10.14639/0392-100X-N1435
Objective. COVID-19 respiratory insufficiency has augmented demand of tracheostomies in intubated patients. Herein, we analyse our experience with Suspension Laryngoscopyassisted Percutaneous Dilatational Tracheostomy (SL-PDT) to assess the safety for both healthcare personnel and patients.Methods. We conducted a retrospective review of all patients who underwent SL-PDT in the Intensive Care Unit (ICU) between March 13 and April 17, 2020 (first peak of SARSCoV- 2 pandemic).Results. We included 28 SL-PDTs conducted in the ICU by a single operator using standard personal protective equipment (PPE) for high-risk procedures. The average procedure time was 30 minutes. Intraoperative complications were few, mild and promptly resolved. No operators were infected after the procedure. Conclusions. SL-PDT is a safe and quick technique: it is preferable to open surgical procedures, where air-flow cessation cannot be achieved and droplet emission is high. The cost/benefit ratio is low. A disadvantage is the need for an ENT surgeon who is familiar with direct laryngoscopy, with the main difficulty being the exposure of the upper airways. Minimal air leakage and good control of occasional bleeding makes it a safe procedure for the patient and medical personnel alike.
text/xml
1827-675X
1435
en
Stefano Carlo Paradisi
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
safety
Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy: a safe method in COVID-19
Text.Serial.Journal
https://www.actaitalica.it/
41
COVID-19
2021-11-05
2021-02-28
2021-11-02
2021-11-02
389-394
1
Stefano Carlo Paradisi
2021/11/05
10.14639/0392-100X-N1435
389
Otorhinolaryngology Unit, Azienda Socio-Sanitaria Territoriale - (ASST) della Brianza, Vimercate (MB), Italy
1827-675X
safety
en
394
Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy: a safe method in COVID-19
https://www.actaitalica.it/article/download/1435/673
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:389-394; doi: 10.14639/0392-100X-N1435




COVID-19


Suspension laryngoscopy-assisted percutaneous
dilatational tracheostomy: a safe method in COVID-19
Tracheotomia percutanea dilatativa in laringoscopia in sospensione nei pazienti affetti
da COVID-19
Franco Parmigiani1, Antonello Alberto Sala2, Cristiana Fumanti1, Andrea Luigi Rescaldani1, Federico Giuseppe Quarta1,
Stefano Carlo Paradisi1
1
 Otorhinolaryngology Unit, Azienda Socio-Sanitaria Territoriale - (ASST) della Brianza, Vimercate (MB), Italy; 2 Anesthesiology Unit,
Azienda Socio-Sanitaria Territoriale - (ASST) della Brianza, Vimercate (MB), Italy


SUMMARY
Objective. COVID-19 respiratory insufficiency has augmented demand of tracheostomies
in intubated patients. Herein, we analyse our experience with suspension laryngoscopy-
assisted percutaneous dilatational tracheostomy (SL-PDT) to assess the safety for both
healthcare personnel and patients.
Methods. We conducted a retrospective review of all patients who underwent SL-PDT in
the Intensive Care Unit (ICU) between March 13 and April 17, 2020 (first peak of SARS-
CoV-2 pandemic).
Results. We included 28 SL-PDTs conducted in the ICU by a single operator using standard
personal protective equipment (PPE) for high-risk procedures. The average procedure time
was 30 minutes. Intraoperative complications were few, mild and promptly resolved. No            Received: January 14, 2021
operators were infected after the procedure.                                                     Accepted: May 17, 2021
Conclusions. SL-PDT is a safe and quick technique: it is preferable to open surgical pro-
cedures, where air-flow cessation cannot be achieved and droplet emission is high. The           Correspondence
cost/benefit ratio is low. A disadvantage is the need for an ENT surgeon who is familiar         Federico Giuseppe Quarta
with direct laryngoscopy, with the main difficulty being the exposure of the upper airways.      Otorhinolaryngology Unit, Azienda Socio-Sanitaria
Minimal air leakage and good control of occasional bleeding makes it a safe procedure for        Territoriale - (ASST) della Brianza, via Santi Co-
the patient and medical personnel alike.                                                         sma e Damiano 10, 20871 Vimercate (MB), Italy
                                                                                                 Tel. +39 039 6657577
KEY WORDS: tracheostomy, laryngoscopy, SARS-CoV-2, COVID-19, safety                              E-mail: federico.quarta@unimi.it


