LAUSR

Despite significant progress in our understanding of COVID-19 critical illness, a standardized approach to tracheostomy care remains elusive. Questions remain about candidacy, optimal timing, preferred insertion technique, and best practice in subsequent management. The pandemic’s rapid global spread and constant shapeshifting—due to both emergence of variants as well as different environs—has meant that the answers to these questions were unknown at the outset, were challenging to work out as the pandemic has unfolded and were not amenable to the prospective multinational investigations necessary to address them. As a result, guidance was primarily based on local experience and expert opinion. Sood et al in this issue of the Journal of Intensive Care Medicine describe their multidisciplinary experiences of managing an early cohort of patients in their tertiary ICU who required tracheostomy. This single-center experience, while bounded by some of the necessary constraints of pandemic investigations, affords a fleeting glimpse of possibilities on the horizon for enhancing outcomes in this population. These small steps in the right direction lay the path for large-scale efforts to improve tracheostomy care. The University of Massachusetts team describes their multidisciplinary approach to tracheostomy care in critically ill patients. Their practices are described in detail, and patient outcomes were favorable relative to other early pandemic experiences in the United States, with data collection until July 2020. The patient demographics, indications, and timing of tracheostomy are in keeping with most reports from this period; however, their center may not have experienced surges of the same magnitude seen in COVID hot spots in the United States and worldwide, as suggested by the relatively modest cohort size of 37 patients. The consideration of hospital capacity strain is a critical one and affords important lessons. In centers that were overwhelmed by surges, the outcomes were often demonstrably poorer. Both in the ICU and the broader hospital, a rapid spike in critically ill patients induces seismic shifts in personnel, equipment, and physical space. Crisis standards of care may interfere with the normal, or standard, level of care to patients and affect critical care outcomes; it may also require reallocation of regional resources, assuming a relative surplus of resources at other areas less acutely affected. Prior to the pandemic, the outcomes of early versus late tracheostomy were investigated in several randomized clinical trials, and the pandemic added new urgency to question of optimal timing.3–5 The data demonstrate that earlier tracheostomy can bring several important benefits to the patient and the healthcare system: tracheostomy reduces sedation requirements, decreases requirement for invasive ventilation, shortens ICU length of stay, decrease incidence ventilatorassociated pneumonia, and alleviates risk of laryngeal injury associated with prolonged trans-laryngeal intubation of the trachea. Notably, tracheostomy also eases the burden on critical care resources during surges. These benefits must be counterbalanced against the consideration that tracheostomy insertion is an aerosol-generating procedure, posing potential risks to operators and attending healthcare teams. Delaying tracheostomy for up to 10 days after intubation has been hypothesized to benefit staff by