Letter to the Editor In Reference to Tracheostomy for COVID-19 in India: A Herculean Task of Keeping Two Lives Safe Dear Editor: We thank the authors for their meaningful response to our recent manuscript. The decision of when, how, and for whom to perform tracheostomy in COVID-19 patients remains challenging. Preliminary studies have provided evidence that bed- side tracheostomy for COVID-19 patients can be per- formed safely without transmission to healthcare workers. In these studies, personal protective equipment (PPE) included at least an N95 mask, face shield or goggles, and surgical gown and gloves. 1,2 Access to PPE has improved with increased supply and the feasibility of reprocessing/ reuse; however, as indicated, access to PPE may still be incomplete in regions with limited resources. Patients with COVID-19 requiring prolonged mechan- ical intubation have a more grim prognosis, for which we concur that careful consideration of the potential benefit should be taken before performing tracheostomy. However, one study demonstrated that 32 of 98 tracheostomized patients were able to be successfully weaned from mechan- ical support. 2 Although not reaching statistical signifi- cance, another prospective series of 50 patients suggested improved success in weaning from ventilator when tra- cheostomy was performed earlier compared to later. 1 Although the ideal timing of tracheostomy in COVID-19 is uncertain, there is sufficient evidence to postulate benefit in select patients. 3 The suboptimal equipment of bedside tracheostomy and cumbersome nature of enhanced PPE can increase the difficulty of the procedure but can still be performed safely. One concern proposed is the risk of bleeding in COVID-19 patients due to anticoagulation. In the Aviles- Jurado study, 15 of 50 patients were anticoagulated. No major bleeding complications were noted, and minor bleeding occurred in only 6 of 50. The authors credit suc- cessful hemostasis to the use of electrocautery, although some experts favor cold instrumentation to decrease aerosolization. 4 We have had no documented transmissions in our experience with six carefully selected patients for bedside tracheostomy. To date, none have required secondary operation for hemostasis or have had bleeding complica- tions. Several of these patients have been anticoagulated or have even been on extracorporeal membrane oxygena- tion. From a technical standpoint, surgeon control of the orotracheal tube to aid in withdrawal (i.e. prepping the tube into the field), cessation of ventilation at the time of exchange, meticulous hemostasis at the time of the opera- tion, and cephalad retraction of the thyroid isthmus (rather than dividing) have resulted in short operative times and positive operative outcomes. There is still much uncertainty regarding tracheostomy in COVID-19. Current guidelines and recommendations should be applied judiciously by the experienced physician to individual factors of the institution, surgeon, and patient. JEFFREY C. MECHAM, BS OLIVIA J. THOMAS, BS Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, U.S.A. PHILLIP PIRGOUSIS, MD JEFFREY R. JANUS, MD Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, U.S.A. Editor’s Note: This Manuscript was accepted for publication on December 11, 2020. The authors have no funding, financial relationships, or conflicts of inter- est to disclose. BIBLIOGRAPHY 1. Aviles-Jurado FX, Prieto-Alhambra D, Gonzalez-Sanchez N, et al. Timing, complications, and safety of tracheotomy in critically ill patients with COVID-19. JAMA Otolaryngol Head Neck Surg 2020. Online ahead of print. 2. Angel L, Kon ZN, Chang SH, et al. Novel percutaneous tracheostomy for crit- ically ill patients with COVID-19. Ann Thorac Surg 2020;110:1006–1011. 3. Lamb CR, Desai NR, Angel L, et al. Use of tracheostomy during the COVID- 19 pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interven- tional Pulmonology Program Directors Expert Panel Report. Chest 2020; 158:1499–1514. 4. Parker N. Tracheotomy recommendations during the COVID-19 pandemic. Airway and Swallowing Committee of the American Academy of Otolaryngology-Head and Neck Surgery. 2020. Send correspondence to Dr. Jeffrey R. Janus, MD, Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Clinic, Jacksonville, FL. E-mail: janus.jeffrey@mayo.edu DOI: 10.1002/lary.29340 Laryngoscope 131: May 2021 Mecham et al.: Letter to the Editor E1572 The Laryngoscope © 2020 The American Laryngological, Rhinological and Otological Society, Inc.