Early Tracheostomy or Ever Tracheostomy

Has anyone had the experience of doing a tracheostomy? In some of our early cases we are approaching 3 weeks of intubation time. Initially I thought early tracheostomy was among the guidelines.
What does your institution require? Is a repeat negative test needed? Bedside vs OR? Just looking for insight.

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We’ve been discussing this as well… no clear guidance that I am aware of but am wondering if we need to consider things like running low on sedation and thus trach’ing early(er)…?

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Recommendations from the UK ENT and American Academy of Otolaryngology

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We are placing our first trach in a COVID 19 patient today. Vent day #18 and STILL COVID positive, but making progress as far as weaning (FIO2 down to 45%, peep down to 12). Issues that I had not thought of now coming up: Trach causing more aerosolization/popping off the ventilator; when the patient is ready for trach mask trial what then? Again an open airway and more aerosolization. When will an LTAC/SNF be willing to accept the patient? Obviously when COVID negative, but how long might that be? And even when COVID turns negative will an institution be willing to accept because of the basically open airway?
Should we not be offering tracheostomy to these patients at all, but guiding family into comfort care if we can’t get them extubated? Which feels wrong if the patient is making progress.
Sorry, I have no answers, no guidance.
I will continue this thread with what happens to this patient.

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At our institution we have a policy against performing trachs in positive patients in the OR, but with PAPR and a negative pressure icu room we are planning our first one Monday. She’s been on the vent for 29 days but continues to not seroconvert and has tested positive three times. (Our institution actually just received its second shipment of PAPRs this week).

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