Radiol Oncol 2024; 58(4): 556-564. doi: 10.2478/raon-2024-0034
556
research article
Tracheostomy before and during COVID-19 
pandemic
Sara Jensterle1, Janez Benedik2,3, Robert Sifrer1,3
1 Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
2 Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
3 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
Radiol Oncol 2024; 58(4): 556-564.
Received 4 April 2024 
Accepted 16 May 2024
Correspondence to: Assist. Prof. Robert Šifrer, M.D., Ph.D., Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical 
Centre Ljubljana, Slovenia. E-mail: robert.sifrer@kclj.si and Assist. Prof. Janez Benedik, M.D., Ph.D., Department of Anaesthesiology and 
Surgical Intensive Therapy, University Medical Centre Ljubljana, Slovenia. E-mail: janez.benedik@kclj.si
Disclosure: No potential conflicts of interest were disclosed.
This is an open access article distributed under the terms of the CC-BY license (https://creativecommons.org/licenses/by/4.0/).
Background. The aim of the study was to provide insight into the influence of the COVID-19 on the frequency and 
characteristics of urgent and emergent tracheostomies (TS), comparing data collected both before and during the 
pandemic. Our two hypotheses were that during COVID-19, more TS were performed in the emergent setting and 
that during COVID-19 more TS were performed under general anaesthesia.
Patients and methods. The research was retrospective. The study period included the two years before and after 
the COVID-19 outbreak in Slovenia. Forty-one patients in each period met the inclusion criteria. Their medical charts 
were reviewed. The anamnestic, clinical, surgical and anaesthesiological data were collected. The two groups of 
patients from corresponding time periods were statistically compared.
Results. Predominantly men required the surgical resolution of acute upper airway obstruction (76% of patients). 
The causes for acute respiratory distress included head and neck cancer (62%), infections (20%), vocal cord paralysis 
(16%), and stenosis (2%). There were no statistically significant differences either in the (emergent/urgent) setting of TS 
or in the type of anaesthesia used. Both hypotheses were rejected. A statistically significant rise in use of the C-MAC 
laryngoscope during COVID-19 (from 3% to 15%) was reported.
Conclusions. The outbreak of COVID-19 did not have a statistically significant effect on the frequency of perform-
ing emergent and urgent tracheostomies nor on the use of general or local anaesthesia. It did, however, require a 
change of intubation technique. Consequently, a significant rise in the use of the C-MAC laryngoscope was noted.
Key words: upper airway obstruction; emergent tracheostomy; urgent tracheostomy; anaesthesia; SARS-CoV-19; 
orotracheal intubation
Introduction
Acute respiratory distress (ARD) due to upper air-
way obstruction (UAO) is a life-threatening medi-
cal situation leading to, both, the imminent irrepa-
rable ischemic damage of the brain and/or cardiac 
arrest if not treated properly and promptly. These 
catastrophic events can occur in a matter of min-
utes. Thus, quick, determinate action is required 
in order to provide an alternative air conduit and 
ensure a clear, patent airway.1-3
After the identification of the site and degree of 
the UAO, which is the first step, further measures 
are taken to circumvent the obstructed airway. The 
first option is orotracheal intubation (OTI) most 
commonly performed by an anaesthesiologist un-
der general anaesthesia. It is followed by an open 
tracheostomy (TS), which is usually performed by 
an otorhinolaryngologist or other appropriately, 
adequately trained surgical specialist.
Clinical conditions of ARD, where the patient 
can neither be intubated nor ventilated, are known 
Radiol Oncol 2024; 58(4): 556-564.
Jensterle S et al. / Tracheostomy and COVID-19 557
as “cannot intubate-cannot ventilate” situations 
(CICV) and represent truly emergent clinical sce-
narios requiring a quick and effective surgical ap-
proach to the airway.4 The literature describes two 
surgical options for resolving ARD in the circum-
stances of CICV: the cricothyrotomy (CTT) and the 
tracheostomy (TS). 