RIASSUNTO                                                                                        Funding
                                                                                                 None.
Obiettivo. L’insufficienza respiratoria causata da COVID-19 ha incrementato la richiesta
di tracheostomie nei pazienti intubati. Abbiamo analizzato la nostra esperienza con la Tra-
cheostomia Dilatativa Percutanea sotto controllo in Laringoscopia Diretta in Sospensione         Conflict of interest
                                                                                                 The Authors declare no conflict of interest.
(SL-PDT) per valutarne la sicurezza per il personale sanitario coinvolto ed i pazienti.
Metodi. Abbiamo condotto uno studio retrospettivo dei pazienti sottoposti a SL-PDT in
Terapia Intensiva tra il 13 marzo e il 17 aprile 2020 (primo picco della pandemia da SARS-         How to cite this article: Parmigiani F, Sala AA,
CoV-2).                                                                                            Fumanti C, et al. Suspension laryngoscopy-as-
Risultati. Abbiamo incluso 28 SL-PDT realizzate come procedura mono-operatore dotato               sisted percutaneous dilatational tracheostomy:
di Dispositivi di Protezione Individuale (DPI) per procedure ad alto rischio. Le complican-        a safe method in COVID-19. Acta Otorhi-
ze intraoperatorie erano esigue, di grado lieve e prontamente risolte. Nessun operatore è          nolaryngol Ital 2021;41:389-394. https://doi.
                                                                                                   org/10.14639/0392-100X-N1435
risultato infetto dopo la procedura.
Conclusioni. SL-PDT è una tecnica sicura e veloce, preferibile a procedure chirurgiche in
                                                                                                 © Società Italiana di Otorinolaringoiatria
cui non è possibile spegnere la ventilazione e l’emissione di aerosol è elevata. Il rapporto     e Chirurgia Cervico-Facciale
costi/benefici è basso. Richiede un chirurgo ORL avvezzo alla laringoscopia diretta, essen-
do la difficoltà principale l’esposizione delle vie aeree superiori. La minima perdita di aria                  OPEN ACCESS
e l’agevole controllo dell’eventuale sanguinamento la rendono una procedura sicura per i
professionisti coinvolti.                                                                        This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
PAROLE CHIAVE: tracheotomia, laringoscopia, SARS-CoV-2, COVID-19, sicurezza                      Commercial-NoDerivatives 4.0 International) license. The
                                                                                                 article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
                                                                                                 only in the original version. For further information: https://
                                                                                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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F. Parmigiani et al.




