Is Surgical Tracheostomy Better Than Percutaneous Tracheostomy in Coronavirus Disease 2019-Positive Patients?

Abstract

To the Editor Under the current situation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, evidence on patient management has been published in real-time, changing according to new experiences and release of clinical research that cover the comprehensive care of patients with coronavirus disease 2019 (COVID-19). The study by Bassi et al1 is very appropriate, mainly the algorithm on the correct choice of the tracheostomy technique in agreement with the characteristics and conditions of the patients. After reading the article, we present the following considerations: Patients with COVID-19 show a decrease in viral load from day 14 of the onset of symptoms. Therefore, the risk of transmission, even by aerosols, is significantly reduced by this time. Thus, there are no advantages between percutaneous and open tracheostomy,2 as mentioned in the article. Furthermore, there is evidence showing no difference in infection rate between personnel performing these approaches.3 The average time required to perform percutaneous tracheostomy is lower than the time needed for the conventional technique.3 We believe the reduction in the duration of the procedure may be an advantage, as patients are often critically ill with poor tolerance to hypoxia. Given the necessity to incise the trachea under direct vision, the use of energy devices, such as bipolar cautery or harmonic scalpel, to control bleeding during an open tracheostomy may lead to an increased risk of aerosolization. Moreover, the use of a bronchoscope as a guide in tracheostomy might increase aerosol production, due to the requirement to intermittently open the circuit under positive pressure ventilation. Thus, a sealing port is used, and ventilation is paused for insertion and extraction of the bronchoscope.4 Perioperative complications are less common using the percutaneous approach when compared to the open tracheostomy. These complications include accidental decannulation, air leak from de fistula, major bleeding, surgical site infection, and tracheal stenosis.5 The election of an approach (percutaneous or open tracheostomy) depends on different factors like availability of resources, surgeon experience, and characteristics of patients. Open tracheostomy may require the patient to be transferred to the operating room, with the consequent circuits’ disconnection. In our institution, percutaneous tracheostomies are the election technique in patients with COVID-19. We have performed around 100 percutaneous tracheostomies in our hospital, all carried out in the intensive care unit (ICU). We believe the best approach is whatever the surgical team feels more comfortable with and the one they have the most experience. Oswaldo Amaya, MDEnrique Arango, MDStefanie Pabón, MDSara Mejía, MDMaría C. Montoya, MDGuillermo Madrid, MDDepartment of AnesthesiaFundación Santa Fe de BogotáBogotá D.C., Colombia[email protected]