In December 2019, a new strand of Coronavirus, 
now named SARS-CoV-2 was discovered. Its out-
break negatively affected healthcare accessibil-
ity all over the world and, among other things, 
demanded the adaptation of surgical procedures 
to avoid viral transmission to healthcare provid-
ers. In regards to TS, the opening of the trachea 
and excision of tracheal window as the essential 
steps of the TS, might cause cough generating a 
large quantity of aerosol containing mucus, blood, 
and the virus. This would be directed towards the 
surgical and anaesthesiological teams, so the con-
tamination of healthcare personnel with SARS-
CoV-2 is highly probable during ordinary, i.e. not 
adapted, TS.5
There is a plethora of articles in the pertinent lit-
erature discussing the various surgical and anaes-
thesiological adaptations of the TS to the pandemic 
of COVID-19. Some of them were also proposed by 
our department.4,6 
In this study, we chose to analyse the changing 
paradigm of ARD treated by TS as a result of the 
outbreak of COVID-19. The aim was to provide an 
in-depth comparison between the two eras (before 
the outbreak vs. during the COVID-19 pandemic) 
including the causes of ARD, the indications for 
emergent and urgent TS, the risk factors in the 
case of a difficult intubation, the surgical and an-
aesthesiological aspects of TS as well as the tim-
ing of the surgery. Our hypotheses firstly focused 
on the proposition that “during the pandemic there 
were more TS performed in the emergent setting”, and, 
secondly that “during COVID-19 more TS were per-
formed under general anaesthesia”. 
Patients and methods
This retrospective study was conducted at 
the Department of Otorhinolaryngology and 
Cervicofacial Surgery at the University Medical 
Centre of Ljubljana, Slovenia. Medical charts, sur-
gical and anaesthesiological reports from consecu-
tive patients treated with TS for UAO associated 
with ARD during a four-year-long period, i.e., be-
tween 4th of March 2018 and the 3rd of March 2022 
were reviewed. The data associated with the pa-
tient, ARD, the risk factors for difficult OTI, surgi-
cal establishment of alternative airway and anaes-
thesiological parameters were all systematically 
collected.
The patients were categorised into two groups, 
i.e., those managed during the COVID-19 pan-
demic (study group) and those treated before the 
outbreak of COVID-19 (control group). The divid-
ing date was the 4th of March 2020 as this was the 
day when the first case of COVID-19 was reported 
in Slovenia. Thus, the length of each period was 
exactly two years. The groups were statistically 
compared according to the above-mentioned pa-
rameters under evaluation.
From the point of a time-dependent aspect of 
TS, the TS were divided into emergent and urgent 
ones.7 For the purpose of our study, one of the fol-
lowing criteria had to be fulfilled for the definition 
of the emergent TS:
• The TS was performed on working days during 
regular hours immediately following the estab-
lishment of the UAO diagnosis. The on-going 
elective surgical program of the department 
was interrupted to carry out the TS.
• The TS was performed during “on duty” ser-
vice.
• The TS was performed following the diagnostic 
direct laryngoscopy during which the immi-
nent deterioration of the upper airway obstruc-
tion was recognised or suspected.
• The TS was performed in a CICV scenario.
On the other hand, if the dyspnoea was not se-
vere enough to demand an emergent procedure, 
the TS was defined as urgent:
• The TS was not performed immediately after 
the establishment of UAO but scheduled for (at 
least) the following day.
• The TS did not fulfil the criteria for emergent TS
The elective TS performed, for example, in 
patients with curative or palliative treatment of 
head-and-neck cancer (HNC), with long-term OTI 
or with chronic aspiration were excluded from the 
study.  
The statistical analyses were performed using 
the IBMI SPSS Statistics Version 25 (Chicago, IL). 
For comparative analyses, the Chi-Square test, 
Fisher’s exact test, t-test, and Mann-Whitney U test 
were used. All statistical tests were two-sided and 
p-values below 0.05 were considered statistically 
significant.
This study has been approved by the National 
Medical Ethics Committee of the Republic of 
Slovenia on 26th of May 2022 under the number 
0120-176/2022/3.