Introduction                                                    first SARS-CoV-2 outbreak beginning in late February
                                                                2020. We selected all patients who underwent tracheosto-
Pneumonia caused by Coronavirus Disease 2019 (COV-
                                                                my during their ICU stay and we included 28 cases. These
ID-19) can cause in a number of cases a rapid progression to
                                                                interventions took place between March 13 to April 17,
acute respiratory distress syndrome (ARDS): it is character-
                                                                2020 and in all cases we performed SL-PDT.
ised by respiratory failure and can lead to death if mechani-
                                                                SL-PDT was chosen because: 1) its external-internal path
cal ventilation procedures are not promptly performed. The
                                                                (rather than the other way around) reduces potential viral
high rates of hospital and intensive care unit (ICU) admis-
                                                                spread from the trachea; 2) we wanted to minimise changes
sions during the virus outbreak resulted in serious conges-
                                                                in the tracheostomy tube during recovery in, or after dis-
tion in hospitals and extreme measures were taken to avoid
                                                                charge from, the ICU (i.e., in the hospital ward); 3) there
collapse of healthcare services. Patients who need prolonged
                                                                are few complications; 4) we had previous experience with
sedation and intubation in the ICU often require safer and
                                                                its use in ICU patients.
easier airway management, such as tracheostomy 1.
                                                                As previously described by Sharp and Castellanos 8, the
A recent study revealed that early tracheostomy (i.e., per-
                                                                patient is positioned and prepped in the same way as for
formed within the first 10 days after orotracheal intubation)
                                                                standard operative tracheostomy. With the patient under
is associated with a reduction in mechanical ventilation du-
                                                                general anaesthesia and intubated with an oro-tracheal
ration, mortality rate and length of stay in the ICU 2. How-
                                                                tube, the operator is positioned at the head of the ICU bed.
ever, during surgical tracheostomy procedures the risk of
                                                                The laryngoscope is placed just into the laryngeal inlet
exposure of healthcare personnel to COVID-19 is high 3.
                                                                within the aperture of the false vocal folds. The position
Surgical tracheostomies place surgeons in the highest risk
                                                                of the laryngoscope is then secured and the patient’s head
category along with ICU nurses and anesthesiologists, be-
                                                                is stabilised with the suspension apparatus. This manoeu-
cause direct access to the airway and mechanical ventila-
                                                                ver allows the surgeon to aspirate secretions under laryn-
tion generate considerable quantities of droplets when air
                                                                goscopic view and to obtain a good vision of the tracheal
leaks from the tube cuff 4. Other bedside techniques have
the same problem (e.g., Rapitrac, Fantoni) 5,6. We reviewed     walls for the subsequent steps. The laryngeal tube cuff is
the limited data and found no clear evidence in favour of       moved in the lower part of the trachea: in this way the tube
one technique over another from the standpoint of viral         cuff is protected from rupture during the procedure and the
spread and protection for healthcare professionals.             lower airways, where the viral load is maximum, are sepa-
At our institution, we routinely adopt suspension laryngos-     rated from the operators. We routinely use a single dilator
copy-assisted percutaneous dilatational tracheostomy (SL-       Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer
PDT) 7,8 on sedated and intubated patients and believe that     Kit (Cook Critical Care Inc, Bloomington, Indiana, USA)
it may be preferable to open tracheostomy and percutane-        or Portex ULTRAperc Single Stage Dilator Technique Kit
ous cricothyrotomy 9, where air-flow cessation is not possi-    (Smiths Medical MD Inc, Minneapolis, Minnesota, USA).
ble and droplet emission is inevitably higher. Two critically   After having palpated the anatomical landmarks (supraster-
important preoperative criteria for SL-PDT are: 1) the abil-    nal notch, first tracheal rings and cricoid cartilage), the
ity to hyperextend the neck and 2) the presence of at least     operator makes a transcervical puncture in the intercarti-
1 cm between the cricoid cartilage and suprasternal notch,      laginous space between the second and third tracheal ring,
ensuring that the patient will be amenable to reintubation in   having caution to remain in the midline of the neck in order
case of accidental extubation.                                  to avoid piercing anterior venous vessels. The continuous
We experienced a large augmentation of demand for tra-          vision of the anterior wall of the trachea through the laryn-
cheostomy in patients intubated in the ICU during the first     goscope also allows good control of transcervical puncture
SARS-CoV-2 outbreak in 2020. In this study, we analyse          of the trachea from the inside of the airways (Fig. 1) and
our experience with SL-PDT.                                     subsequent positioning of the guidewire (Fig. 2) 10. In ad-
                                                                dition, the surgical laryngoscope bears suspension of the
                                                                laryngeal box, increasing the rigidity of the tracheal com-
Materials and methods                                           partment. This facilitates all dilatation manoeuvers with the
The study is designed as a retrospective review. Due to its     ventilation tube in place (Figs. 3, 4). Two small horizontal
retrospective design, it did not need approval from Azienda     cutaneous cuts are made at each side of the dilator to make
Socio-Sanitaria Territoriale (ASST) della Brianza Institu-      insertion easier. We do not use flexible bronchoscopes.
tional Ethics Committee.                                        After dilatation, we insert the tracheostomy cannula
We retrospectively evaluated the charts of all COVID-19         (Fig. 5); once the initial part is visible, the mechanical
patients, hospitalised and intubated in the ICU during the      ventilation is held for the time of exchange of the ventila-



390
                                                         Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy: safe method in COVID-19




Figure 1. Insertion of the guide needle. Dislocation of the orotracheal tube    Figure 4. Introduction of the final part of dilator.
downward.

                                                                                tion tubes: the endotracheal tube is pulled out, the operator
                                                                                adjusts the final position of the cannula and then connects
                                                                                it with the ventilation circuit; only during this step is the
                                                                                airway open.

