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


This study is the first to report on multicenter and multidisciplinary experience of tracheostomy in COVID-19 patients with acute respiratory failure in the United States. Differences in protocols at institutions allowed us to identify sources of variation and to investigate outcomes associated with different approaches. Almost all the tracheostomies were performed at bedside in negative pressure rooms in the intensive care units, using enhanced personal protective equipment. Percutaneous tracheostomy was the first-line technique, with surgical tracheostomy reserved for patients with difficult anatomy. Most tracheostomies were performed after >2 weeks of mechanical ventilation, and limited bleeding was the most common complication.

Percutaneous tracheostomy, as compared to surgical tracheostomy, was associated with decreased total ventilator days, earlier weaning from the ventilator post-tracheostomy, and shorter ICU and hospital length of stay. This outcome contrasts with a randomized controlled trial by two surgeons at a single institution that compared percutaneous versus surgical tracheostomy in 67 patients with COVID-19 and found no difference between the 2 techniques.[21] The decreased total ventilator days may have led to lower incidence of VAP in the percutaneous group when compared to the surgical cohort (59% vs 81%, P = 0.039), as other patient characteristics like BMI were similar in both groups. Lower VAP rate can also explain other improved outcomes seen with percutaneous tracheostomy.

There was no significant difference in complications between percutaneous and surgical techniques. The most common complication associated with tracheostomy was non–life-threatening bleeding (n = 10, 8.5%). This incidence of bleeding falls within the range reported in previous COVID-19 cohorts of 2% to 30%.[18,19,21,22] Tracheostomy-associated bleeding in patients with COVID-19 could be explained by the high use of anticoagulants in COVID-19 patients due to their prothrombotic state[23] and ECMO cannula maintenance. Additional factors that might have predisposed to bleeding risk include the lack of standardized use of ultrasonography between centers to avoid vascular structures and the avoidance of electrocautery use.

There is a significant controversy as to which tracheostomy technique should be first-line in COVID-19 patients.[12,13] Proponents of percutaneous tracheostomy cite lower incidence of infection and bleeding,[24] whereas advocates of surgical tracheostomy point to previous experience with severe acute respiratory syndrome (SARS) outbreak and possibly decreased aerosolization.[13,14] Such recommendations are likely influenced by not only the available evidence in the literature but also the experience and expertise of the operators.[22,25] In our study, we observed that percutaneous technique was the routine first-line procedure, with surgical tracheostomy reserved for patients whose anatomy was not conducive to percutaneous method. This approach was also the standard practice at all institutions before the COVID-19 pandemic, indicating that institutions may maintain their practice with additional safety measures to minimize aerosolization.

No previous studies have compared different timings of tracheostomy in COVID-19 patients. An important caveat in this study was our use of a definition for what constituted early (≤14 days), middle (15–21 days), and late (>21 days) tracheostomy groups based on time from intubation. Although several publications during the pandemic have alluded to timing of tracheostomy within 14 days,[18–20] or 21 days,[8,10,11,21,26] the guideline with broadest stakeholder engagement suggests that tracheostomy need only be delayed until day 10 of invasive mechanical ventilation.[9] In our cohort, relatively few patients underwent tracheostomy before 14 days. We observed that the early tracheostomy group was associated with decreased ventilator days compared to late groups in patients who were weaned, but there was no significant association between tracheostomy timing and the rate of VAP. Nonetheless, a significant body of literature attests to the salutary effect of early tracheostomy on reducing days on ventilator and ventilator associated pneumonia.[6,27,28] In addition, we observed that early tracheostomy was associated with non-significant increase in complications. A larger cohort will be needed to delineate possible benefits from earlier tracheostomy in COVID-19 respiratory failure.

Outcomes of COVID-19 patients who underwent tracheostomy have been reported with varying levels of detail.[18–22,25,26,29,30] Detailed outcomes, such as comparison of different techniques, sedation duration, and mechanical ventilator parameters, were not reported. In our study, the ventilator weaning rate of 66.1% was similar to other studies, and ECMO weaning rate was 83.3%. About 25% of our patients were on ECMO, after failing the routine ventilator support and proning, as our institutions were tertiary care centers specializing in ECMO care. Tracheostomy was associated with accelerated weaning from sedation, consistent with studies predating the pandemic.[5] In our cohort, 15.3% of patients died, corresponding to a mortality rate similar to the other large reported studies.[19,26,30] We observed a 63.6% incidence of ventilator-associated pneumonia (VAP), which is notable since few data are available on VAP in COVID-19 patients on mechanical ventilation.

The strengths of our study include its multicenter design; performance of the tracheostomy by a variety of specialists with both percutaneous and surgical techniques; and identification of significant associations with patient outcomes, which are missing in some larger registries.[19,30] Our study is limited by its observational design and small sample size, precluding causal inferences regarding tracheostomy technique and outcomes. We observed that the early tracheostomy group was associated with decreased ventilator days compared to late groups in patients who were weaned, but there was no significant association between tracheostomy timing and the rate of VAP. We also hypothesize that systematic differences in patient selection, rather than effects of procedural technique, may account for the association of percutaneous tracheostomy with reduced time on ventilator, VAP, and length of stay. Although performance of tracheostomy by different specialties increased the heterogeneity of the data, it reflected the real world, multidisciplinary practice at the institutions and increased the generalizability of the findings.

Percutaneous tracheostomy is a safe and effective procedure for patients with COVID-19 respiratory failure and has become a first line approach at several institutions, with surgical tracheostomy often reserved for patients with challenging anatomy. The outcomes of early percutaneous tracheostomy versus surgical tracheostomy should be evaluated in prospective, randomized trials assessing tracheostomy timing and technique in COVID-19 respiratory failure.