Radiol Oncol 2024; 58(4): 556-564.
Jensterle S et al. / Tracheostomy and COVID-19558
Results
All patients, both periods
A total of 82 patients were included into the study. 
The mean age of the patients was 69 years (range 
28–97) and 62 (76%) of these were male. 
From the surgical aspect, in the majority of the 
patients (72, 88%) the UAO was solved by means 
of a TS. The CTT as the first step in resolving up-
per airway obstruction was used in 6 cases (7%) 
and was transformed into TS immediately. Re-TS 
was performed in 4 cases (5%), meaning a patient 
already had a TS beforehand, and was success-
fully decannulated afterwards. From the aspect 
of emergency, the TS was considered emergent in 
59 (72%) and urgent in 23 (28%) patients. In most 
of the cases, the surgery was performed by expe-
rienced otorhinolaryngologists, namely, in 68 pa-
tients (83%). In the remaining 14 cases (17%), the TS 
was performed by residents under the supervision 
of the experienced surgeon.
The UAO was most commonly caused by HNC 
(62%, 51 patients). The primary tumour sites in-
cluded the larynx in 24 patients (47%), pharynx in 
20 patients (39%), and other primary sites in 7 pa-
tients (14%). Other causes for the obstruction were 
infections including both mucosal upper airway 
infections and deep neck infections, as well as bi-
lateral vocal cord paralysis and laryngotracheal 
stenosis. These results are detailed in Table 1. The 
UAO was caused by a single disease in 60 patients 
(73%), whereas in the remaining 22 patients (27%) 
multiple causes were registered. In these cases, the 
cause playing the most significant role was consid-
ered to be the main one. 
Among the symptoms accompanying the dysp-
noea, dysphagia was reported by 26 patients (32%), 
pain in 19 patients (23%), inspiratory stridor in 31 
patients (38%), and biphasic stridor in a single pa-
tient (1%). The trismus was present in 6 cases (7%).
Thirty-six patients were previously treated for 
various diseases of the head and neck: 14 patients 
(17%) by surgery, 11 patients (13%) received radio-
therapy (RT) and 11 patients (13%) chemo-radio-
therapy (CRT). 
Taking into account the 51 patients with HNC 
as a cause of UAO requiring TS at the time of our 
study, 33 had de novo cancer while 18 had a recur-
rence or a new primary cancer. Specifically, 20% 
(10/51) had previously received RT and 16% (8/51) 
CRT. 
Thirty-one patients had other causes of the 
UAO, namely infections, bilateral vocal cord pa-
ralysis and laryngotracheal stenosis. Thirteen 
percent (4/31) had a history of previous HNC and 
were treated by RT (one patient) and CRT (three 
patients).
Sixty-six (80%) patients had an available ASA 
score and were classified as ASA II (7%, 6/82), ASA 
III (53%, 44/82), and ASA IV (20%, 16/82).
Mallampati score was noted in 44 patients (54%, 
44/82). Most of them (17%, 14/82) were ranked with 
the highest score 4, whilst score 3, 2 and 1 were at-
tributed to 16% (13/82), 12% (10/82), and 9% (7/82) of 
patients, respectively.
Mouth opening was noted in 41 examinees. An 
adequate mouth opening was defined as an inter-
incisor distance of more than 3 cm, as opposed to 
inadequate of less than 3 cm. Forty-one percent 
(34/82) of those were evaluated to have adequate 
mouth opening, whereas in 9% (7/82) it was inad-
equate.
Hyo-mental and thyro-mental distances were 
noted in 28 and 12 patients, respectively. Hyo-
thyromental distance was the parameter coined by 
us for the purpose of the study and comprises the 
measurement of either of the two distances. It was 
obtained in 40 examinees. The distance was suffi-
cient in 43% of the patients (35/82) and insufficient 
in 6% (5/82).
In 77 patients (94%), general anaesthesia was 
used, while in the remaining 5 patients (6%), the 
TS was performed under local anaesthesia.