                                                                                Results
                                                                                From March 13 to April 17, 2020, we performed 28 SL-
                                                                                PDTs, 15 of which were performed within the first 3 weeks
                                                                                of the outbreak, during maximum ICU use (Tab. I).
                                                                                All SL-PDTs were conducted in the ICU by an ear, nose and
                                                                                throat surgeon using standard personal protective equip-
                                                                                ment (PPE) for high-risk procedures (i.e., N95/FFP2 mask,
                                                                                double gloves, shoe covers, disposable protective uniform,
                                                                                and ventilated helmet with a frontal light). All the proce-
                                                                                dures were conducted with the assistance of the patient’s
Figure 2. Positioning of the guidewire.                                         ICU nurse: the intensivist attended in case of particularly
                                                                                fragile patients who needed close monitoring. The average
                                                                                procedure time was 30 minutes (range: 20-50 minutes).
                                                                                In our series, there were 26 males and 2 females (M:F ratio,
                                                                                13:1); the mean age was 62 years (range: 50-76 years) and
                                                                                the average time from ICU admission to tracheostomy was
                                                                                10 days (range: 5-19 days).
                                                                                All patients received heparin (low-molecular-weight-hep-
                                                                                arin, LMWH, or ultrafractionated heparin, UH) at prophy-
                                                                                lactic or therapeutic dosages: in 5 cases patients were re-
                                                                                ceiving continuous venovenous haemodialysis (CVVHD).
                                                                                During the procedures we experienced 4 minor haemor-
                                                                                rhagic complications (14.3%): these consisted in mild sub-
                                                                                dermal bleeding resulting from the skin incision made to
                                                                                facilitate dilator and cannula insertion and were promptly
                                                                                resolved with bipolar coagulation (two cases) or gauze
                                                                                package dressing (two cases). Only in one case (3.6%) was
Figure 3. Insertion of the first part of dilator.                               a major haemorrhagic complication experienced (a large



                                                                                                                                                    391
F. Parmigiani et al.




                                                                                 ostomy. However, due to the direct access to the airway
                                                                                 and mechanical ventilation, which generates the spread of
                                                                                 a large amount of droplets in case of air-leakage from the
                                                                                 tube cuff, tracheostomies expose surgeons to high risk of
                                                                                 contagion, along with with ICU nurses and anaesthesiolo-
                                                                                 gists.
                                                                                 From open surgical procedures to percutaneous dilatational
                                                                                 systems, there are different techniques commonly used to
                                                                                 perform a tracheostomy in critically-ill patients. After a
                                                                                 review of the available literature, there are no clear data
                                                                                 to establish the superiority of one approach over another
                                                                                 from the standpoint of infectious transmission or safety:
                                                                                 operators should continue to do tracheostomies using the
                                                                                 techniques and equipment with which they are familiar,
Figure 5. Introduction of the cannula tip. Only in this moment the orotracheal   confident and experienced in using 12.
tube is removed.                                                                 At our institution, SL-PDT is a commonly used technique
                                                                                 to perform tracheostomy in sedated and intubated patients
haematoma resulting from the lesion of a venous vessel of                        in ICU.
the anterior part of the neck) and required abortion of the                      This technique permits to broaden the field of application of
percutaneous procedure and conversion to open cervico-                           percutaneous dilatational tracheostomy (PDT), because it
tomy for control of haemostasis: eventually we proceeded                         can overcome some classical contraindications to traditional
with surgical tracheostomy.                                                      percutaneous technique, such as unsafe airway, emergency,
The cannula did not need to be changed in any patient, ei-                       presence of a median cervical lesion, non-palpable cricoid
ther during recovery in the ICU or hospital ward, and excel-                     cartilage, obese and overweight patients and coagulopathy.
lent adherence between the skin and cannula avoided the                          SL-PDT is a reasonable alternative to open tracheostomy in
air leaks generating aerosol and thus facilitating viral dif-                    patients who need prolonged ventilation secondary to ARDS,
fusion. No difficulties in care in medium or mild care units                     but some conditions make them unsuitable candidates for tra-
were reported. In all cases, the tracheostomy was removed                        ditional percutaneous tracheostomy 13.
3 days before discharge.                                                         As other techniques of PDT, it can be carried out as a bed-
No surgeon, anaesthesiologist or nurse present at the                            side procedure, eliminating the need to transfer the patient in
procedures had symptoms of COVID-19 disease dur-                                 the operating room (OR), which is difficult and dangerous. In
ing subsequent weeks, none had SARS-CoV-2 antibodies                             fact, due to the fragility of these patients for the acute illness,
by serological test conducted by the Hospital Preventive                         a transfer to the OR needs to be accompanied by the com-
Healthcare Service during the month of May 2020.                                 plex anaesthesia system and ventilator machine and expose
                                                                                 all personnel involved to the risk of contamination.
Discussion                                                                       PDT and SL-PDT share some advantages over convention-
                                                                                 al surgical tracheostomy: it is easier to perform and with
The outbreak of SARS-CoV-2 has reached worldwide pro-                            shorter operative time, lower risk of intra- and postopera-
portions since it began in late 2019. Since mid-February                         tive bleeding, reduced risk of infection of the surgical site,
2020, Italy has been one of the leading nations in the world                     lower costs and reduced time of spontaneous tracheostomy
for infections.                                                                  stoma closure after decannulation 13,14.
According to official online data of the first peak of pan-                      In order to reduce the complication rates, PDT is performed
demic, roughly 10% of the Italians who were infected were                        under flexible endoscopic control of a bronchoscope usu-
health-care workers 11.                                                          ally passed through the orotracheal tube. However, in a pa-
Tracheostomy is a routine procedure in critically-ill patients                   tient with high ventilation demands and complicated ven-
who require an extended period on mechanical ventilation                         tilator settings such as in COVID-19, the use of a flexible
and can facilitate weaning from ventilation and potentially                      endoscope can lead to ventilatory compromise secondary
increase the availability of ICU beds 12.                                        to partial obstruction of the tube and difficulties in main-
During the first peak of the COVID-19 pandemic, ICUs ex-                         taining adequate PEEP and/or minute ventilation 7,13.
perienced a massive influx of patients worldwide who were                        In SL-PDT, the need for endoscopic control during the pro-
critically ill, many of whom became candidates for trache-                       cedure is eliminated by direct vision through the laryngo-



