Permissive Apnea in COVID-19 Tracheostomy: Alternative Health Worker Safe Procedure in Intensive Care Unit

To the Editor:

We read with great interest the study by Angel and associates.¹ We agree to highlight the medical nurse safety, but we would like to offer our contribution with a quick different technique for permissive apnea performed in 25 individuals from 69 COVID patients (36.2%) in our COVID center that is safe for patients and health care workers.^{2 , 3} First of all, the most expert physicians in percutaneous tracheostomy were selected to organize a tracheo team.⁴ Usually, after 14 days, the tracheostomy was performed in patients with difficult weaning and no contraindications. The procedure was performed by the expert team, preceded by an accurate echographic assessment of the patient and a preoxygenation for 30 minutes with FiO2 1.0. Then the patient was positioned, sedation and myoresolution were confirmed, a protective ventilation was applied, and then video bronchoscopy equipment was set up. The procedure began by putting the mechanical ventilator on stand-by mode for a few seconds, avoiding losing positive end-expiratory pressure, and positioning a fibre-optic bronchoscope swivel connector (Portex, Minneapolis, MN). Later, the bronchoscope was positioned in the endotracheal tube; if SpO2 was greater than 90%, the operator proceeded directly to the puncture in bronchoscopic vision and quickly performed a Ciaglia (Bloomington, IN) percutaneous tracheostomy. If SpO2 was less than 90%, then mechanical ventilation was resumed for a few minutes with FiO2 1.0 and then the puncture was performed. In the end, the endotracheal tube was removed only after positioning the cannula. We did not have cases of important bleeding or severe complications; only in 3 cases (12%) did it become necessary to resume ventilation and another permissive apnea time was needed to perform the procedure. In any case, no important variations of PaO2/FiO2 ratio after the procedure was registered.

The great novel technique of Angel and colleagues¹ requires very expert physicians with a bronchoscopist; furthermore, an anatomical conformation of the patient favorable to the introduction of the instrument next to the endotracheal tube is necessary. We consider our technique a feasible alternative; in either case, a great deal of experience in performing percutaneous tracheotomies is mandatory. We believe that, like the technique described by Angel and coworkers, our technique is also advisable and feasible for the health of operators, as long as none of our operators involved has been infected by COVID 19.