The data, considering the type of the orotra-
cheal tube, was able to be retrieved in 43 patients. 
Predominantly, a wire tube was used (39%, 32/82). 
A curved tube was used more seldomly (8 %, 7/82), 
while the straight tube was the least frequently 
used (5%, 4/82). The data concerning the manner of 
OTI in terms of the glottic exposure was reported 
in 67 cases. In 9% of the OTI (7/82), C-MAC video 
laryngoscope was used.
TABLE 1. The main causes of upper airway obstruction
Causes of upper airway obstruction No. of patients Ratio (%)
All patients 82 100
Laryngeal cancer 24 29
Pharyngeal cancer 20 24
Cancer of other primary sites 7 9
Infections 16 20
Bilateral vocal cord paralysis 13 16
Laryngo-tracheal stenosis 2 2
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Jensterle S et al. / Tracheostomy and COVID-19 559
TABLE 2. A comparison of the risk factors in all patients before and during the COVID-19 outbreak in Slovenia
Risk factor Overall
Before the 
outbreak of 
COVID-19
During the 
pandemic of 
COVID-19
p value
All patients 82 41 41
Patients
    Age (years)
    mean, range
66.8
(28–97)
64.8
(28–91)
68.8
(42–97) 0.172
a
    Male sex 62 (76%) 31 (76%) 31 (76%) 1.00c
    Body weight (kg)
    mean, range
73.5
(35–143)
71.9
(35–143)
75.2
(43–110) 0.512 
a
    Body height (cm)
    mean, range
172
(150–185)
172
(150–185)
173
(152–183) 0.933 
a
    Body mass index (kg/m2),
    mean, range
25.4
(12.7–37.6)
24.2
(12.7–37.6)
27.6
(19,4–35,5) 0.178 
a
The upper airway obstruction
    Respiratory distress duration 
    (days), median, range
6
(1–180)
10.5
(1–90)
3
(1–180) 0.373 
b
Causes of acute airway obstruction 0.826 c
    Laryngeal cancer 24 (29%) 12 (29%) 12 (29%)
    Pharyngeal cancer 20 (24%) 8 (20%) 12 (29%)
    Other cancers 7 (9%) 5 (12%) 2 (5%)
    Inflammation 16 (20%) 8 (20%) 8 (20%)
    Vocal cord paralysis 13 (16%) 7 (17%) 6 (15%)
    Laryngotracheal stenosis 2 (2%) 1 (2%) 1 (2%)
    Multiple causes 22 (27%) 11 (27%) 11 (27%) 1.000 c
    Respiration space (mm)
    mean, range
2.3
(1–5)
2.5
(1–4)
2.2
(1–5) 0.635
a
Symptoms
    Dysphagia 26 (32%) 12 (29%) 14 (34%) 0.635 c
    Trismus 6 (7%) 5 (12%) 1 (2%) 0.101d
    Pain 19 (23%) 8 (20%) 11 (27%) 0.432 c
Stridor 0.504 c
    Inspiratory 31 (38%) 17 (42%) 14 (34%)
    Biphasic 1 (1%) 0 1 (2%)
Previous treatment
    Surgery 14 (17%) 5 (12%) 9 (22%) 0.379d
    RT 11 (13%) 5 (12%) 6 (15%) 1.000d
    CRT 11 (13%) 5 (12%) 6 (15%) 1.000d
Surgery
    Re-TS 4 (5%) 0 4 (10%) 0.116 d
    Cricothyrotomy 6 (7%) 3 (7%) 3 (7%) 1.000 d
    Surgeon specialist 68 (83%) 34 (83%) 34 (83%) 1.000 c
    Time-dependent aspect of TS 0.806 c
    Emergent 59 (72%) 29 (71%) 30 (73%)
    Urgent 23 (28%) 12 (29%) 11 (27%)
    Duration (hour)
    median, range
0.75
(0.25–2.50)
0.75
(0.25–2.5)
0.88
(0.25–2)
0.546 b
Anaesthesia 1.000d
     Local 5 (6%) 2 (5%) 3 (7%)
    General 77 (94%) 39 (95%) 38 (93%)
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Jensterle S et al. / Tracheostomy and COVID-19560
A comparison of all patients regarding 
the period before and during COVID-19 
Out of a total of 82 patients that were included in 
the study, 41 of them comprised the study group 
with the same number of patients included in the 
control group.