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                                                                Suspension laryngoscopy-assisted percutaneous dilatational tracheostomy: safe method in COVID-19




Table I. SL-PDT performed in ICU from March 13 to April 17, 2020.
 Gender     Age      Date of ICU             Date of                                   Type of                       Anticoagulation                   Complications
                      admission           tracheostomy                              tracheostomy
 M             72           02-Mar                     13-Mar                          SL-PDT                      LMWH therapeutic                         None
 M             58           09-Mar                     16-Mar                          SL-PDT                      LMWH prophylactic                        None
 M             59           05-Mar                     16-Mar                          SL-PDT                      LMWH therapeutic                         None
 M             73           03-Mar                     18-Mar                          SL-PDT                      LMWH prophylactic                        None
 M             54           08-Mar                     20-Mar                          SL-PDT                        UH (CVVHD)                             None
 M             51           08-Mar                     20-Mar                          SL-PDT                        UH (CVVHD)                             None
 F             72           15-Mar                     23-Mar                          SL-PDT                      LMWH therapeutic                         None
 M             59           17-Mar                     24-Mar                          SL-PDT                      LMWH therapeutic                         None
 M             74           12-Mar                     24-Mar                          SL-PDT                      LMWH therapeutic                         None
 M             67           09-Mar                     25-Mar                          SL-PDT                      LMWH prophylactic                        None
 F             56           14-Mar                     25-Mar                          SL-PDT                            UH                                 None
 M             50           18-Mar                     26-Mar                          SL-PDT                      LMWH therapeutic                       Bleeding
 M             62           22-Mar                     27-Mar                          SL-PDT                            UH                                 None
 M             59           19-Mar                     27-Mar                          SL-PDT                      LMWH therapeutic                         None
 M             52           23-Mar                     30-Mar                          SL-PDT                      LMWH therapeutic                         None
 M             61           24-Mar                     01-Apr                          SL-PDT                            UH                                 None
 M             55           13-Mar                     02-Apr                          SL-PDT                      LMWH prophylactic                        None
 M             57           26-Mar                     02-Apr                          SL-PDT                      LMWH therapeutic                         None
 M             76           17-Mar                     02-Apr                          SL-PDT                        UH (CVVHD)                           Bleeding
 M             61           01-Apr                     06-Apr                          SL-PDT                      LMWH prophylactic                      Bleeding
 M             68           28-Mar                     06-Apr                          SL-PDT                        UH (CVVHD)                             None
 M             55           29-Mar                     06-Apr                          SL-PDT                        UH (CVVHD)                             None
 M             61           30-Mar                     07-Apr                          SL-PDT                      LMWH therapeutic                         None
 M             65           27-Mar                     08-Apr                  SL-PDT, converted OPEN              LMWH therapeutic                      Haematoma
 M             72           24-Mar                     08-Apr                          SL-PDT                      LMWH prophylactic                        None
 M             73           04-Apr                     16-Apr                          SL-PDT                      LMWH therapeutic                       Bleeding
 M             63           10-Apr                     16-Apr                          SL-PDT                      LMWH therapeutic                         None
 M             61           05-Apr                     17-Apr                          SL-PDT                      LMWH therapeutic                         None
SL-PDT: suspension laryngoscopy-assisted percutaneous dilatational tracheostomy; CVVHD: continuous venovenous haemodialysis; LMWH: low molecular weight heparin; UH: unfractioned
heparin.


