Is Surgical Tracheostomy Better Than Percutaneous Tracheostomy in COVID-19–Positive Patients?

Massimiliano Bassi, MD; Franco Ruberto, MD; Camilla Poggi, MD; Daniele Diso, MD; Marco Anile, MD; Tiziano De Giacomo, MD; Ylenia Pecoraro, MD; Carolina Carillo, MD; Francesco Pugliese, MD; Federico Venuta, MD; Jacopo Vannucci, MD


Anesth Analg. 2020;131(4):1000-1005. 

In This Article

Abstract and Introduction


During the past decades, percutaneous tracheostomy (PT) has gained popularity over surgical tracheostomy (ST) for its safety and technique; several studies were performed to compare these 2 options with conflicting results. PT appears to be more intuitive and technically easier than ST; overall, it might show a reduced rate of operative complications.[1] However, it is relatively more expensive than ST and there are some technical aspects requiring careful attention. In fact, it is related to possible major complications, especially if performed without videobronchoscopic assistance.[2] Conversely, ST requires greater technical skill and longer operative time with an associated higher complication rate compared to PT; nonetheless, certain patient factors favor ST such as goiter, obesity, subcutaneous emphysema, or difficult neck anatomy.[3] A recent meta-analysis by Klotz et al[4] revealed that both procedures are safe and effective, without evident differences in terms of mortality rate and potential life-threatening events. However, PT significantly reduces the incidence of stoma infection but encompasses a few technical issues, especially in particular conditions such as previous surgery, coagulopathy, or difficult airway management. These conclusions are confirmed by other meta-analysis and reviews.[5,6] Definitive guidelines are lacking but the current consensus tends to consider PT the first option in case of elective noncomplicated tracheostomy in standard population.[7]

The coronavirus disease 2019 (COVID-19) outbreak is presenting several problems in terms of management of infected patients. Significant precautions are required to minimize infection of health care workers and virus spread within the hospital. This is of particular importance in procedures with a high aerosolization risk such as tracheal intubation, noninvasive ventilation, bronchoscopy, thoracotomy, and tracheostomy.

It is reported that 9.8%–15.2% of COVID-19 patients require prolonged invasive mechanical ventilation.[8] On April 6, 28,976 patients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Italy were hospitalized; among them, 3898 (13.5%) were in intensive care units (ICU) requiring intubation and mechanical ventilatory support. Prolonged endotracheal intubation is still the most common indication for tracheostomy.[3,8] At the epidemic peak, many patients were in need of tracheostomy to optimize ventilatory management and improve support during the weaning phase.

The lessons learned from the severe acute respiratory syndrome (SARS) outbreak in 2002 included that ST is preferred over PT, under epidemic condition, to minimize the risk of contamination. Indeed, PT produces more airway manipulation and aerosol spread due to serial trachea dilatations, bronchoscopy, and ventilator connection/disconnection.[9,10] Several case reports and case series on PT and ST management in SARS-CoV patients were published during the SARS outbreak in 2004, focusing on technique, equipment, and surgical tips to avoid contamination.[9–13] In that context, the preference for PT over ST was only anecdotally described.[14] However, during the current SARS-CoV-2 outbreak in Italy, we performed either PT or ST in selected COVID-19 patients with particular precautions to minimize the aerosolization spread. We believe that PT can be safely performed during a respiratory epidemic and offers some advantages compared to ST as stated above.

At present, there is no clinical study comparing the safety and effectiveness of the 2 procedures in such a respiratory epidemic environment, and no guidelines regarding PT in COVID-19 setting are available so far. For this reason, we propose our decision-making flowchart in case of a COVID-19 patient requiring tracheostomy (Figure 1).

Figure 1.

Decision-making flowchart to approach tracheotomy in COVID-19 patients. COVID-19 indicates coronavirus disease 2019; PaO2/FIO2, arterial oxygen partial pressure to fractional inspired oxygen ratio; PT, percutaneous tracheostomy; ST, surgical tracheostomy.

Considering the lack of guidelines, a focused assessment on technical aspects, based on the available literature and experience, could be of help to improve the strategy.