In Response.

Abstract

We have read with interest the Letter from Amaya et al1 with their remarks on how to perform and to manage tracheostomy in coronavirus disease (COVID)-19 patients. First of all, we appreciate the positive comments on our article2 and we believe that the reported considerations must be taken into the highest attention. In fact, the authors emphasize a series of important aspects according to their own experience and to recent studies. Management of COVID-19 patients is still changing according to new clinical research and experience. At the time of the article, no guidelines and no clinical studies comparing the safety of surgical and percutaneous tracheostomy were available. However, we came to believe that percutaneous approach could be a safe option in an epidemic setting. This hypothesis has been supported by latest experiences and new studies.3,4 As mentioned by Amaya et al1 in point 1, a similar contagion rate between personnel performing percutaneous versus open tracheostomy is becoming more and more clear, possibly due to the decrease of the overall risk after 14 days from the onset of symptoms. Moreover, we agree in stressing the value of the reduced operative time supporting the choice for the percutaneous procedure in severe clinical conditions unless the patient is critical or even unstable (point 2) and, to extensively use a sealing port for the bronchoscope (point 3). Regarding complication and procedure setup (point 4), the authors clearly underline the risk for infection of the surgical site after surgical tracheostomy. Infection of the stoma represents a major issue in these patients and we also had cases of infection of the peristomal tissues after surgical tracheostomy even if they were few. Therefore, a surgical tracheostomy might be preferred due to patients’ characteristics and team experience. In these cases, a bedside approach has been described to be safe and feasible5,6 and we believe that represents a concrete option to reduce the transfer-related risk of contagion (point 5). In conclusion, we totally agree with Amaya et al1 in supporting the percutaneous tracheostomy, which has become the election technique in COVID-19 patients, without excluding the open approach as the first choice in particular and selected patients such as obesity, goiter, subcutaneous emphysema, or difficult airway management. Moreover, we want to stress the importance of a surgical standby when a percutaneous tracheostomy is planned. Massimiliano Bassi, MDDepartment of Thoracic Surgery and Lung TransplantationUniversity of Rome SapienzaPoliclinico Umberto IRome, Italy Franco Ruberto, MDDepartment of Anesthesiology and Critical CareUniversity of Rome SapienzaPoliclinico Umberto IRome, Italy Camilla Poggi, MDDaniele Diso, MDMarco Anile, MDTiziano De Giacomo, MDYlenia Pecoraro, MDCarolina Carillo, MDDepartment of Thoracic Surgery and Lung TransplantationUniversity of Rome SapienzaPoliclinico Umberto IRome, Italy Francesco Pugliese, MDDepartment of Anesthesiology and Critical CareUniversity of Rome SapienzaPoliclinico Umberto IRome, Italy Federico Venuta, MDJacopo Vannucci, MDDepartment of Thoracic Surgery and Lung TransplantationUniversity of Rome SapienzaPoliclinico Umberto IRome, Italy[email protected]