1. Decision for tracheostomy-
The patient should have a good expectation of achieving complete recovery.

• Tracheostomy is indicated in laryngeal injury, trauma or dysfunction, ventilator associated pneumonia, ventilator associated respiratory muscle atrophy, cumulative effect of sedation etc.
• Tracheostomy is not recommended in patients who still need high ventilator requirements, high fractions of inspired oxygen (FiO2), multi-organ failure and who might require prone positioning.

2. Timing For Tracheostomy- Tracheostomy should be delayed for at least 10 days after ventilator support.

3. Place for tracheostomy- Whenever possible tracheostomy should be performed in the operation theatre. The Operating room should have negative pressure environment with high frequency air changes (25 per hour) and separate ventilating system with integrated high efficiency particulate air (HEPA) filter.

4.Staff Preparation- - All staff must wear Personal protective equipment (PPE) like cap, Powered Air Purifying Respirator (PAPR), eye protection, face shield, fluid-repellent disposable surgical gown, double gloves and shoe cover.

5. Equipment for Tracheostomy-The equipment includes cuffed non-fenestrated tracheostomy tubes of appropriate sizes and HME (simple heat and moisture exchange filter) with viral filter. Ensure only closed in-line suction is used for ETT (Endotracheal Tube) and tracheostomy tube.

6. Tracheostomy procedure- -The patient lies in supine position with hyper-extended head and face

Before opening of trachea

• Confirm full paralysis throughout to reduce risk of cough.
• Pre-oxygenate with PEEP (Positive End Expiratory Pressure) then stop ventilation and turn off flows.
• Allow time for passive expiration with open APL (Adjustable Pressure Limiting) valve and consider clamping of the ETT then advance cuff beyond proposed tracheal window.
• Hyperinflate cuff and re-establish oxygenation with PEEP.

Creating tracheal window

• Tracheal window is made as much cranially as possible (e.g. 1st or 2nd inter-tracheal space) and ensure tracheal window is of sufficient size to allow easy insertion of tracheostomy tube.
• Insert cuffed, non-fenestrated tracheal tube through the tracheal window and inflate tracheostomy tube cuff immediately and resume ventilation.
• Secure tube with sutures and tracheostomy tapes.

7.Secure tube with sutures and tracheostomy tapes.

8. Post-operative care

• Humidified oxygen is avoided if possible, instead HME (simple heat and moisture exchange filter) are used.
• Use only in line closed suction circuits at all times.
• Periodic check of cuff pressures- pressures is maintained at 20-30 cm of H2O and checked every 12 hours. Dressings should not be changed unless there are frank signs of infection.
• First tube change is done after 10 days and subsequent planned tube changes at 30 days interval.
• If patient is confirmed COVID negative, then the patient is moved to a COVID negative ward and then considered trials of cuff deflation.
• To prevent the spread of aerosol, face masks and tracheostomy shields are used.