for diagnosis and treatment decisions, including those with lung cancer.

The societal and association guidelines have yet to undergo revisions, with the majority having been written in the rst 6 months of a now 2-year pandemic. How healthcare providers need to account for the difference in circulating strains; duration of the pandemic; and the availability, effectiveness, and utilization of, by both patients and providers, vaccines when making judgments about bronchoscopy triage and timing.

Preparing for the Next Pandemic

The COVID-19 pandemic has highlighted the need to have up-to-date and accurate information for healthcare providers to provide optimal care for those with, without, and recovering from severe respiratory viruses such as SARS- CoV-2. As the rst droplet-transmitted viral pandemic in the modern age of rapid global communication, epidemiology, and healthcare, as well as advanced bronchoscopy; information and resources infuenced all aspects of patient care. Regional, national and global differences in practice and resources also lead to differences in practices in provided care, including bronchoscopy. Initial studies about the safety and role of bronchoscopy during the COVID19 pandemic, as well as the rapid development of effective vaccines, led to additional changes in practice. As additional data in the post-pan- demic years to come is gathered and more studies complete, guidelines around bronchoscopy in airborne viral pandemics will no doubt be updated. We hope this will lead to improved outcomes, recommendations, and preparedness for the role of bronchoscopy in the next pandemic arises.

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Historical Perspective

Mechanical ventilation is lifesaving in severe respiratory failure, and few medical therapies have the same potential to rapidly stabilize critically ill patients. Mechanical ventilation may be provided via non-invasive or invasive methods, with invasive positive pressure ventilation requiring the placement of an arti cial airway. Tracheostomy is commonly performed when patients are predicted to require prolonged mechanical ventilation. The use of this procedure has increased, especially following the introduction of a bedside percutaneous tracheostomy technique in 1985 [1], such that up to one-third of patients requiring prolonged mechanical ventilation now receive a tracheostomy [2, 3]. Transitioning from orotracheal intubation to percutaneous tracheostomy provides many potential bene ts. Tracheostomy improves airway security, lessens airway resistance (even for tubes of identical inner diameter), facilitates oral care and speech, provides more effective bronchopulmonary toilet, and increases patient comfort and potentially allows reduced sedation [4]. Extensive evidence exists which guides the practice of tracheostomy placement though some of the data on timing is conficting and as such timing is also guided by institutional

L. K. Frye (*)

Division of Pulmonary and Critical Care, University

of Wisconsin, Madison, WI, USA

practices. Tracheostomy is commonly performed 7–21 days following the initiation of mechanical ventilation.

For many years, the evidence to guide the timing of tracheostomy was based on small, single center randomized controlled trials. In 2010, Terragni et al. reported the results of an Italian study, which was the rst large multicenter randomized trial of early vs. late tracheostomy [5]. Early was de ned as 6–8 days after initiation of ventilation and late was de ned as 13–15 days after intubation. Conducted in 12 intensive care units, the trial enrolled 600 patients who had undergone 24 h of mechanical ventilation. The 600 patients were followed up for another 48 h and the 419 patients (70%) who were deemed eligible for a potential tracheostomy were randomized to early or late tracheostomy. In the early group, 145 patients (69%) underwent tracheostomy, and 119 patients (57%) underwent tracheostomy in the late group. The primary end point of ventilator associated pneumonia was not different between the 2 groups. Nearly half of the late treatment group never required a tracheostomy and therefore favored the late wait-and-see strategy.

In 2013, Young et al. reported the results of a larger trial examining early vs. late tracheostomy [6]. This trial was conducted at 72 centers in the United Kingdom and randomized 909 patients who had been mechanically ventilated for less than 5 days and with the expectation to require at