Response.

To the Editor:

We thank Brenner et al for their interest in our consensus statement and for highlighting specific considerations relevant to performing tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic. In their letter, Brenner et al cite the need to balance risk reduction of infection transmission among health-care workers during an aerosol-generating procedure, such as tracheostomy, while optimizing patient safety and readiness for the procedure. We agree that, for specific aerosol-generating procedures, the uncertainty and lack of definitive best practices regarding risk reduction early in the pandemic may have led to a preferential focus on health-care worker safety. In fact, that is one of the main reasons we decided to perform a systematic review of the available literature and follow a formal expert panel and consensus statement method, rather than simply publish a series of opinion-based recommendations.

Brenner et al discuss the benefit of a preprocedural apnea trial. They also highlight the importance of a multidisciplinary team approach in the performance of tracheostomy and aftercare. We echo these specific observations in our article because we delineate in the third recommendation and in Table 3 the importance of performing a brief apnea test prior to tracheostomy and performing coordinated apnea during key aspects of the procedure along with sedation, analgesia, and neuromuscular blockade to minimize potential aerosolization. We also advocate to have the most experienced operators and the least number of personnel present during the procedure to further reduce transmission of infection. We also agree with them that our statement will be more engaging by involving all teams participating in the care of patients with COVID-19. That is the reason that, in recommendation 7, we highlight the role of the key stakeholders and that of a multidisciplinary team for procedural assessment and planning. We summarize the recommendations from several surgical and medical societies pertinent to considerations for tracheostomy aftercare. There is evidence that such teams enhance safety and also may achieve a more efficient pathway to downsizing and decannulation. , Increasing awareness on the assessment and management of such patients by a broader pool of providers is relevant, especially during the surge of the pandemic, which further reinforces the need for a multidisciplinary care plan in this setting. Best practices and therapies for patients with COVID-19 continue to evolve rapidly, and it will be important to use and continue to learn from the global experience to refine the timing, technique, and aftercare of patients with COVID-19 whose condition requires tracheostomy.