Article Data

  • Views 501
  • Dowloads 153


Open Access Special Issue

Emergency surgical tracheotomy in the era of COVID-19 pandemic

  • Piergiorgio Muriana1
  • Paola Ciriaco1
  • Angelo Carretta1,2
  • Giampiero Negri1,2

1Department of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy

2Vita-Salute San Raffaele University, Milan, Italy

DOI: 10.22514/sv.2021.055 Vol.17,Issue 3,May 2021 pp.69-78

Submitted: 02 February 2021 Accepted: 04 March 2021

Published: 08 May 2021

*Corresponding Author(s): Piergiorgio Muriana E-mail:


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.


Emergency tracheotomy; Open surgical tracheotomy; CICO scenario; Cricothyrotomy; Emergency surgical airway; Endotracheal intubation failure; Tracheostomy; COVID-19; SARS-CoV-2; ARDS

Cite and Share

Piergiorgio Muriana,Paola Ciriaco,Angelo Carretta,Giampiero Negri. Emergency surgical tracheotomy in the era of COVID-19 pandemic. Signa Vitae. 2021. 17(3);69-78.


[1] Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. New England Journal of Medicine. 2020; 382: 727-733.

[2] Salzberger B, Buder F, Lampl B, Ehrenstein B, Hitzenbichler F, Holzmann T, et al. Epidemiology of SARS-CoV-2. Infection. 2020; 1-7.

[3] World Health Organization. WHO announces COVID-19 outbreak a pandemic. Accessible at:

[4] Berlin DA, Gulick RM, Martinez FJ. Severe COVID-19. New England Journal of Medicine. 2020; 383: 2451-2460.

[5] Kumar R, Srivastava JK, Singh R, Siddiqui MH, Mansouri RA, Abdulhakim JA, et al. Available compounds with therapeutic potential against COVID-19: antimicrobial therapies, supportive care, and probable vaccines. Frontiers in Pharmacology. 2020; 11: 582025.

[6] Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, et al. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. New England Journal of Medicine. 2020; 383: 2603-2615.

[7] Karaba SM, Jones G, Helsel T, Smith LL, Avery R, Dzintars K, et al. Prevalence of co-infection at the time of hospital admission in COVID-19 patients, a multicenter study. Open Forum Infectious Diseases. 2020; 8: ofaa578.

[8] Mahmoudi H. Bacterial co-infections and antibiotic resistance in patients with COVID-19. GMS Hygiene and Infection Control. 2020; 15: Doc35.

[9] Cataldo MA, Tetaj N, Selleri M, Marchioni L, Capone A, Caraffa E, et al. Incidence of bacterial and fungal bloodstream infections in COVID-19 patients in intensive care: an alarming “collateral effect”. Journal of Global Antimicrobial Resistance. 2020; 23: 290-291.

[10] Gattinoni L, Chiumello D, Caironi P, Busana M, Romitti F, Brazzi L, et al. COVID-19 pneumonia: different respiratory treatments for different phenotypes? Intensive Care Medicine. 2020; 46: 1099-1102.

[11] Grieco DL, Bongiovanni F, Chen L, Menga LS, Cutuli SL, Pintaudi G, et al. Respiratory physiology of COVID-19-induced respiratory failure compared to ARDS of other etiologies. Critical Care. 2020; 24: 529.

[12] Balzanelli M, Distratis P, Catucci O, Amatulli F, Cefalo A, Lazzaro R, et al. Clinical and diagnostic findings in COVID-19 patients: an original research from SG Moscati Hospital in Taranto Italy. Journal of Biological Regulators and Homeostatic Agents. 2021; 35: 171-183.

[13] Turcato G, Panebianco L, Zaboli A, Scheurer C, Ausserhofer D, Wieser A, et al. Correlation between arterial blood gas and CT volumetry in patients with SARS-CoV-2 in the emergency department. International Journal of Infectious Diseases. 2020; 97: 233-235.

