Narrative Review of Tracheostomy Procedure during COVID-19 Pandemic

The COVID-19 pandemic has led to an unprecedented increase in the number of critically ill patients requiring mechanical ventilation. Tracheostomy played an important role to wean off the patients from ventilator support and maximize the resources. Tracheostomy is an aerosol generating procedure (AGP) which raised some controversial issues as it carries a risk of infection to healthcare workers.  This study aims to review the issues related to tracheostomy procedure in COVID-19 patients, including the appropriate time to perform tracheostomy, criteria for patient selection, safer approach and risk of infection among healthcare workers. Related information retrieved via online search of original articles, paper reviews, recommendations and guidelines from PubMed, Medline and Google Scholar using keywords tracheostomy, COVID-19, intensive care and mechanical ventilation are summarized in this article. The suggested time frame to perform tracheostomy ranged from 7 to 21 days. Early tracheostomy performed between day 10 to 14 had beneficial outcome for the patients and helped to reduce ICU occupancy. Decision for appropriate timing was made after considering the viral load and the course of the disease. Criteria for patient selection based on suggestions from studies and guidelines were lower oxygen requirement (FiO2<0.4, PEEP< 10), low Sepsis Related Organ Failure (SOFA) scores, ventilation for at least 10 days and signs of improvement. Patient factors, availability of facilities and expertise were important criteria for decision to undertake tracheostomy. The patient outcomes from tracheostomy varied between centers. Most of the studies reported that none of the healthcare workers had been infected by utilizing appropriate PPE and by taking important precautions during the procedure. In conclusion, guidelines were established for tracheostomy procedure during COVID-19 but the decision to undertake the procedure still depend on a case by case basis.