Emergency surgical tracheotomy in the era of COVID-19 pandemic

Abstract

At the beginning of 2020 a novel variant of coronavirus, named SARS-CoV-2, was identified as responsible for the development of severe pneumonia and acute respiratory distress syndrome (ARDS) with very high mortality, exceeding 30%. The disease caused by SARS-CoV-2, called Coronavirus Disease 2019 (COVID-19), was declared a pandemic by WHO on March 11th, 2020. Patients affected by COVID-19 may present with subtle, specific symptoms, but the sudden onset of life-threatening acute respiratory failure is not uncommon. The peculiarities of the disease combined with the single patient’s comorbidities, e.g. advanced age and cardiovascular diseases, plus hypoxia and hypotension secondary to ARDS, and multiorgan failure, may lead to unexpected difficulties in the case of tracheal intubation. The occurrence of the ‘Cannot-Intubate-Cannot-Oxygenate’ (CICO) scenario in COVID-19 patients represents a hazard not only for the patients but also for the assisting healthcare workers due to the high risk of aerosol-generating infected particles during conventional rescue airway procedures. While international consensus guidelines on the management of CICO scenario in COVID-19 patients are still lacking, there is evidence that both scalpel cricothyrotomy (CT) and open surgical tracheotomy (OST) represent valid alternatives for the establishment of a front-of-neck emergency airway. Primary CT requires a staged conversion to formal tracheotomy; conversely, OST represents a definitive mastery of the airway in COVID-19 patients in case of prolonged mechanical ventilation dependency, avoiding a second procedure and further exposure to aerosols. Furthermore, in patients with facial trauma and/or head and neck tumors, OST allows obtaining safe airway control. In the context of the current pandemic, emergency OST procedure in SARS-CoV-2 positives (or with unknown status) requires adequate arrangements and the use of proper personal protective equipment to limit risks for clinicians.