[14] Shang Y, Xu C, Jiang F, Huang R, Li Y, Zhou Y, et al. Clinical characteristics and changes of chest CT features in 307 patients with common COVID-19 pneumonia infected SARS-CoV-2: a multicenter study in Jiangsu, China. International Journal of Infectious Diseases. 2020; 96: 157-162.

[15] Berlin DA, Gulick RM, Martinez FJ. Severe COVID-19. New England Journal of Medicine. 2020; 383: 2451-2460.

[16] Lentz S, Roginski MA, Montrief T, Ramzy M, Gottlieb M, Long B. Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS. The American Journal of Emergency Medicine. 2020; 38: 2194-2202.

[17] Zheng H, Li S, Sun R, Yang H, Chi X, Chen M, et al. Clinical experience with emergency endotracheal intubation in COVID-19 patients in the intensive care units: a single-centered, retrospective, descriptive study. American Journal of Translational Research. 2020; 12: 6655-6664.

[18] Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. British Journal of Anaesthesia. 2020; 125: e28-e37.

[19] Potnuru P, Artime CA, Hagberg CA. The lost airway. Anesthesiology Clinics. 2020; 38: 875-888.

[20] Ono Y, Kakamu T, Kikuchi H, Mori Y, Watanabe Y, Shinohara K. Expert-performed endotracheal intubation-related complications in trauma patients: incidence, possible risk factors, and outcomes in the prehospital setting and emergency department. Emergency Medicine International. 2018; 2018: 5649476.

[21] Cabrini L, Baiardo Redaelli M, Ball L, Filippini M, Fominskiy E, Pintaudi M, et al. Awake fiberoptic intubation protocols in the operating room for anticipated difficult airway: a systematic review and meta-analysis of randomized controlled trials. Anesthesia & Analgesia. 2019; 128: 971-980.

[22] Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827-848.

[23] Patel SA, Meyer TK. Surgical airway. International Journal of Critical Illness and Injury Science. 2014; 4: 71-76.

[24] Airway and ventilatory management. In Henry S, Brasel K, Stewart RM, editors. ATLS, Advanced Trauma Life Support, Student course manual (pp. 22-41). 10th edn. Chicago, IL: American College of Surgeons. 2018.

[25] Sheykholeslami K, Rezaee R, Lavertu P. Percutaneous tracheotomy. Atlas of the oral and maxillofacial surgery clinics of North America. 2010; 18: 51-60.

[26] Klotz R, Probst P, Deininger M, Klaiber U, Grummich K, Diener MK, et al. Percutaneous versus surgical strategy for tracheostomy: a systematic review and meta-analysis of perioperative and postoperative complications. Langenbeck’s Archives of Surgery. 2018; 403: 137-149.

[27] Gillespie MB, Eisele DW. Outcomes of emergency surgical airway procedures in a hospital-wide setting. The Laryngoscope. 1999; 109: 1766-1769.

[28] Darby JM, Halenda G, Chou C, Quinlan JJ, Alarcon LH, Simmons RL. Emergency surgical airways following activation of a difficult airway management team in hospitalized critically ill patients: a case series. Journal of Intensive Care Medicine. 2018; 33: 517-526.

[29] Britt CJ, Rohrbach MR, McCulloch TM. Tracheal exposure: anticipatory management of the difficult airway. Head & Neck. 2016; 38: E2446-E2448.

[30] Abdelkader M, Dempster J. Emergency tracheostomy: indications and technique. Surgery. 2003; 21: 153-155.

[31] Grillo HC. Surgery of the trachea and bronchi. Der Chirurg: Zeitschrift Fur Alle Gebiete Der Operativen Medizen. 1987; 58: 511-520. (In German)

[32] Taylor CB, Otto RA. Open tracheostomy procedure. Atlas of the Oral and Maxillofacial Surgery Clinics of North America. 2015; 23: 117-124.

