Synopsis of key and new findings
The entire healthcare system helped manage the region’s COVID-19 pandemic. Many patients required ICU stays, often with prolonged mechanical ventilation, resulting in nearly all centres to perform at least one tracheostomy. Notably, Lombardy’s ICUs reached maximum occupancy, which required converting operating theatres into ICUs for invasive ventilation.1 This unprecedented situation forced the entire region to face the wide-scale clinical emergency without patient-treatment guidelines. We observed that non-existent criteria for performing tracheostomies on intubated COVID-19 patients result in significant discrepancies between their timing and techniques.
This survey revealed two distinct timing approaches: most centres reverted to tracheostomy for prolonged intubations, lasting more than 10–12 days, whereas some others performed tracheostomies after 5–6 days to accelerate weaning from mechanical ventilation. The latter group is among those performing a higher number of procedures.
Median reported ICU stay is nine days,3 therefore, waiting for respiratory disorder recovery seems reasonable. However, tracheostomy within seven days reduces the duration of mechanical ventilation and ICU stays as well as hospital-acquired pneumonia and mortality.4 Early tracheostomy also reduces the need for sedation and may accelerate rehabilitation.5Further studies are needed to provide data for determining appropriate approach.
Percutaneous tracheostomy is the preferred technique, most often performed by anaesthesiologists, whereas otolaryngologists are required for STs in case of predicted anatomical difficulties. However, a closer collaboration between these specialists is advisable since each of the two techniques has its advantages. Percutaneous tracheotomies reduce the risk for major bleeding and stoma infection. This proves vital due to the high prevalence of multi-resistant bacteria in ICUs and the use of anticoagulants for COVID-19 patient because of suspected microvascular pulmonary thrombosis.6 Concurrently, recently proposed COVID-19-specific ST techniques reduce hypoxia time and minimise aerosol generation and operator infection.7-10 Furthermore, in an emergency setting, shortages of resources, PT-experienced staff and PT kits must be considered.