Timing
We opted for late tracheostomies for two reasons. International
experience of the care of intubated patients with COVID-19 pneumonia
describes a patient group with complex ventilatory requirements,
unpredictable trajectory and high acuity. Performing a tracheostomy
early in the course of the illness appeared to confer high risk to the
patient with questionable benefit [3]. Given the poor outcomes for
many COVID-19 patients demonstrated internationally, it appeared prudent
to delay tracheostomy until patients have survived the acute period, to
avoid operating on patients who are unlikely to survive and exposing the
theatre teams to unnecessary risk [5,6]. Furthermore performing
early tracheostomies in these patients exposes the operating team to
risk of exposure at a time SARS-CoV-2 viral load is likely to be higher.
Although there is a risk of subglottic stenosis from prolonged
intubation, this is thought to be only 1-2% with the low pressure cuffs
now in common use [4].