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.