To the Editor We read with great interest the study of Berges et al1 and congratulate them for quantifying the particles emitted during tracheostomy and tracheostomy care to evaluate the contamination risk for health care workers. This method is probably the most objective to evaluate the particle dissemination and the efficiency of protective measures.

The authors found that combination of heat moisture exchangers with surgical masks helped to decrease aerosolization during tracheostomy care in a tracheostomy manikin model. However, it is essential to recall that the use of such protective devices is associated with a risk of secondary aerosolization following device withdrawal.2 This risk led to the proposal of other means of protection (such as boxes with suction) that should be similarly evaluated.

The authors also found that electrocautery increased total aerosolized particles during surgery in a swine model.1 However, caution must be observed when interpreting particle quantification because the precise risk associated with cautery use is still not known. The additional aerosol does not necessarily contain viable viral material. In fact, the particle emission coming from the respiratory tract—with leaks in the ventilation system during the tracheostomy procedure—is very likely the most dangerous. The experiments conducted by Berges et al1 were performed without mechanical ventilation; therefore, only the aerosolization induced by cautery and suction can be evaluated. Thus, the actual aerosolization during the whole procedure might be even superior to what is estimated here. This is why it is necessary to recall—in addition to the protective equipment recommended by the authors—the precautions to be taken to minimize aerosol leaks in a COVID-19 context. During the surgical procedure, it is of utmost importance to advance the endotracheal tube into the trachea to put the cuff below the site of tracheal incision,3 perform the procedure with the patient under complete paralysis to avoid cough, and perform an end expiratory pause during the phases that are dangerous for health care workers.4 In addition, room ventilation settings can considerably modify the risk for health care workers. If the room ventilation is fewer than 12 air changes per hour, it is insufficient to protect health care workers from aerosols and the use of a mobile device is recommended.5

Therefore, we regret that the authors did not integrate these adaptations and suggest that the method used by Berges et al1 should be applied more broadly for the evaluation of protective measures against aerosolization.

Corresponding Author: Valentin Favier, MD, Department of Otolaryngology–Head and Neck Surgery, University Hospital of Montpellier, 80 Ave Augustin Fliche, 34090 Montpellier, France (valentin_favier@hotmail.com).

Published Online: November 4, 2021. doi:10.1001/jamaoto.2021.3224

Conflict of Interest Disclosures: None reported.

2.Favier  V, Grimmer  L, Florentin  A, Gallet  P.  Withdrawal of protective equipment for nasolaryngoscopy may be at risk of secondary aerosolization.   Otolaryngol Head Neck Surg. 2021;194599821991084.PubMedGoogle Scholar4.Michetti  CP, Burlew  CC, Bulger  EM, Davis  KA, Spain  DA; Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma.  Performing tracheostomy during the Covid-19 pandemic: guidance and recommendations from the Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma.   Trauma Surg Acute Care Open. 2020;5(1):e000482. doi:10.1136/tsaco-2020-000482PubMedGoogle Scholar