LAUSR

“Fog of War” aptly describes the many uncertainties that characterized the early days of the COVID-19 pandemic. Carl von Clausewitz, who is credited with the term, observed in 1832 that, “A sensitive and discriminating judgment is called for; a skilled intelligence to scent out the truth.” In von Clausewitz’s era, decisions around tracheostomy were fraught; the procedure was perilous and reserved primarily for asphyxia and acute respiratory obstruction. Mackenzie, commenting on tracheostomy in 1830, noted “The question always arises in the mind of the young [clinician] whether the symptoms are sufficiently urgent to render the operation necessary.” In 1833, Trousseau reported the outcomes of 215 tracheostomies performed for diphtheria; only 47 of the patients survived. Although the safety of tracheostomy has improved and its indications have evolved, many of the same vexing questions remain nearly 200 years later: When is the right time to perform tracheostomy? In which patients? How does tracheostomy affect outcomes?