[33] Šifrer R, Urbančič J, Piazza C, van Weert S, García-Purriños F, Benedik J, et al. Emergent tracheostomy during the pandemic of COVID-19: Slovenian National recommendations. European Archives of Oto-Rhino-Laryngology. 2020; 1-9.

[34] Jackson C. High tracheotomy and other errors-the chief causes of chronic laryngeal stenosis. The American Journal of the Medical Sciences. 1921; 32: 392-398.

[35] Macêdo MB, Guimarães RB, Ribeiro SM, Sousa KMMD. Emergency cricothyrotomy: temporary measure or definitive airway? A systematic review. Revista do Colegio Brasileiro De Cirurgioes. 2016; 43: 493-499.

[36] Talving P, DuBose J, Inaba K, Demetriades D. Conversion of emergent cricothyrotomy to tracheotomy in trauma patients. Archives of Surgery. 2010; 145: 87-91.

[37] Zasso FB, You-Ten KE, Ryu M, Losyeva K, Tanwani J, Siddiqui N. Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: a systematic review. BMC Anesthesiology. 2020; 20: 216.

[38] Dillon JK, Christensen B, Fairbanks T, Jurkovich G, Moe KS. The emergent surgical airway: cricothyrotomy vs. tracheotomy. International Journal of Oral and Maxillofacial Surgery. 2013; 42: 204-208.

[39] DeVore EK, Redmann A, Howell R, Khosla S. Best practices for emer-gency surgical airway: a systematic review. Laryngoscope Investigative Otolaryngology. 2019; 4: 602-608.

[40] Sadda R, Turner M. Emergency tracheotomy in the dental office. International Journal of Oral and Maxillofacial Surgery. 2009; 38: 1114-1115.

[41] Warner MA, Smith HM, Zielinski MD. Impaired ventilation and oxygenation after emergency cricothyrotomy: recommendations for the management of suboptimal invasive airway access. A & A Case Reports. 2016; 7: 212-214.

[42] Jotic AD, Milovanovic JP, Trivic AS, Folic MM, Krejovic-Trivic SB, Radin ZZ, et al. Predictors of complications occurrence associated with emergency surgical tracheotomy. Otolaryngology-Head and Neck Surgery. 2021; 164: 346-352.

[43] Radhakrishnan S, Perumbally HA, Surya S, Ponneth MS. Guidelines for surgical tracheostomy and tracheostomy tube change during the COVID-19 pandemic: a review article. Indian Journal of Otolaryngology and Head & Neck Surgery. 2020; 72: 398-401.

[44] Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS ONE. 2012; 7: e35797.

[45] Skoog H, Withrow K, Jeyarajan H, Greene B, Batra H, Cox D, et al. Tracheotomy in the SARS-CoV-2 pandemic. Head & Neck. 2020; 42: 1392-1396.

[46] Brewster DJ, Chrimes N, Do TB, Fraser K, Groombridge CJ, Higgs A, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Medical Journal of Australia. 2020; 212: 472-481.

[47] Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: guidelines from the difficult airway society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-799.

[48] Michetti CP, Burlew CC, Bulger EM, Davis KA, Spain DA. Performing tracheostomy during the COVID-19 pandemic: guidance and recommen-dations from the Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma. Trauma Surgery & Acute Care Open. 2020; 5: e000482.

[49] Shiba T, Ghazizadeh S, Chhetri D, St. John M, Long J. Tracheostomy Considerations during the COVID-19 Pandemic. OTO Open. 2020; 4: 2473974X20922528.

[50] Hassani V, Amniati S, Ahmadi A, Mohseni M, Sehat-Kashani S, Nikoubakht N, et al. Emergency tracheostomy in two airway trauma patients suspected of COVID-19: a case report. Anesthesia and Pain Medicine. 2020; 10: e104648.

