Tracheostomy for COVID-19 Respiratory Failure

Multidisciplinary, Multicenter Data on Timing, Technique, and Outcomes

Kamran Mahmood, MD, MPH; George Z. Cheng, MD, PhD; Keriann Van Nostrand, MD; Samira Shojaee, MD, MPH; Max T. Wayne, MD; Matthew Abbott, MD; Darrell Nettlow, MD; Alice Parish, MSPH; Cynthia L. Green, PhD; Javeryah Safi, MD; Michael J. Brenner, MD; Jose De Cardenas, MD


Annals of Surgery. 2021;274(2):234-239. 

In This Article

Abstract and Introduction


Objective: The aim of this study was to assess the outcomes of tracheostomy in patients with COVID-19 respiratory failure.

Summary Background Data: Tracheostomy has an essential role in managing COVID-19 patients with respiratory failure who require prolonged mechanical ventilation. However, limited data are available on how tracheostomy affects COVID-19 outcomes, and uncertainty surrounding risk of infectious transmission has led to divergent recommendations and practices.

Methods: It is a multicenter, retrospective study; data were collected on all tracheostomies performed in COVID-19 patients at 7 hospitals in 5 tertiary academic medical systems from February 1, 2020 to September 4, 2020.

Result: Tracheotomy was performed in 118 patients with median time from intubation to tracheostomy of 22 days (Q1–Q3: 18–25). All tracheostomies were performed employing measures to minimize aerosol generation, 78.0% by percutaneous technique, and 95.8% at bedside in negative pressure rooms. Seventy-eight (66.1%) patients were weaned from the ventilator and 18 (15.3%) patients died from causes unrelated to tracheostomy. No major procedural complications occurred. Early tracheostomy (≤14 days) was associated with decreased ventilator days; median ventilator days (Q1–Q3) among patients weaned from the ventilator in the early, middle and late groups were 21 (21–31), 34 (26.5–42), and 37 (32–41) days, respectively with P = 0.030. Compared to surgical tracheostomy, percutaneous technique was associated with faster weaning for patients weaned off the ventilator [median (Q1–Q3): 34 (29–39) vs 39 (34–51) days, P = 0.038]; decreased ventilator-associated pneumonia (58.7% vs 80.8%, P = 0.039); and among patients who were discharged, shorter intensive care unit duration [median (Q1–Q3): 33 (27–42) vs 47 (33–64) days, P = 0.009]; and shorter hospital length of stay [median (Q1–Q3): 46 (33–59) vs 59.5 (48–80) days, P = 0.001].

Conclusion: Early, percutaneous tracheostomy was associated with improved outcomes compared to surgical tracheostomy in a multi-institutional series of ventilated patients with COVID-19.


Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has taken a staggering toll around the world, with most of the mortality attributable to respiratory failure and acute respiratory distress syndrome (ARDS).[1,2] Approximately 10% to 15% of COVID-19 patients develop respiratory failure and require prolonged invasive mechanical ventilation.[1,3] Previous studies have shown that tracheostomy leads to decreased need for sedation, earlier weaning from mechanical ventilation, and decreased ventilator-associated pneumonia in patients with prolonged respiratory failure.[4,5] Tracheostomy also improves pulmonary hygiene, reduces intensive care unit (ICU) capacity strain, decreases risk of chronic laryngeal injury, and expedites rehabilitation.[6] However, either performing tracheotomy or providing post-procedure patient care may lead to aerosolization of respiratory secretions that contain SARS-CoV-2, thereby posing a risk of infection to medical staff.[7]

During the pandemic, multiple professional organizations and groups issued guidelines about the timing and performance of tracheostomy.[8–11] Many of the early guidelines recommended performing tracheostomy after 21 days of mechanical ventilation, based on the assumption that the delay would allow for lower viral load.[8,11] However, others supported the procedure after 10 days to leverage the anticipated advantages of early tracheostomy.[9] The lack of evidence around the timing of tracheostomy is widely acknowledged, and some expert panel consensus statements have refrained from providing any specific recommendations.[10] Controversy also exists about the preferred technique, with advocates divided between surgical and percutaneous methods.[12–14] Thus, institutions are following different guidelines, and the resulting variations in practice likely translate into overall lower quality care.[15,16] As the subsequent waves of the pandemic unfold, data remain limited about the best approach to manage prolonged COVID-19 respiratory failure. The aim of the present study was to assess tracheostomy-related practices in a multicenter cohort of COVID-19 patients in the United States (US). We also investigated whether different timing and techniques of tracheostomy were associated with better patient outcomes.