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4.
Indian J Otolaryngol Head Neck Surg ; : 1-5, 2020 Nov 09.
Article in English | MEDLINE | ID: covidwho-1616248

ABSTRACT

Background This study outlines the unique modifications to surgical tracheostomy procedure to combat the extraordinary situation the world has found itself in due to COVID 19 pandemic. We explain the modifications employed to the operative setup, anesthetic considerations and surgical procedure to enable us to provide timely and safe tracheostomy to the COVID ICU patients requiring it, while simultaneously maximally protecting our surgical personnel from the deadly exposure. Methods- We conducted 55 surgical tracheostomies in severely sick ICU patients with the modifications deemed fit to achieve safe procedure for both the patient and the operating team. We analyzed the hospital record data of these patients and the surgical teams COVID 19 status to assesss the efficacy of our procedural modifications. Discussion- The COVID 19 pandemic has thrown the entire medical fraternity into a dilemma as to how to provide the best possible care to the patients while protecting ourselves from its grip. Severely sick COVID patients often require tracheostomy for improved prognosis. We performed bedside open surgical tracheostomy and induced transient apnoea periprocedur along with carinal intubation. By making these simple and cost effective modifications to the procedure, we have ensured that patients get tracheostomised as and when required but not at the cost of the health and lives of our health care workers.

5.
Crit Care Med ; 49(7): 1058-1067, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1494030

ABSTRACT

OBJECTIVES: To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN: Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING: Critical care units at two large metropolitan hospitals in New York City. PATIENTS: Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS: Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS: Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS: In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.


Subject(s)
COVID-19/therapy , Respiration, Artificial , Tracheostomy/methods , Aged , Cohort Studies , Critical Care , Dilatation/methods , Female , Humans , Male , Middle Aged , New York City/epidemiology , SARS-CoV-2 , Time Factors
6.
Head Neck ; 42(7): 1392-1396, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-1384168

ABSTRACT

The severe acute respiratory syndrome (SARS)-CoV-2 pandemic continues to produce a large number of patients with chronic respiratory failure and ventilator dependence. As such, surgeons will be called upon to perform tracheotomy for a subset of these chronically intubated patients. As seen during the SARS and the SARS-CoV-2 outbreaks, aerosol-generating procedures (AGP) have been associated with higher rates of infection of medical personnel and potential acceleration of viral dissemination throughout the medical center. Therefore, a thoughtful approach to tracheotomy (and other AGPs) is imperative and maintaining traditional management norms may be unsuitable or even potentially harmful. We sought to review the existing evidence informing best practices and then develop straightforward guidelines for tracheotomy during the SARS-CoV-2 pandemic. This communication is the product of those efforts and is based on national and international experience with the current SARS-CoV-2 pandemic and the SARS epidemic of 2002/2003.


Subject(s)
Clinical Decision-Making , Coronavirus Infections/epidemiology , Hospital Mortality/trends , Pandemics/statistics & numerical data , Pneumonia, Viral/epidemiology , Severe Acute Respiratory Syndrome/therapy , Tracheotomy/methods , COVID-19 , Coronavirus Infections/prevention & control , Critical Care/methods , Elective Surgical Procedures/methods , Elective Surgical Procedures/statistics & numerical data , Emergencies , Female , Follow-Up Studies , Humans , Intensive Care Units/statistics & numerical data , Internationality , Intubation, Intratracheal , Male , Occupational Health , Pandemics/prevention & control , Patient Safety , Pneumonia, Viral/prevention & control , Respiration, Artificial/methods , Risk Assessment , SARS Virus/pathogenicity , Survival Rate , Time Factors , Treatment Outcome , United States/epidemiology , Ventilator Weaning/methods
7.
JAMA Otolaryngol Head Neck Surg ; 147(7): 678-679, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1340220
8.
Ann Surg ; 274(2): 234-239, 2021 08 01.
Article in English | MEDLINE | ID: covidwho-1304022