scope: this permits excellent vision which helps in seeing                                 nia, in which anticoagulation is a mainstay in current man-
palpation on the anterior tracheal wall and visualisation of                               agement. In these conditions, the operative setting of the
the planned puncture site, while reducing to a minimum the                                 laryngeal suspension system allows easy control of haemo-
risk of posterior tracheal wall injury.                                                    stasis in case of endotracheal bleeding with the possibility
Thanks to the suspension system, the airway is rigidly fixed                               to use rigid suction instruments, mechanical pressure and
in place while being lifted and extended anteriorly, im-                                   monopolar or bipolar coagulation devices 13,14.
proving identification and palpation of anatomical airway                                  The only complications observed in our study were intra-
landmarks. This makes SL-PDT a good alternative even in                                    operative bleedings. These consisted primarily in small cu-
overweight and obese patients, which have very short, thick                                taneous bleedings from the skin incision made to facilitate
necks and challenging airway access, traditionally a con-                                  dilator and cannula insertion, which are easily controlled
traindication to PDT 7,8,15.                                                               with electrocautery or mechanical compression. The dila-
SL-PDT can be performed in patients with bleeding disor-                                   tational technique, thanks to the insertion of dilators with
ders defined as INR > 1.5 or platelet count < 50,000/mm3,                                  progressively greater diameter and the tracheostomy can-
patients treated with heparin either at prophylactic or thera-                             nula, achieves haemostasis on the involved tissues during
peutic dosages or receiving CVVHD. This is particularly                                    these manoeuvers.
important in patients hospitalised for COVID-19 pneumo-                                    In our experience, after transcervical puncture and progres-



                                                                                                                                                                           393
F. Parmigiani et al.




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tions that do not allow good visualisation of the laryngeal
                                                                  12
                                                                       Brass P, Hellmich M, Ladra A, et al. Percutaneous techniques versus
plane.                                                                 surgical techniques for tracheostomy. Cochrane Database Syst Rev
                                                                       2016;7:CD008045. https://doi.org/10.1002/14651858.CD008045.pub2
Conclusions                                                       13
                                                                       Moulin M, Aboussouan MP, Castellanos PD, et al. Evaluation of per-
                                                                       cutaneous dilatational tracheostomy under laryngosuspension. Eur
The COVID-19 pandemic required a new approach to care                  Arch Otorhinolaryngol 2020;277:3391-3396. https://doi.org/10.1007/
                                                                       s00405-020-06141-1
for ICU patients to reduce the length of stay and compli-         14
                                                                       Moulin M, Castellanos PF, Atallah I. Suspension laryngoscopy-
cations. SL-PDT is an excellent tracheostomy technique                 assisted percutaneous dilatational tracheostomy. Eur Ann Otorhi-
in patients intubated for SARS-CoV-2 disease and can be                nolaryngol Head Neck Dis 2021;138:53-55. https://doi.org/10.1016/j.
preferable due to its various advantages over traditional              anorl.2020.06.024
                                                                  15
                                                                       Blankenship DR, Kulbersh BD, Gourin CG, et al. High-risk tra-
techniques: it is a bedside and single-surgeon procedure;              cheostomy: exploring the limits of the percutaneous tracheosto-
it is easy and quick to perform, without increased risk for            my. Laryngoscope 2005;115:987-989. https://doi.org/10.1097/01.
complications; it can be carried out in practically any pa-            MLG.0000163107.80668.12
tient, even if obese or on anticoagulant therapy; it is a safe    16
                                                                       Ben Nun A, Orlovsky M, Best LA. Percutaneous tracheostomy in
                                                                       patients with cervical spine fractures - feasible and safe. Interact
method in terms of potential viral spread, preventing expo-            Cardiovasc Thorac Surg 2006;5:427-429. https://doi.org/10.1510/
sure of healthcare personnel.                                          icvts.2005.125690




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