Indications for Tracheostomy
The benefits of tracheostomy are well-established. These include facilitated ability to wean sedation and mitigation of sedation-associated delirium, improved patient comfort, and facilitation of weaning to spontaneous ventilation. The optimal timing of tracheostomy varies by clinical context; outside of the current pandemic, it is generally recommended to be performed within 2 weeks post-intubation. Prolonged intubation is associated with post-intubation laryngotracheal stenosis, but in systematic reviews, early tracheostomy (typically < 10 days) has not been shown to reduce risk of this complication.17,18
The role of tracheostomy during the COVID-19 pandemic remains to be determined. Poor patient outcomes and resource scarcity may well have a dramatic influence on the total number of tracheostomies performed. In published studies from the Chinese experience, survival of COVID-19 after mechanical ventilation is low (< 20%) and Zhou et al. determined that the time from illness onset to death in non-survivors of COVID-19 was just 18.5 days.3-5 If this trend holds as the pandemic progresses, the obvious implication is that early tracheostomy may be a futile endeavor for most patients, and late tracheostomy is not likely to assist in ventilatory weaning.