ABSTRACT

OBJECTIVE: The aim of this study was to assess the outcomes of tracheostomy in patients with COVID-19 respiratory failure. SUMMARY BACKGROUND DATA: Tracheostomy has an essential role in managing COVID-19 patients with respiratory failure who require prolonged mechanical ventilation. However, limited data are available on how tracheostomy affects COVID-19 outcomes, and uncertainty surrounding risk of infectious transmission has led to divergent recommendations and practices. METHODS: It is a multicenter, retrospective study; data were collected on all tracheostomies performed in COVID-19 patients at 7 hospitals in 5 tertiary academic medical systems from February 1, 2020 to September 4, 2020. RESULT: Tracheotomy was performed in 118 patients with median time from intubation to tracheostomy of 22 days (Q1-Q3: 18-25). All tracheostomies were performed employing measures to minimize aerosol generation, 78.0% by percutaneous technique, and 95.8% at bedside in negative pressure rooms. Seventy-eight (66.1%) patients were weaned from the ventilator and 18 (15.3%) patients died from causes unrelated to tracheostomy. No major procedural complications occurred. Early tracheostomy (≤14 days) was associated with decreased ventilator days; median ventilator days (Q1-Q3) among patients weaned from the ventilator in the early, middle and late groups were 21 (21-31), 34 (26.5-42), and 37 (32-41) days, respectively with P = 0.030. Compared to surgical tracheostomy, percutaneous technique was associated with faster weaning for patients weaned off the ventilator [median (Q1-Q3): 34 (29-39) vs 39 (34-51) days, P = 0.038]; decreased ventilator-associated pneumonia (58.7% vs 80.8%, P = 0.039); and among patients who were discharged, shorter intensive care unit duration [median (Q1-Q3): 33 (27-42) vs 47 (33-64) days, P = 0.009]; and shorter hospital length of stay [median (Q1-Q3): 46 (33-59) vs 59.5 (48-80) days, P = 0.001]. CONCLUSION: Early, percutaneous tracheostomy was associated with improved outcomes compared to surgical tracheostomy in a multi-institutional series of ventilated patients with COVID-19.


Subject(s)
COVID-19/therapy , Pneumonia, Viral/therapy , Respiration, Artificial , Respiratory Insufficiency/therapy , Respiratory Insufficiency/virology , Tracheostomy/methods , Adult , Aged , Cross Infection/transmission , Female , Humans , Male , Middle Aged , Pneumonia, Viral/virology , Retrospective Studies , SARS-CoV-2 , Tracheotomy/methods , United States
10.
J Surg Res ; 266: 361-365, 2021 10.
Article in English | MEDLINE | ID: covidwho-1275539

ABSTRACT

BACKGROUND: Tracheostomy improves outcomes for critically ill patients requiring prolonged mechanical ventilation. Data are limited on the use and benefit of tracheostomies for intubated, critically ill coronavirus disease 2019 (COVID-19) patients. During the surge in COVID 19 infections in metropolitan New York/New Jersey, our hospital cared for many COVID-19 patients who required prolonged intubation. This study describes the outcomes in COVID-19 patients who underwent tracheostomy. METHODS: We present a case series of patients with COVID-19 who underwent tracheostomy at a single institution. Tracheostomies were performed on patients with prolonged mechanical ventilation beyond 3 wk. Patient demographics, medical comorbidities, and ventilator settings prior to tracheostomy were reviewed. Primary outcome was in-hospital mortality. Secondary outcomes included time on mechanical ventilation, length of ICU and hospital stay, and discharge disposition. RESULTS: Fifteen COVID-19 patients underwent tracheostomy at an average of 31 d post intubation. Two patients (13%) died. Half of our cohort was liberated from the ventilator (8 patients, 53%), with an average time to liberation of 14 ± 6 d after tracheostomy. Among patients off mechanical ventilation, 5 (63%) had their tracheostomies removed prior to discharge. The average intensive care length of stay was 47 ± 13 d (range 29-74 d) and the average hospital stay was 59 ± 16 d (range 34-103 d). CONCLUSIONS: This study reports promising outcomes in COVID-19 patients with acute respiratory failure and need for prolonged ventilation who undergo tracheostomy during their hospitalization. Further research is warranted to establish appropriate indications for tracheostomy in COVID-19 and confirm outcomes.


