Commentary: Coronavirus disease 2019 (COVID-19) tracheostomies-The "how" but not the "why" or "when".

Peter Abraham, MD, and Benjamin Wei, MD

Maximizing provider safety during high exposure risk procedures such as tracheostomies is essential to maintaining a healthy workforce as the COVID-19 pandemic rages on.

See Article page 183.

The coronavirus disease 2019 (COVID-19) pandemic has thrust health care providers into unconventional work environments with often-unfamiliar patient populations. Although most institutions have well-established tracheostomy protocols, the pandemic has necessitated revisions to these existing protocols to mitigate risk to health care providers, often with little-to-no evidence to use for guidance. In their article, Bribriesco and colleagues outline their institution's approach to tracheostomies in patients with COVID-19, emphasizing a multidisciplinary approach with simulation-based training.

The strength of the authors' work lies in the supplemental video, which provides a step-by-step presentation of a percutaneous tracheostomy with multiple safety tips included along the way. This demonstration provides an outstanding model that can be replicated by viewers. The emphasis placed on limiting aerosolization of the virus throughout the procedure is exceptional and may prove useful to both learners and established clinicians alike.

The authors support common-sense precautions that are nonetheless worth stating explicitly in protocol form: using appropriate protective equipment, mitigating staff exposure by having intravenous pumps and ventilators located outside the operating room, and performing the operation with the patient under apnea. Unfortunately, the study does not provide much useful data on outcomes regarding either medical staff or patients, nor does this study address the timing and decision to perform tracheostomy in patients with COVID-19, which arguably are more important topics than technique. Could a simple requirement to retest patients for the virus before going ahead with tracheostomy be more effective at minimizing risk? Would a delay in performing tracheostomy in intubated patients with COVID-19 have any negative effect on a patient population that has up to a 97% mortality rate?

Recent publications have detailed new algorithms and recommendations regarding tracheostomy placement in patients with COVID-19 at both the institutional and national levels, as shown in the author's Table E3.3, 4, 5, 6, 7, 8 A cursory review of this table, however, illustrates the absence of consensus about best practice. Nonetheless, Bribriesco and colleagues provide a thoughtful, multidisciplinary approach to tracheostomy placement in patients with COVID-19. The dissemination of such informative material may help refine institutional practices and improve patient outcomes as the pandemic continues.