The parameters concerning the characteristics 
of the patients and prior treatments as well as the 
data associated with the actual disease causing 
UAO and its management from both a surgical 
and anaesthesiological perspective were statisti-
cally compared. The results of the statistical com-
parison between the study and control group are 
presented in Table 2.
Regarding the main questions of the study, 
there were no differences between the study and 
control group in our research. Namely, before the 
outbreak of COVID-19, TS was performed in the 
emergent setting in 71% (29/41) of patients, where-
as during the COVID-19 pandemic, that number 
was 73% (30/41). Thus, there is no statistically 
Risk factor Overall
Before the 
outbreak of 
COVID-19
During the 
pandemic of 
COVID-19
p value
    Duration (hour)
    median, range
1.50
(0.75–3.25)
1.5
(0.75–3.25)
1.75
(1–3,25) 0.198 
b
ASA classification 0.952c
    II 6 (7%) 3 (7%) 3 (7%)
    III 44 (53%) 23 (56%) 21 (51%)
    IV 16 (20%) 9 (22%) 7 (17%)
    Unknown 10 (20%) 6 (15%) 10 (25%)
Mallampati classification 0.810 c
    I 7 (9%) 5 (12%) 2 (5%)
    II 10 (12%) 6 (15%) 4 (10%)
    III 13 (16%) 7 (17%) 6 (14%)
    IV 14 (17%) 7 (17%) 7 (17%)
    Unknown 38 (46%) 16 (39%) 22 (54%)
Mouth opening 0.207d
    Inadequate 7 (9%) 6 (15%) 1 (2%)
    Adequate 34 (41%) 18 (44%) 16 (39%)
    Unknown 41 (50%) 17 (41%) 24 (59%)
Hyo/thyromental distance 1.000 c
    Insufficient 5 (6%) 3 (7%) 2 (5%)
    Sufficient 35 (43%) 21 (51%) 14 (34%)
    Unknown 42 (51%) 17 (42%) 25 (61%)
Endotracheal tube type 0.072 c
    Wire 32 (39%) 18 (44%) 14 (34%)
    Straight 4 (5%) 4 (10%) 0
    Curved 7 (8%) 2 (5%) 5 (12%)
    Unknown 39 (48%) 17 (41%) 22 (54%)
Orotracheal intubation 0.043 d *
    C-MAC laringoscope 7 (9%) 1 (3%) 6 (15%)
    Laryngoscope 60 (73%) 35 (85%) 25 (61%)
    Unknown 15 (18%) 5 (12%) 10 (24%)
ASA = American Society of Anaesthesiologists; COVID-19 = Coronavirus infectious disease 19; CRT = chemo-radiotherapy; RT = radiotherapy; TS = 
tracheostomy
a = T test, b= Mann-Whitney U-test, c= hi-square test, d= Fisher exact test
Radiol Oncol 2024; 58(4): 556-564.
Jensterle S et al. / Tracheostomy and COVID-19 561
significant difference demonstrated (p = 0.806). 
Furthermore, there was no statistically significant 
difference in relevance to the general anaesthesia 
(p = 1.000), either, as before the era of COVID-19, TS 
was performed under general anaesthesia in 95% 
(39/41) and during the pandemic in 93% (38/41) of 
patients.
Nevertheless, Table 2 gives us insight into some 
differences between the two groups, with the most 
prominent ones implicated through endotrache-
al intubation. A trend of less frequent use of the 
straight orotracheal tube during the pandemic 
(0%, 0/41) in comparison to the time prior to the 
COVID-19 (10%, 4/41) outbreak has been noted. 