Subject(s)
COVID-19/complications , Intubation, Intratracheal/statistics & numerical data , Respiration, Artificial/statistics & numerical data , Respiratory Insufficiency/therapy , Tracheostomy/statistics & numerical data , COVID-19/mortality , COVID-19/therapy , Critical Care/methods , Critical Care/statistics & numerical data , Critical Illness , Female , Hospital Mortality , Humans , Intensive Care Units/statistics & numerical data , Intubation, Intratracheal/adverse effects , Length of Stay/statistics & numerical data , Male , Middle Aged , Prospective Studies , Respiration, Artificial/adverse effects , Respiration, Artificial/methods , Respiratory Insufficiency/etiology , Respiratory Insufficiency/mortality , Retrospective Studies , Time Factors , Time-to-Treatment/statistics & numerical data , Tracheostomy/adverse effects , Treatment Outcome , Ventilator Weaning/statistics & numerical data
11.
BMJ Case Rep ; 14(6)2021 Jun 08.
Article in English | MEDLINE | ID: covidwho-1262388

ABSTRACT

Tracheostomy is an aerosol-generating procedure and performing it in patients with COVID-19 requiring mechanical ventilation raises significant concerns of infection risk to healthcare workers. We herein report a case of tracheostomy in a critically ill patient with severe COVID-19 acute respiratory distress syndrome. This article depicts the use of personal protective equipment, highlighting the common challenges it presents and ways to address them.


Subject(s)
COVID-19 , Obesity, Morbid , Humans , Obesity, Morbid/complications , Personal Protective Equipment , SARS-CoV-2 , Tracheostomy
12.
Am J Otolaryngol ; 42(6): 103102, 2021.
Article in English | MEDLINE | ID: covidwho-1260644

ABSTRACT

BACKGROUND: Tracheostomy is one of the most common surgical procedures performed on ventilated COVID-19 patients, yet the appropriate timing for operating is controversial. OBJECTIVES: Assessing the effect of early tracheostomy on mortality and decannulation; elucidating changes in ventilation parameters, vasopressors and sedatives dosages immediately following the procedure. METHODS: A retrospective cohort of 38 ventilated COVID-19 patients, 19 of them (50%) underwent tracheostomy within 7 days of intubation (early tracheostomy group) and the rest underwent tracheostomy after 8 days or more (late tracheostomy group). RESULTS: Decannulation rates were significantly higher while mortality rates were non-significantly lower in the early tracheostomy group compared with the late tracheostomy group (58% vs 21% p < 0.05; 42% vs 74% p = 0.1, respectively). Tidal volume increased (446 ml vs 483 ml; p = 0.02) while PEEP (13 cmH20 vs 11.6 cmH2O, p = 0.04) decreased at the immediate time following the procedure. No staff member participating in the procedures was infected with SARS-CoV-2 virus. CONCLUSION: Early tracheostomy might offer improved outcomes with higher decannulation rates and lower mortality rates in ventilated COVID-19 patients, yet larger scale studies are needed. Most likely, early exposure to COVID-19 patients with appropriate personal protective equipment during open tracheostomy does not put the surgical team at risk.


Subject(s)
COVID-19/surgery , Respiration, Artificial , Tracheostomy/methods , Aged , COVID-19/mortality , COVID-19/physiopathology , COVID-19/therapy , Device Removal/statistics & numerical data , Female , Humans , Intubation, Intratracheal/statistics & numerical data , Male , Middle Aged , Retrospective Studies , Tidal Volume , Time Factors , Tracheostomy/statistics & numerical data
13.
J Oral Maxillofac Surg ; 79(8): 1629-1642, 2021 08.
Article in English | MEDLINE | ID: covidwho-1248986

ABSTRACT

PURPOSE: Approximately 3-15% of COVID-19 patients will require prolonged mechanical ventilation thereby requiring consideration for tracheotomy. Guidelines for tracheotomy in this cohort of patients are therefore required with assessed outcomes of tracheotomies. PATIENTS AND METHODS: A retrospective chart review was performed of COVID-19 patients undergoing tracheotomy. Inclusion criteria were the performance of a tracheotomy in COVID-19 positive patients between March 11 and December 31, 2020. Exclusion criteria were lack of consent, extubation prior to the performance of a tracheotomy, death prior to the performance of the tracheotomy, and COVID-19 patients undergoing tracheotomy who tested negative twice after medical treatment. The primary predictor variable was the performance of a tracheotomy in COVID-19 positive patients and the primary outcome variable was the time to cessation of mechanical ventilation with the institution of supplemental oxygen via trach mask. RESULTS: Seventeen tracheotomies were performed between 4-25 days following intubation (mean = 17 days). Seven patients died between 4 and 16 days (mean = 8.7 days) following tracheotomy and 10 living patients realized cessation of mechanical ventilation from 4 hours to 61 days following tracheotomy (mean = 19.3 days). These patients underwent tracheotomy between 4 and 22 days following intubation (mean = 14 days). The 7 patients who died following tracheotomy underwent the procedure between 7 and 25 days following intubation (mean = 18.2 days). Seven patients underwent tracheotomy on or after 20 days of intubation and 3 survived (43%). Ten patients underwent tracheotomy before 20 days of intubation and 7 patients survived (70%). Significant differences between the mortality groups were detected for age (P = .006), and for P/F ratio at time of consult (P = .047) and the time of tracheotomy (P = .03). CONCLUSIONS: Tracheotomies are safely performed in COVID-19 patients with a standardized protocol. The timing of tracheotomy in COVID-19 patients is based on ventilator parameters, P/F ratio, patient prognosis, patient advanced directives, and family wishes.


