Assessing Candidacy for Tracheostomy in Ventilated Patients With Coronavirus Disease 2019: Aligning Patient-Centered Care, Stakeholder Engagement, and Health-Care Worker Safety.

To the Editor:

With their recent consensus statement in CHEST (October 2020), Lamb et al bring much-needed clarity to the role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic. Such guidance will be particularly impactful if implemented in a manner that engages multidisciplinary teams, diverse stakeholders, and delivers patient-centered care.

In the acute phase of the pandemic, clinical operations centered on minimizing the risk of infectious transmission to health-care workers and building the critical care capacity; far less attention was afforded to fostering multidisciplinary engagement and shared decision-making. This dichotomy was particularly evident in the use of tracheostomy, where concerns for health-care worker safety and hospital strain overshadowed important, but less pressing, patient-focused interests (such as early restoration of speech, oral intake, or rehabilitation). Fortunately, strategies have emerged that help to address this imbalance by protecting staff and optimizing patient-centered care.

An apnea trial is one example of a simple tool that can facilitate judgments of timing and candidacy for tracheostomy while minimizing risk to health-care workers. Risk of aerosolization for severe acute respiratory syndrome coronavirus 2 is likely greatest during cuff deflation or entering and manipulating the airway; such risks are exacerbated by positive pressure ventilation. Although apnea during such maneuvers is advisable, many patients with COVID-19 have high oxygen and ventilator requirements; suspending ventilation leads to significant and potentially life-threatening de-recruitment and desaturation. An apnea trial that consists of preoxygenation followed by suspending ventilation can clarify the patient’s physiologic reserve to tolerate apneic tracheostomy. Rapid desaturation suggests that tracheostomy is best deferred by avoiding the exposure risks to staff of unnecessary transfers to the operating room and of high-risk airway procedures complicated by rapid desaturation. It thus ensures that the timing of tracheostomy is optimized for the patient. A “failed” apnea test can identify inadequate pulmonary reserve and facilitate both critical care management and later intraoperative planning.

As we enter a more chronic phase of the pandemic, time-tested standards of care that are built on decades of data for management of ARDS will likely assume a greater role. The prognosis remains guarded for patients with severe COVID-19, but tracheostomy is appropriate for those with evidence of improvement and anticipated prolonged mechanical ventilation. Multidisciplinary planning and rehabilitation towards patient-focused goals is essential. The pandemic has seen global collaboration, rapid learning, and sharing of experiences. Optimal, safe, patient-centered tracheostomy care is possible and will continue to be refined by forthcoming data. Lamb et al deserve praise for their contribution to tracheostomy care during the pandemic era.