Tracheostomy for COVID-19: Evolving Best Practice

Thomas Williams; Brendan A. McGrath


Crit Care. 2021;25(316) 

In This Article

Abstract and Introduction


This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at Further information about the Annual Update in Intensive Care and Emergency Medicine is available from


The global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a dramatic impact upon all areas of healthcare, and this is no more evident than in critical care. Management of the critically ill evolved over time, with variability in admission criteria and the use of invasive ventilation reported from around the world and within individual countries.[1] However, the majority of patients admitted to intensive care units (ICUs) required advanced respiratory support,[1] often for longer periods than expected when compared with historical viral pneumonias.[2] Tracheostomy is an entrenched element of modern critical care, with the dominant indication established as facilitating long-term ventilation and 'weaning' from respiratory support. Additional indications include actual or threatened upper airway obstruction, facilitating pulmonary clearance and to offer a degree of 'protection' against pulmonary aspiration. Prior to this pandemic, tracheostomy could be anticipated in 8–13% of patients receiving advanced respiratory support in modern ICUs;[3] usually temporary, but often in situ for several weeks (a median of 28 days in one recent UK-wide study).[4] Reported rates of tracheostomies utilized during the coronavirus pandemic vary significantly from 16% to 61%,[5,6] but are certainly significantly higher than pre-pandemic rates.

As with many aspects of management, our understanding of how best to employ tracheostomy during the pandemic has evolved. There are many potential benefits of tracheostomy for the patient and for stressed healthcare systems, which have led some institutions to employ tracheostomy relatively early in the patient's ICU stay, but detailed outcome data from large case series are not available. Tracheostomy insertion and subsequent management also requires trained, equipped and supported staff to minimize the potential for complications and patient safety incidents.[7] It is essential that we understand which patients with coronavirus disease 2019 (COVID-19) may benefit from tracheostomy, along with when and how it should be employed. Importantly, in non-COVID-19 patients, only around 20% of tracheostomy patients survive beyond ICU discharge to 1 year,[8] repeatedly raising questions about patient selection, which are relevant as hospitals around the world struggle to manage large volumes of critically ill patients. These problems are compounded in the pandemic with patients frequently managed in makeshift or unfamiliar settings, often by non-CU trained medical, nursing and allied healthcare professional staff.

In this state-of-the-art review, we consider these important issues affecting around one-fifth of critically ill patients presenting to our ICUs with severe respiratory failure resulting from COVID-19.