Subject(s)
COVID-19 , Tracheotomy , Humans , Respiration, Artificial , Retrospective Studies , SARS-CoV-2 , Tracheostomy
14.
JAMA Otolaryngol Head Neck Surg ; 147(7): 646-655, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1245338

ABSTRACT

Importance: Approximately 5% to 15% of patients with COVID-19 require invasive mechanical ventilation (IMV) and, at times, tracheostomy. Details regarding the safety and use of tracheostomy in treating COVID-19 continue to evolve. Objective: To evaluate the association of tracheostomy with COVID-19 patient outcomes and the risk of SARS-CoV-2 transmission among health care professionals (HCPs). Data Sources: EMBASE (Ovid), Medline (Ovid), and Web of Science from January 1, 2020, to March 4, 2021. Study Selection: English-language studies investigating patients with COVID-19 who were receiving IMV and undergoing tracheostomy. Observational and randomized clinical trials were eligible (no randomized clinical trials were found in the search). All screening was performed by 2 reviewers (P.S. and M.L.). Overall, 156 studies underwent full-text review. Data Extraction and Synthesis: We performed data extraction in accordance with Meta-analysis of Observational Studies in Epidemiology guidelines. We used a random-effects model, and ROBINS-I was used for the risk-of-bias analysis. Main Outcomes and Measures: SARS-CoV-2 transmission between HCPs and levels of personal protective equipment, in addition to complications, time to decannulation, ventilation weaning, and intensive care unit (ICU) discharge in patients with COVID-19 who underwent tracheostomy. Results: Of the 156 studies that underwent full-text review, only 69 were included in the qualitative synthesis, and 14 of these 69 studies (20.3%) were included in the meta-analysis. A total of 4669 patients were included in the 69 studies, and the mean (range) patient age across studies was 60.7 (49.1-68.8) years (43 studies [62.3%] with 1856 patients). We found that in all studies, 1854 patients (73.8%) were men and 658 (26.2%) were women. We found that 28 studies (40.6%) investigated either surgical tracheostomy or percutaneous dilatational tracheostomy. Overall, 3 of 58 studies (5.17%) identified a small subset of HCPs who developed COVID-19 that was associated with tracheostomy. Studies did not consistently report the number of HCPs involved in tracheostomy. Among the patients, early tracheostomy was associated with faster ICU discharge (mean difference, 6.17 days; 95% CI, -11.30 to -1.30), but no change in IMV weaning (mean difference, -2.99 days; 95% CI, -8.32 to 2.33) or decannulation (mean difference, -3.12 days; 95% CI, -7.35 to 1.12). There was no association between mortality or perioperative complications and type of tracheostomy. A risk-of-bias evaluation that used ROBINS-I demonstrated notable bias in the confounder and patient selection domains because of a lack of randomization and cohort matching. There was notable heterogeneity in study reporting. Conclusions and Relevance: The findings of this systematic review and meta-analysis indicate that enhanced personal protective equipment is associated with low rates of SARS-CoV-2 transmission during tracheostomy. Early tracheostomy in patients with COVID-19 may reduce ICU stay, but this finding is limited by the observational nature of the included studies.


