Table 1.

Worldwide guideline comparison. OR (Operating Room), COVID-19 (Coronavirus disease 2019), ICU (Intensive Care Unit), PPE (Personal Protective Equipment), NE (Not especified), PARP (Powered air-purifying respirator).

Country/Society	Last update	Indications and COVID-19 status.	General precautions (PPE)	Technique	Team	Operative Setting	Type of dissection	Post-tracheostomy care	Other
The Australian and New Zealand Intensive Care Society (Australia & New Zealand) [13]	March 16, 2020	Clinical Decision Making COVID-19 Test required.	Optimal PPE	NE	NE	NE	NE	NE	ICU guideline, not specific for tracheostomy.
The South African Society of Otorhinolaryngology- Head & Neck Surgery. (South Africa) [28]	March 19, 2020	COVID-19 testing to be performed in all patients prior to elective tracheostomy. In COVID-19 positive patients ENT & ICU consultant need to discuss appropriateness of tracheostomy.	Full PPE. FFP3 mask. Eye/Face Protection. Full Face Shield/Visor.	NE	Most Skilled Surgeon. Minimal Staff.	NE	NE	Cuffed non-fenestrated tracheostomy should be used to avoid aerosolizing the virus. HME filter. Avoid changing the tracheostomy tube until COVID-19 has passed. Cuff to remain inflated and check for leaks First tube changes in confirmed negative COVID-19 test	No
ENT-UK (UK) [22]	March 19, 2020	Semi-elective procedure. Consider whether the patient is relatively stable and will tolerate lying flat with periods of brief apnea.	Full PPE	Open or percutaneous according to local factors, competencies, and experience	Essential personnel.	Negative pressure theatre or isolation room.		Use only closed suction circuits. First tube changes 7–10 day after tracheostomy.	Create a COVID airway team. Decannulation when patient is confirmed COVID-19 negative and is to be moved to a COVID-19 negative ward.
NTSP – UK (National Tracheostomy Safety Project) (UK) [20]	March 20, 2020	Tracheostomy should ideally be undertaken when the patient is COVID-19 negative. For patients at high risk of a failed extubation, a tracheostomy can be considered.	Full PPE	NE	Minimal Staff	ICU or isolated room with negative pressure.	NE	Cuffed tracheostomy.	Laryngectomy patients’ needs to wear a Stomal HME filter. Hands-Free valves minimize touching the stoma.
Canadian Society of Otolaryngology - Head and Neck Surgery (Canada) [14]	March 22, 2020	Strongly recommendation against tracheotomy in COVID-19 patients who are still infectious. This should only be considered if the endotracheal tube ventilation is insufficient PCR Test is Required for elective tracheostomy. In Emergency tracheostomy, every patient Needs to be Manage the patient as presumed COVID-19 positive	Full aerosol PPE. N95 mask. Complete neuromuscular paralysis. Non-fenestrated, cuffed tracheostomy tube with balloon inflated. HME filter.	Open tracheostomy	NE	ICU or OR With negative pressure.	NE	NE	Initial advancement of the endotracheal tube could be performed to make the cuff distal to the tracheotomy incision (to prevent airflow through the surgical tracheotomy). Awake tracheotomy and cricothyroidotomy are to be considered very high risk for viral plume spread and should be avoided
Societá Italiana di Otorinolaringologia e Chirurgia Cervico-Faciale (Italy) [26]	March 25, 2020	Semi-Elective procedure.	Full PPF FFP3 or FFP2 mask. Face Shield or helmet. Double glove. Closed circuit aspiration	Open tracheostomy	Team COVID	OR	Try to avoid diathermy.	First tube changes 7–10 day after tracheostomy.	Cuffed and non-fenestrated cannulas must be used until the patient is confirmed COVID-19 negative.
Henry Ford Health System (USA) [17]	March 25, 2020	In case of emergent or urgent tracheostomy, proceed. In case of elective. Staff physician discussion. Decision confirmed by two intensivists. COVID-19 negative test is necessary to consider a patient candidate for elective tracheostomy. In high risk patients two-documented negative COVID-19 test being performed 48–72 h after first test.	N95 mask (or PAPR if available) Face shield Head covering. Moisture barrier gown, and gloves. Proper removal of PPE will be followed.	When possible and appropriate, percutaneous tracheostomy at bedside is preferable to Open tracheostomy in the OR to minimize aerosolization, transport and resource utilization.	Minimal Staff	OR	NE	No tracheostomy tube exchange unless clinically indicated Cuff to remain inflated and check for leaks Make every effort not to disconnect the circuit Only closed in line suctioning should be used	As a rule, COVID-19 positive cases will NOT undergo tracheostomy unless there is a life-threatening situation that the tracheostomy has the potential to improve, such as upper airway obstruction with inability to intubate.
The Michigan Critical Care Collaborative Network (USA) [18]	March 25, 2020	ICU patients: multidisciplinary decision. Elective: Prolonged mechanical ventilation, major head and neck cancer/reconstructive cases to bypass potential airway obstruction. If previously COVID-19 positive and considering elective tracheostomy, recommend 2 negative COVID-19 tests separated by 24 h and resolution of fever and improvement of symptoms prior to proceeding to tracheostomy.	In patients with unknown COVID19 status, COVID19-positive or pending, all health care providers performing emergent tracheostomy should wear COVID19 PPE.	Consider either open tracheostomy or percutaneous tracheostomy at the discretion of the faculty performing the procedure	Minimal Staff	ICU or airborne isolation rooms with negative pressure. Negative pressure rooms with HEPA filter. Avoid Neutral rooms.	NE	HME filters and closed suctioning if available.	Decannulation: Should be done as soon as medically safe and immediately place occlusive dressing. In laryngectomy patients HME filter should be placed immediately and kept at all times regardless of COVID19 status given many carriers are asymptomatic.
