In this month's Editorial, we have chosen to highlight an article by Takhar et al., published in this month's issue.^{Reference Takhar, Tornari, Amin, Wyncoll, Tricklebank and Arora1} This study provides one of the most comprehensive reports to date on tracheostomy outcomes in coronavirus disease 2019 (Covid-19).

Tracheostomy for weaning critically ill patients with Covid-19 who are receiving invasive mechanical ventilation remains a matter of debate.^{Reference Glibbery, Karamali, Walker, Fitzgerald O'Connor, Fish and Irune2–Reference Volo, Stritoni, Battel, Zennaro, Lazzari and Bellin4} Controversy exists regarding timing, outcomes, prognosis, and optimal technique (open vs percutaneous vs hybrid techniques) to reduce aerosol generation and risk of transmission to healthcare workers. The paper by Takhar et al. primarily aimed to analyse the intra–operative and post-tracheostomy outcomes in 81 patients with Covid-19 pneumonitis requiring prolonged mechanical ventilation. In addition, the authors critically sought to analyse any effect of timing of tracheostomy upon outcomes in their cohort, and report their experience of both staff and patient safety.

On univariate analysis, there was no difference in outcomes between early tracheostomy (before day 14) and late tracheostomy (day 14 or later following endotracheal intubation). The authors conclude that timing may not be the single most important factor that should determine the decision to proceed with tracheostomy, and the broader clinical picture should be considered, including markers of disease severity and levels of respiratory support. Early tracheostomy, however, may avoid the glottic complications of long-term endotracheal intubation (e.g. posterior glottis stenosis). Furthermore, the authors found that percutaneous tracheostomy techniques performed via a multidisciplinary approach, with appropriate training, were safe and optimised healthcare resource utilisation (e.g. avoiding transfer to the operating theatre). In their study, there were no identified cases of healthcare worker transmission. The authors of the study acknowledge that given the current variation in practice and outcomes, there is an urgent need for further work, to better understand the optimal timing, indications and outcomes of tracheostomy patients with Covid-19 infection.