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].