patients receiving IMV who underwent surgical tracheotomy in a third-level public hospital and a private hospital that treated patients from both the private system and the public health service during the pandemic.

Surgeries performed between March 16 and April 24, 2020, the date of the end of follow-up, were analyzed. Variables such as sex, age, intubation days, days until tracheostomy, IMV days after tracheostomy, and surgical complications were collected.

Tracheotomy was indicated in all patients and performed according to the specific recommendations of the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) for tracheotomies in patients infected with SARS-CoV-2. These recommendations are summarized as follows: use of appropriate protective measures and personal protective equipment (PPE); avoidance of the use of electrical or ultrasonic cutting and coagulation systems; complete muscle relaxation of the patient throughout the procedure to prevent cough and aerosolization; adequate preoxygenation of the patient; apnea after a short period for passive expiration with open adjustable pressure-limiting valve or ventilator disconnection; tracheal incision; orotracheal tube removal; and cannulation with non-fenestrated cannula. Positioning the patient with hyperextension of the neck is required to facilitate the procedure.

A total of 27 patients underwent the procedure, 20 of whom were men (70%). The mean age of the patients was 65 (51–77) years. The median number of days from intubation to tracheostomy was 19 (7–30). Two patients died and 1 patient was weaned from the ventilator and extubated. Of the patients whose tracheostomy cannula remained in place at the end of follow-up period, 4 continue to receive mechanical ventilation, 8 are in the process of weaning, and 11 patients are spontaneously ventilated with or without oxygen therapy. Of the patients in whom IMV has been withdrawn, the median period between tracheotomy and IMV withdrawal was 3 days (1–12) with a mean of 4.7 days.

Three patients (11%) developed complications from surgery: 2 had small bleeds controlled by compression, and 1 had a cervicotomy infection requiring debridement. We did not detect complications between performing the tracheotomy and the end of follow-up period. In 4 cases, the cannula had to be changed for a longer or wider tube due to ventilation difficulties (air leakage or need for very high ventilation pressures).

None of the surgeons who performed the interventions developed symptoms of SARS-CoV-2 infection.

To summarize, in our experience, tracheostomy in patients with SARS-CoV-2 infection can provide potential benefits in terms of airway management, reduction of days of IMV and ICU stay, with a low percentage of complications related to surgery. In our series, the median number of days until tracheotomy exceeds the recommended 7 days. This is due to the lack of consensus on the appropriate moment to perform this intervention, which compelled us to follow the guidelines of our critical units that recommend tracheotomy between the second and third weeks of intubation. Randomized studies are required to ensure that early tracheotomy substantially improves the benefits cited above.

Tracheotomy is a high-risk procedure for medical personnel, but the risk can be dramatically reduced by strictly complying with the protective measures and technical recommendations described. In our experience, it can be safely performed by limiting or completely avoiding the use of electrical or ultrasonic cutting and coagulation systems.

Conflict of interests

The authors state that they have no conflict of interests.