Subject(s)
COVID-19/transmission , Infectious Disease Transmission, Patient-to-Professional , Pneumonia, Viral/transmission , Tracheostomy , COVID-19/prevention & control , Humans , Personal Protective Equipment , Pneumonia, Viral/prevention & control , Pneumonia, Viral/virology , SARS-CoV-2
15.
Am J Otolaryngol ; 42(6): 103090, 2021.
Article in English | MEDLINE | ID: covidwho-1242863

ABSTRACT

INTRODUCTION: Currently we are faced with countless patients with prolonged invasive mechanical ventilation as a result of the COVID-19 pandemic, with the consequent increase in the need for tracheostomies and the risks that this includes for both patients and staff. OBJECTIVE: It is necessary to establish a safety protocol for the performance of percutaneous tracheostomies in order to reduce the associated infections. MATERIAL AND METHODS: 77 patients underwent tracheostomies between March 2020 and March 2021, evaluating the safety of the protocol and the rate of contagion among the staff. RESULTS: Percutaneous tracheostomy was performed according to the protocol in 72 patients, 5 were excluded due to unfavorable anatomy or other reasons. There were no cases of SARS COVID-19 contagion among health personnel attributable to the procedure during the three-week follow-up period. There were no surgical complications in this series. CONCLUSION: The authors recommend implementing security protocols such as the one discussed in this work, given its low contagion rate and ease of implementation.


Subject(s)
COVID-19/prevention & control , COVID-19/transmission , Tracheostomy/adverse effects , COVID-19/epidemiology , Female , Follow-Up Studies , Humans , Male , Medical Staff/statistics & numerical data , Risk , Safety , Time Factors , Tracheostomy/methods
16.
Laryngoscope ; 131(12): E2849-E2856, 2021 12.
Article in English | MEDLINE | ID: covidwho-1242750

ABSTRACT

OBJECTIVE: Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN: Review of prospectively collected data. METHODS: Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS: One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION: Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2849-E2856, 2021.


Subject(s)
COVID-19/therapy , SARS-CoV-2 , Tracheostomy/methods , Aged , Airway Extubation/mortality , Airway Extubation/statistics & numerical data , COVID-19/mortality , Cause of Death , Conscious Sedation/mortality , Conscious Sedation/statistics & numerical data , Female , Humans , Male , Middle Aged , New York City/epidemiology , Prospective Studies , Respiration, Artificial/mortality , Respiration, Artificial/statistics & numerical data , Time Factors , Tracheostomy/mortality , Treatment Outcome , Ventilator Weaning/mortality , Ventilator Weaning/statistics & numerical data
17.
Acute Med Surg ; 8(1): e662, 2021.
Article in English | MEDLINE | ID: covidwho-1233166

ABSTRACT

AIM: An early tracheostomy is often considered for patients with veno-venous extracorporeal membrane oxygenation (VV-ECMO). However, there is no consensus on the timing of a tracheostomy in patients on VV-ECMO for coronavirus disease 2019 (COVID-19). The present report described the optimal timing of tracheostomy for these patients. METHOD: The present study was a single-center case series. We retrospectively reviewed the medical records of nine consecutive patients who underwent tracheostomy either during or after VV-ECMO treatment in our center between January 1, 2020 and December 31, 2020. RESULTS: All the patients received a percutaneous dilatational tracheostomy, which was performed during VV-ECMO in four patients. Three of these patients experienced hemorrhagic complications, and the remaining patient required a circuit change on the day after the operation. Heparin was discontinued 8 h preoperatively and resumed 1-14 h later. The platelet count was below normal in two patients, but no transfusion was performed. APTT was almost normal, and D-dimer was elevated postoperatively. The remaining five patients received a tracheostomy after weaning off VV-ECMO, and no complication was observed. Eight patients were deeply sedated during VV-ECMO to prioritize lung rest and prevent infecting the healthcare workers. CONCLUSION: In the present study, patients who underwent a tracheostomy during VV-ECMO tended to have more hemorrhagic complications. Because an early tracheostomy during ECMO has little benefit for patients with COVID-19, it should be performed after weaning off VV-ECMO to protect the safety of the healthcare workers concerned.

20.
Cureus ; 13(4): e14345, 2021 Apr 07.
Article in English | MEDLINE | ID: covidwho-1217167

ABSTRACT

Tracheostomies are often utilized in critically ill patients on prolonged mechanical ventilation, to enhance respiratory function and facilitate ventilator weaning. Many coronavirus disease 2019 (COVID-19) patients develop serious respiratory illness requiring ventilator management. In the early phase of this pandemic, the risk of disease spread lead to the development of conservative guidelines which advocated delaying tracheostomy at least two to three weeks from intubation and, preferably, with negative COVID-19 testing. The morbidly obese patient population, however, presents a unique scenario in which early tracheostomy may be beneficial. In this article, we discuss our institution's current practices along with clinical outcomes with reference to intensive care literature and propose that early tracheotomy in COVID-19 patients should be considered on a case by case basis.

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