There is an increase in the use of the curved tube 
from 5% (2/41) to 12% (5/41), the difference is, how-
ever, not statistically significant (p = 0.072). The 
change in implementation of the C-MAC video-
laryngoscope proved to be statistically signifi-
cant (p = 0.043). Before COVID-19, it was used in 
3% (1/41) of cases and in 15% (6/41) of cases during 
COVID-19.
A comparison of patients with HNC 
regarding the period before and during 
COVID-19 
Since some of the risk factors are specific for pa-
tients with HNC (such as prior RT and CRT) and 
not for patients with other diseases, another com-
parison was made. This included 51 patients with 
HNC, 26 of whom were in the study group and 25 
in the control group. The results are depicted be-
low in Table 3.
There were no differences in the primary tu-
mour sites between the two periods. Nevertheless, 
we observed a trend of higher incidence in the in-
vasion of hypopharynx in the study group as op-
posed to the control group (39% vs. 12%, p = 0.052).
There was also a significant rise in the use of 
C-MAC during COVID-19, from 4% to 23% (p = 
0.047).
Discussion
The first hypothesis
Throughout the study period, the TS due to ARD 
caused by UAO was performed in 72% as an emer-
gency surgical procedure. The rates of emergent TS 
before and during the COVID-19 pandemic were 
71% and 73%, respectively. This difference did not 
attain statistical significance. Therefore, our first 
hypothesis stating that “during the pandemic there 
were more TS performed in the emergent setting” was 
rejected.
During the epidemic, access to sport and out-
door activities was severely limited. As physical 
activity diminished, the average body mass index 
rose from 24,2 to 27,6 kg/m2, so not significantly. 
Similarly, patients’ access to their general prac-
titioners was also limited so patients received no 
regular medical attention. The cancers, inflam-
mations and other medical conditions progressed 
unimpededly leading to higher stages of diseases 
and more clinical problems when patients finally 
found their way to their doctors. In this way, the 
suboptimal accessibility of general practitioners 
could explain the (not significantly) decreased 
width of the airway – from 2.5 to 2.2 mm at the 
narrowest point of the airway. An elevated BMI 
and decreased width of airways led us to expect 
a higher rate of difficult intubations and emergent 
TS in COVID-19 on account of the urgent ones. 
However, this was not the case, as the difference 
did not emerge as significant.
For the same reasons, more patients with CICV 
situations were expected. The literature offers two 
options to treat ARD in a CICV scenario: CTT and 
TS.8 In emergent situations, otorhinolaryngolo-
gists, as a general rule, prefer TS, which is sup-
ported by our results – 93% of patients received 
TS, whereas only 7% received CTT, which was 
then immediately converted into TS. The deci-
sion for (a more complicated, longer and riskier) 
TS as opposed to a (technically less demanding 
and speedier) CTT in the emergent setting is sur-
prising. Moreover, The Advanced Trauma Life 
Support (ATLS) guidelines recommend CTT in 
an emergency CICV situation.9 Nevertheless, the 
otorhinolaryngologists are trained in emergent 
surgical airway management very early on in their 
careers, so the educational goals in the residency 
programmes prepare them to perform TS within 
a few minutes.4,10 This actually means that the 
otorhinolaryngologists are more experienced in 
performing TS than CTT explaining the low rate 
of CTT on account of TS in an emergency setting. 
However, for all other specialists who may not 
have TS in their residency programme, the CTT is 
suggested followed by the referral of the patient to 
the closest otorhinolaryngological unit.
There was an equal rate of CTT during both 
periods – 7%. A higher rate was expected during 
COVID-19 as the Slovenian national guidelines for 
emergent TS during the era of COVID-19 advised 
CTT as the first step in emergent TS.4 However, the 
guidelines target a CICV situation in COVID-19 
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Jensterle S et al. / Tracheostomy and COVID-19562
patients or those with an unknown COVID-19 sta-
tus. Since the incidence of true CICV situations is 
only 0.4%11 the amount of CTT performed before 
and during COVID-19, remained the same.