American College of surgeons (USA) [16]	March 27, 2020	NE	Wash hands frequently and maintain safe social distancing. PPE. N95 mask. Smoke evacuator when electrocautery is used Remove clothes worn from home and keep in garment bag Wear scrub clothes after arrival at hospital	This guideline follows Considerations for tracheostomy from the ENT-UK guideline.	Establish a minimum number of personal for each task.	NE	NE	NE	Guide for optimum surgeon protection and not specific for tracheostomy.
University of California San Francisco (USA) [19]	March 28, 2020	The optimal timing of tracheostomy in patients with COVID-19 is unknown. The decision for tracheostomy will be made on a case-by-case basis. In most circumstances, patients should have two negative COVID-19 PCR tests prior to surgery.	Full PPE	NE	NE	NE	NE	NE	Hospital guideline, not specific for tracheostomy.
Spanish Society of Maxillofacial - Head & Neck Surgery. (Spain) [24]	March 28, 2020	NE	Full PPE. N95 (FFP2 – FFP3) masks. Facial Shield and goggles.	Percutaneous tracheostomy	Minimal and most experienced staff	ICU	Minimize use of diathermy.	NE	No
American Academy of Otolaryngology – Head & Neck Surgery (USA) [15]	April 2, 2020	Decision-making in tracheotomy should take into consideration the surgical and ICU team’s discretion as well as institutional policy. Avoid tracheotomy in COVID-19 positive or suspected patients during periods of respiratory instability or heightened ventilator dependence. Tracheotomy can be considered in patients with stable pulmonary status. Tracheostomy should not take place sooner than 2–3 weeks from intubation and, preferably, with negative COVID-19 testing.	NE	NE	Minimal Staff	NE	Rely on cold instrumentation and avoid monopolar electrocautery.	Choose cuffed, non-fenestrated tracheostomy tube. Maintain cuff appropriately inflated post-operatively and attempt to avoid cuff leaks. Avoid circuit disconnections and suction via closed circuit. HME with viral filter Delay routine post-operative tracheotomy tube changes until COVID-19 testing is negative.	Advance ETT and cuff safely below the intended tracheotomy site and hold respirations while incising trachea.
Spanish Society of Otorhinolaryngology – Head & Neck Surgery (Spain) [23]	April 3, 2020	NE	Full PPE. N95, FFp2 or FFP3 mask. Double glove. Face Shield and goggles.	Open or percutaneous according to each hospital protocol.	Minimal Staff required	OR or ICU with negative pressure	Try to avoid the use of diathermy.	First tube change should be deferred for up to 14–21 days. HME filters are recommended. Maintain Cuff always inflated.	No
British Laryngological Association (UK) [21]	April 3, 2020	Unlikely to be indicated after<14 days of ventilation Consider trial of extubation – i.e. high threshold to perform tracheostomy The patient should be apyrexial with falling inflammatory markers (a surgical procedure undertaken during viremia risks precipitating a clinical deterioration) Two Negative viral swabs (48 hrs apart) preferred, but it is accepted this may not always be possible. Hemodynamically stable with minimal pressor requirement	Full PPE. FFP3 mask and visor. Consider Powered Hoods (PAPR).	Open tracheostomy	Consultant surgeon Skilled Assistant Scrub nurse Consultant anesthetist	OR or ICU with negative pressure	Minimize use of diathermy during dissection	Check cuff pressure. First tube change should be deferred for up to 4 weeks.	Consider reducing theatre temperature for staff comfort wearing PPE.
French Society of Otorhinolaryngology - Head & Neck Surgery. (France) [25]	April 9, 2020	Multidisciplinary medical decision made by the anesthesiologist in charge of the patient, in discussion with the ENT surgeon.	Full PPE. N95 (FFP2 – FFP3) masks. Headlight covered by a head cap. An impermeable protective apron or an overcoat that must be worn under the surgical gown as it is not sterile	Percutaneous tracheostomy. Open tracheostomy can be recommended in the event of anatomical contraindications, failure of percutaneous technique or exhaustion of percutaneous kits.	NE	ICU	Minimize use of diathermy.	NE	Suture the cannula particularly if a prone position of the patient is planned. Tracheostomy under local anesthesia is not recommended.
Division of ENT Surgery - University Of Cape Town (South Africa) [27]	April 2020	Multidisciplinary medical decision in case of reduced number of ICU beds. Tracheostomy only once patients is COVID-19 Negative test.	Full PPE N95 Mask	NE	Minimal Staff	NE	NE	NE	No
Singapore General Hospital (Singapore) [29]	April 6, 2020	ICU-ENT Protocol for COVID-19 positive patients. Tracheotomy is performed when the pulmonary function of ventilated patients not show improvement beyond 7 days,	Full PPE N95 Mask Eye protection, Cap, PARP	Open tracheostomy. Percutaneous in selected cases.	Experienced surgeons. Minimal Staff.	Isolated OR specific for COVID-19 positive patient. ICU in selected patients.	NE	NE	Anesthesiology will be focused on reducing aerosolization during procedure.