**8. Tracheostomy**

A lot of COVID 19 patients need long time ventilation that many cases will undergo tracheostomy, currently there is debate about the proper time case selection tracheostomy technique. The major indication for tracheostomy is to facilitate mechanical ventilation for a long period, while reducing complications from a trans-laryngeal endotracheal tube and weaning from ventilation. Airway obstruction, laryngeal oedema might be an emerging feature of COVID-19 which indicate urgent tracheostomy [47, 48].

When elective tracheostomy is done, an inflated tracheostomy tube cuff via which pressure support ventilation can be delivered affords a closed system for controlled weaning of respiratory support.

Tracheostomy in COVID 19 patients is like intubation a high risk for aerosol generating same consideration will apply for intuatbion however based on recent reports for tracheostomised COVID 19 patients it is recommended to use of enhanced PPE, with PAPRs(powered air-purifying respirators), eye protection, fluid-repellent disposable surgical gown, and gloves If a PAPR is not available, we advise the use of a fit-tested filtering face piece 3 (FFP3) or N95 mask with an additional fluid shield, minimizing number of people during the procedure is necessary.

Surgical tracheostomies were generally favored over percutaneous tracheostomies during the SARS outbreak, however, percutaneous techniques have subsequently advanced and no data are available to establish superiority of one approach over the other from the standpoint of infectious transmission or safety. Single-use bronchoscopes with a sealed ventilator circuit are preferable when doing percutaneous tracheostomies.

Good sedation should ensure during the procedure to avoid cough and muscle relaxant might be used.

#### **9. Extubation**

Like intubation, extubation is an aerosol generating procedure (AGPs) and need special attention in COVID 19 patients.

Specific considerations during extubation include [49]:

	- Prophylactic and anti-emetics.
	- Adequate analgesia; consider regional anesthesia. (What kind of regional anesthesia for extubation? If it is an advice for surgery it should take place above???)

Ensure good sedation before extubation. Efforts to prevent cough during extubation should be implanted including possible use of medications like Dexmedetomidine, Lidocaine, and/or opioids if there is no contraindication.
