The role of tracheotomy in patients with moderate to severe impairment of the lower airways

Patients affected by severe acute respiratory distress syndrome due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have a high likelihood of needing prolonged intubation. As observed worldwide during the Coronavirus Disease 2019 (COVID-19) pandemic, the need for tracheotomy in patients with prolonged respiratory failure has dramatically increased. Tracheotomy in these patients offers several advantages over prolonged translaryngeal intubation: improved patient comfort may allow a reduction in intravenous administration of analgesics, sedatives and muscle relaxant drugs, enhance mobility with particular regard to respiratory muscles, and patients may achieve autonomy earlier. However, there is still debate about the optimal timing and surgical technique of tracheotomy. Similarly, debate is still open regarding the relative merits of open surgical tracheotomy (ST) versus percutaneous dilatational techniques (PDT). In general, PDT is commonly used in elective tracheotomy in adult patients in intensive care units; ST may be preferred depending upon the practitioner's experience and patient's characteristics. Correct timing of tracheotomy should be individualised and the indication for tracheotomy should balance the problems related to prolonged intubation and the risk of early or late complications related to the surgical procedure.