Comment on: ‘timing and clinical outcomes of tracheostomy in patients with COVID-19’

Dear Editor

The optimal time to perform a tracheostomy in patients with difficult weaning has been the object of study for many years. Various outcomes such as the type of technique implemented, the presence of complications, and economic costs have been evaluated. The COVID-19 pandemic has again fueled the debate about the optimal time to perform it, and the need to obtain a polymerase chain reaction for SARS-CoV-2 (PCR) samples to avoid aerosolization and possible contagion from personnel.

Authors of recent publication on tracheostomy timing in COVID-19 patients mentioned there is no significant usefulness in waiting until day 21 (measured since beginning of symptoms) with a negative test for SARS-CoV-2, in order to perform tracheostomy¹.

From a non-surgical standpoint of view, there are aspects to emphasize when deciding the best timing to perform tracheostomy in the context of this particular disease. Patients with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 present prolonged and fluctuating periods of hypoxemia, and they are exposed to deep sedation and neuromuscular blockade for a long period of time. The previous increases intensive care unit (ICU) acquired muscle-weakness and delirium prevalence, thus prolonging weaning.

In our experience, the decision to perform a tracheostomy within 15 days should be adjusted to individual clinical evolution. Given the case that it had been performed in that period, an important percentage of our patients did not have any spontaneous ventilation period, and were not ready to start weaning, also a considerable number of patients at that day have a positive polymerase chain reaction for SARS-CoV-2. In this scenario, health personnel would have been exposed to possible risk of infection, without obtaining a substantial benefit for patients.

In our opinion an integrating clinical and surgical knowledge is paramount to establish an optimal timing to perform tracheostomy in patients with severe COVID-19, ir order to both customize procedure to the patient's respiratory status and ensure safety of the health care staff.