The second hypothesis
The TS were performed over the entire four-year-
long period, mainly under general anaesthesia 
– in 94% of cases. Again, there are no statistically 
significant differences demonstrated in the peri-
ods before or during the pandemic, where general 
anaesthesia was used in 93% and 95% of cases, 
respectively. Therefore, our second hypothesis 
claiming that “during COVID-19 more TS were per-
formed in the general anaesthesia” was also rejected.
Irrespective to the studied periods, we noticed 
a significantly higher percentage of TS under gen-
eral anaesthesia as compared to reports from the 
literature.12,13 At first, TS under local anaesthesia is 
TABLE 3. A comparison of the risk factors in patients with HNC before and during the COVID-19 outbreak in Slovenia
Risk Factor Overall
Before the 
Outbreak of 
COVID-19
During the 
Pandemic of 
COVID-19
p value
All Patients 51 25 26
Patients
    Age (years)
    mean, range
66.2
(28–88)
64.6
(28–88)
67.8
(42–87) 0.374 
a
    Male sex 44 (86%) 22 (88%) 22 (85%) 1.000 d
Primary site 0.365 c
    Laryngeal cancer 24 (47%) 12 (48%) 12 (46%)
    Pharyngeal cancer 20 (39%) 8 (32%) 12 (46%)
Other cancers 7 (14%) 5 (20%) 2 (8%)
Invasion of subsites
    Glottis 21 (42%) 13 (52%) 8 (31%) 0.124 c
    Supraglottis 32 (63%) 16 (64%) 16 (62%) 0.856 c
    Subglottis 11 (22%) 6 (24%) 5 (19%) 0.743 d
    Trachea 2 (4%) 1 (4%) 1 (4%) 1.000 d
    Hypopharynx 13 (26%) 3 (12%) 10 (39%) 0.052 d
    Oropharynx 16 (31%) 10 (40%) 6 (23%) 0.193 c
    Oral cavity 8 (16%) 4 (16%) 4 (15%) 1.000 d
    Respiration Space (mm),
    mean, range
2.4 ± 1.5
(1–5)
3 ± 1.7
(1–4)
2.2 ± 1.5
(1–5) 0.714 
b
Previous treatment
    Surgery 8 (16%) 3 (12%) 5 (19%) 0.703 d
    RT 10 (20%) 4 (16%) 6 (23%) 0.726 d
    CRT 8 (16%) 4 (16%) 4 (15%) 1.000 d
Surgery
    Time-dependent aspect of TS 0.806 c
    Emergent 34 (67%) 16 (64%) 18 (69%)
    Urgent 17 (33%) 9 (36%) 8 (31%)
    Orotracheal intubation 0.047 d *
    C-MAC 7 (14%) 1 (4%) 6 (23%)
    Laryngoscope 38 (74%) 22 (88%) 16 (62%)
Unknown 6 (12%) 2 (8%) 4 (15%)
COVID-19 = coronavirus infectious disease 19; CRT = chemo-radiotherapy); RT = radiotherapy, TS = tracheostomy
a = T test, b = Mann-Whitney U-test, c = hi-square test, d = Fisher exact test
Radiol Oncol 2024; 58(4): 556-564.
Jensterle S et al. / Tracheostomy and COVID-19 563
much more unpleasant and uncomfortable for the 
patient as well as for the surgeon. Furthermore, the 
dyspnoeic, restless and hypoxic patients frequent-
ly do not cooperate with the surgical team and 
impede the course of the surgery. In addition, the 
opening of the trachea results in the generation of 
aerosol potentially transmitting the SARS-CoV-2 
and/or other diseases to the health personnel.4,5 To 
conclude, TS under local anaesthesia is associated 
with a great many issues and is, therefore, avoided. 
This applies to all patients and does not depend on 
the presence of the COVID-19.
Secondly, with the advent of sophisticated 
equipment such as C-MAC, the bonfils endoscope 
and procedures such as transnasal awake fiber-
optic intubation11,14, the endotracheal intubation 
almost always succeeds. This would explain the 
high rate of implementation of general anaesthe-
sia in TS. Therefore, TS under local anaesthesia is 
reserved only for occasional occurrences of CICV.
