Considerations about Timing to Perform Elective Tracheostomies in Patients Hospitalized in COVID-19 Units

Since the beginning of the pandemic caused by the new Coronavirus (SARS- CoV-2), critically ill patients care has been challenging. It is necessary to perform the best available practice and protect the health team, preserving human resources and rationalizing costs. Changes in tracheostomies institutional protocols are necessary according to each health care services reality. This is particular important in developing countries. The aim of this study is to establish a practical and sucint guideline to minimize controversies regarding the proper timing to perform elective tracheostomies in critically ill coronavirus infected patients.


Introduction
Since the announcement of the first cases of pneumonia due to an unknown cause in December 2019, with the establishment of a disease caused by the new Coronavirus (SARS-CoV-2), a pandemic has been installed with more than 3,000,000 cases reported worldwide. Of these cases, about 17% develop the Acute Respiratory Distress Syndrome in different degrees of intensity. Care of these patients has become a challenge, mostly because is necessary to understand the clinical-epidemiological characteristics of the disease. And is an urgent premise to protect the health professionals involved and not exhaust the financial re- sources available for assistance [1] [2]. Tracheostomy is a routine procedure in patients requiring mechanical ventilation due to respiratory failure. It helps the airway hygiene, prevents trachea stenosis and facilitates weaning from mechanical ventilation [2]. Tracheostomy is not always benefit to patients. Half patients do not survive for more than one year after requiring a tracheostomy [3]. The coronavirus spreads through respiratory droplets and by direct contact with surfaces or objects used by infected people. In critical care facilities, aerosolizing procedures are the most dangerous way to contaminate health care team [4]. The viral detection in mucosal samples in most patients usually decreases after 11 days from viral initial exposure. As time goes by the infectivity also decreases [2]. Elective tracheostomy is usually performed from the seventh day from intubation, but it is also acceptable from 5 to 14 days [6]. The aim of this study is to establish a practical and sucint guideline regarding the proper timing to perform elective tracheostomies in COVID-19 infected patients.

Methods
An integrative review was done regarding the studies published during the Covid-19 pandemic. PubMed, Lilacs, Google Scholar and Scielo databases were used to search relacted articles. Only texts in english and portuguese were used.
The terms used in the bibliographic search were "tracheostomy" and "coronavirus". The inclusion criteria were studies that discussed the safety procedures and timing to perform elective tracheostomies.

Results and Discussion
During the pandemic, the following considerations must be reinforced. Tracheostomy plays an important role in the weaning process of mechanical ventilation. There is a need to adapt the usual procedures during a COVID-19 Pandemic. The reality and availability of local staff and material resources are always taken into account when making decisions. Tracheostomy and post-procedure care expose the health team at risk of contamination. The decision to perform the tracheostomy must consider the best existing practice. A tracheostomy in patient COVID-19 may not always be beneficial [5] [6] [7] [8].
The majority of studies reviewed agreed that a multidisciplinary approach is mandatory to decide indications and ideal time to perform elective tracheostomies. A resume of these recommendations is on  Modifications of institutional protocols for performing elective tracheostomies are necessary, according to the proper realities of each assistance service, specially in developing countries [1] [2] [9].
Tracheostomies must be a safer procedure during the pandemic. Delay in indications protect pacients from unnecessary procedures and expose the team to a lesser risk of contamination due to a decreased virus count on patient airway [5] [6].

Conclusion
In order to preserve health care team and give chance of survival to patients able to recovery, it is mandatory to accomplish the best available practice to performing elective tracheostomies during the COVID-19 pandemic.