**10. Extubation technique**

aerosols and contamination [46], Front neck kit should be available immediately in case needed however it is better keep nearby the room not inside to avoid

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

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

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,

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 percuta-

Good sedation should ensure during the procedure to avoid cough and muscle

Like intubation, extubation is an aerosol generating procedure (AGPs) and need

i. Strategies for supporting respiration after extubation, such as noninvasive ventilation (NIV) and high-flow nasal oxygen (HFNC), are relatively contraindicated because of their ability to aerosolize SARS-CoV-2

iv. Personal protective equipment (PPE) with airborne precautions is required during extubation and for personnel entering the room for a variable period

ii. Extubation should ideally take place in a negative pressure room, if

iii. All non-essential staff should exit the room before extubation.

of time after extubation, dependent on room ventilation.

minimizing number of people during the procedure is necessary.

Specific considerations during extubation include [49]:

contaminate it.

**8. Tracheostomy**

urgent tracheostomy [47, 48].

neous tracheostomies.

relaxant might be used.

available.

**14**

special attention in COVID 19 patients.

**9. Extubation**

controlled weaning of respiratory support.

*Special Considerations in Human Airway Management*

Many techniques have been described to minimize exposure to aerosols during extubation although no clear evidence behind them [50].