[51] Ahmad I, Jeyarajah J, Nair G, Ragbourne SC, Vowles B, Wong DJN, et al. A prospective, observational, cohort study of airway management of patients with COVID-19 by specialist tracheal intubation teams. Canadian Journal of Anesthesia. 2021; 68: 196-203.

[52] Lee D, Kim S, Kim J, Kim BG, Chang K, Park J. Protection of medical staff during tracheotomy: lessons learned from the COVID-19 pandemic. Journal for Oto-Rhino-Laryngology, Head and Neck Surgery. 2020; 82:

304- 309.

[53] Lima DS, Ribeiro Junior MF, Vieira-Jr HM, Campos T, Saverio SD. Alternatives for establishing a surgical airway during the COVID-19 pandemic. Revista do Colégio Brasileiro de Cirurgiões. 2020; 47: e20202549.

[54] Mesolella M. Is timing of tracheotomy a factor influencing the clinical course in COVID-19 patients? Ear, Nose & Throat Journal. 2021; 100: 120S-121S.

[55] Chua H, Wong T, Lim WY, Wong P. Emergency front-of-neck airway in the COVID-19 patient: Cannula or surgical cricothyroidotomy?Anaesthesia Critical Care & Pain Medicine. 2020; 39: 475-477.

[56] Heyd CP, Desiato VM, Nguyen SA, O’Rourke AK, Clemmens CS, Awad MI, et al. Tracheostomy protocols during COVID-19 pandemic. Head & Neck. 2020; 42: 1297-1302.

[57] Broderick D, Kyzas P, Sanders K, Sawyerr A, Katre C, Vassiliou L. Surgical tracheostomies in COVID-19 patients: important considerations and the “5Ts” of safety. British Journal of Oral and Maxillofacial Surgery. 2020; 58: 585-589.

[58] Ahmad I, Wade S, Langdon A, Chamarette H, Walsh M, Surda P. Awake tracheal intubation in a suspected COVID-19 patient with critical airway obstruction. Anesthesiology Reports. 2020; 8: 28-31.

[59] Crossley J, Clark C, Brody F, Maxwell JH. Surgical considerations for an awake tracheotomy during the COVID-19 pandemic. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2020; 30: 477-480.

[60] George CK, Varghese BT, Divya GM, Janardhan D, Thomas S. Emergency tracheostomy during COVID 19 pandemic in a head and neck surgical oncology unit. Oral Oncology. 2020; 107: 104784.

[61] Picetti E, Fornaciari A, Taccone FS, Malchiodi L, Grossi S, Di Lella F, et al. Safety of bedside surgical tracheostomy during COVID-19 pandemic: A retrospective observational study. PLoS ONE. 2020; 15: e0240014.

[62] Bier-Laning C, Cramer JD, Roy S, Palmieri PA, Amin A, Añon JM, et al. Tracheostomy during the COVID-19 pandemic: comparison of international perioperative care protocols and practices in 26 countries. Otolaryngology-Head and Neck Surgery. 2020; 194599820961985.

[63] Zangrillo A, Beretta L, Silvani P, Colombo S, Scandroglio AM, Dell’Acqua A, et al. Fast reshaping of intensive care unit facilities in a large metropolitan hospital in Milan, Italy: facing the COVID-19 pandemic emergency. Critical Care and Resuscitation. 2020; 22: 91-94.

[64] Botti C, Lusetti F, Neri T, Peroni S, Castellucci A, Salsi P, et al. Comparison of percutaneous dilatational tracheotomy versus open surgical technique in severe COVID-19: complication rates, relative risks and benefits. Auris Nasus Larynx. 2020; S0385-8146(20)30296-0.

[65] Chen Z, Lv Y, Feng Y. Case report of acute airway obstruction caused by transglottic squamous carcinoma (stage IV) during the coronavirus pandemic cured by ECMO-assisted tracheostomy. Ear, Nose & Throat Journal. 2021; 100: 113S-115S.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

IndexCopernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 0.5(2019) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time