Thirdly, as TS under general anaesthesia gener-
ates less aerosol due to the surgical technique ad-
justment, we expected fewer TS under local anaes-
thesia during COVID-19. We attribute the lack of 
the expected difference to the fact that there were 
not many CICV occurrences in the studied period, 
as they are rare, per se.11 According to the Slovenian 
guidelines in the case of an occurrence of CICV in 
COVID-19, CTT under general anaesthesia is pro-
posed as one of the essential steps of the emergent 
TS in patients with COVID-19.4,15 CICV incidence 
was not determined in our study, however, with an 
incidence of 0.4% from the literature11, we expected 
only occasional CICV cases.11,16,17
Other comparisons
In the majority of OTI, a wire tube was used (32 
patients, 39%), which is also recommended in sur-
gical procedures and difficult intubations.18 There 
was a trend demonstrating the less frequent use 
of the straight tube (10% vs. 0) and more frequent 
use of the curved endotracheal tubes (5% vs. 12%) 
during the pandemic. The preference for curved 
tubes during COVID-19 could be explained by its 
convenient use in combination with C-MAC, espe-
cially in the case of a difficult intubation. Curved 
tubes reduce the risk of obstruction due to folding, 
in comparison to a straight tube. The diversity of 
tube types in the study could also be attributed to 
various anaesthesiologists being involved in emer-
gent TS and therefore a deviation from regular in-
tubation protocol. 
The increased use of C-MAC during COVID-19 
proved to be statistically significant, as it rose from 
3% to 15%. What is more, it was also considered 
statistically significant during a separate analy-
sis of patients with HNC (4% vs. 23%). This can be 
attributed to international guidelines, which rec-
ommend C-MAC video-laryngoscopes in patients 
with confirmed or suspected COVID-19 since it 
enables a further and, consequently, safer dis-
tance between the anaesthesiologist’s face and pa-
tient’s mouth, therefore minimising the anesthe-
siologist’s exposure to the contaminated aerosol.19 
Video laryngoscopes enable the anaesthesiologist 
to execute the intubation and observe the insertion 
of the tip of the tube on a monitor rather than look-
ing directly into the patient’s airway. An addition-
al benefit to this method is the shorter intubation 
time required.18
An interesting trend was also noted from the 
perspective of tumour subsites invasion. After the 
separate analysis of patients with HNC, we noted 
an increase in HNCs invading the hypopharynx. 
This rose from 12% in the control group to 39% in 
the study group. This trend could be attributed 
to the fact that patients, due to COVID-19, sought 
medical help later, with more widely spread can-
cer.
The appearance of the SARS-CoV-2 had a sig-
nificant impact on the management of UAO, both 
in Slovenia and around the world. Although 
COVID-19 changed the surgical and anaesthesio-
logical perspectives of the management of ARD 
in patients with UAO, emergent TS remains one 
of the most important and time-honoured solu-
tions. The study compared the time period before 
the onset of COVID-19 to that during the epidem-
ics. Eighty-two patients were included in the study 
with 41 in each observed period.
The elderly male patients were (not significant-
ly) more often affected by ARD caused by UAO 
and required intervention more often than young-
er, female counterparts. The UAO was most often 
caused by HNC (62%), followed by patients with 
inflammatory diseases (20%) and recurrent laryn-
geal nerve palsy (16%). Among HNC, the laryngeal 
(47%) and pharyngeal cancer (39%) predominated.
Conclusions
In terms of TS, the comparison between the two 
eras (before the outbreak vs. during the COVID-19 
pandemic) revealed no significant differences nei-
Radiol Oncol 2024; 58(4): 556-564.
Jensterle S et al. / Tracheostomy and COVID-19564
ther in the proportions of emergent and urgent TS 
nor in use of general or local anaesthesia. However, 
the C-MAC video laryngoscope was (statistically 
significantly) more often used during COVID-19 
(from 3% to 15%) which goes hand in hand with 
the international anaesthesiological guidelines.
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