Key points:Covid-19 patients are often intubated for a long time, with indication to tracheotomy, at high risk for transmitting the disease.Open surgical sub-isthmic tracheotomy above the ETT cuff should always be performed on fully paralyzed patients, to minimize the airflow and aerosolisation from alveolar space.Other technical refinements described in the paper are finalized to reduce the “no seal” time from ETT cuff deflation and cannula cuff inflation, which can become shorter than 2 seconds.Risks connected to tracheotomy in Covid-19, a conceptually extremely hazardous procedure, can be significantly reduced by rational measures and teamwork.Dear Editor,Tracheotomy, more than any other procedure, increases the risk of transmission from Covid-19 patients to operators because of aerosolisation1: a cough with an opened trachea and no seal from a cuff is the worst exposure situation.We describe our experience with tracheotomy in Covid-19, analyzing steps at risk and describing technical refinements to minimize such risk.