Adolescent Tracheostomy for COVID-19 Respiratory Failure

Abstract

Pediatric tracheostomy for COVID-19 infections is uncommon and requires age-appropriate adaptations. This case adds to a limited body of literature related to tracheostomy placement and management in an adolescent. Thoughtful planning and communication by a dedicated tracheostomy team was crucial in obtaining a successful outcome.

Children are less susceptible to COVID-19 infections and typically have milder manifestations than adults. ^{1 -3} In the United States, 2% of pediatric COVID-19 cases require hospitalization, and 0.0% to 0.03% result in death. ⁴ Approximately 0.5% to 18% of hospitalized children with COVID-19 need ventilatory support ^5,6 and 2.1% need intubation. ³ This report describes an adolescent tracheostomy for COVID-19 respiratory failure and offers strategies that resulted in a safe outcome.

A 16-year-old female with a history of asthma and morbid obesity presented with 14 days of progressive dyspnea. She had no past surgical history and her mother was in intensive care at that time for COVID-19 pneumonia. Chest X-ray identified ground glass opacities and polymerase chain reaction testing was positive for severe acute respiratory syndrome coronavirus 2. She was placed on bilevel positive airway pressure with initiation of remdesivir and dexamethasone. On hospital day 4, endotracheal intubation was required for worsening respiratory distress. Veno-venous extracorporeal membrane oxygenation (ECMO) cannulation via the right internal jugular vein was initiated on day 5 for continued hypoxia. Continuous renal replacement therapy (CRRT) was subsequently needed to improve diuresis and treat metabolic alkalosis.

She continued to have low tidal volumes and ventilator dyssynchrony. Given the expectation for prolonged ECMO cannulation, a multidisciplinary team discussed tracheostomy placement. Operating room transport was considered dangerous due to aerosolization risk, body habitus, and the positionally dependent ECMO cannulas. The family consented to an open tracheostomy at the bedside that occurred on hospital day 30. A team of twelve providers included anesthesiology, critical care, ECMO specialists, operating room nursing, critical care nursing, and a tracheostomy nurse. Surgery was performed by two fellowship-trained pediatric otolaryngologists including a senior surgeon.

The procedure was notable for cervical adiposity and bleeding given heparin anticoagulation. Care was needed to protect the tenuous ECMO cannulas in the neck. Several steps were agreed upon to increase staff protection. First, endotracheal ventilation stopped prior to the vertical tracheotomy and the airway was covered with pledgets to reduce aerosolization. Right and left stay sutures were placed around the second tracheal ring along with superior- and inferior-based maturation sutures. A dual-cannula 5.0 Shiley Distal XLT 90 mm length tracheostomy tube was placed with intraluminal positioning confirmed by flexible tracheoscopy. Finally, the tracheostomy tube was secured to the skin and soft neck ties were gently applied to avoid jeopardizing the internal jugular vein catheters.

Postoperative care resulted in positioning challenges to optimize ECMO cannulas and maintain ventilation. All otolaryngology encounters occurred without trainees and relied on a small team of providers. No prone positioning was needed. Flexible tracheoscopy and tube repositioning were performed on postoperative day 2 due to back walling. Since it was a nonflextend tube, a TRACOE mini extension was placed to facilitate positioning with a ventilator circuit stabilizer to offload pressure. On postoperative day 4, she was decannulated from ECMO decreasing sedation and anticoagulation requirements. The first tracheostomy tube change commenced without difficulty on postoperative day 7, where a 5.0 Shiley Proximal XLT 90 mm length tube was placed with soft ties.

Her ventilator settings were subsequently weaned and 3 weeks after tracheostomy placement an inline speaking valve trial was successful. Inner cannula changes were performed daily and as needed. After discharge to inpatient rehabilitation, she was weaned off the ventilator. Three months after placement, she was successfully decannulated and has made a complete recovery.

Reports of tracheostomy for pediatric COVID-19 infections are scarce. In addition to less severe infections, ^{1 -3} several children-specific considerations contribute to this finding. First, the pliable cartilaginous airway, especially among neonates, tolerates longer intubation time and does not justify earlier tracheostomy to minimize airway stenosis. ^7,8 Second, pediatric tracheostomy is a high-risk procedure ⁹ with placement not amenable to percutaneous techniques and requiring experience. ^10,11 Finally, hospitalization after tracheostomy in children is often prolonged due to caregiver training and discharge barriers. ^12,13 Taken together, these factors explain why teams caring for children might cautiously approach decisions to proceed with tracheostomy.

This patient had several comorbidities contributing to respiratory distress. Severe COVID-19 infections and comorbidities have been described in pediatric intensive care unit patients. Over 85% had at least one comorbid condition, 17% had two and 19% had three or more comorbidities. ¹⁴ A meta-analysis of 285 014 children with COVID-19 found severe disease developing in 5.1% with comorbidities compared to 0.2% without. Pediatric obesity demonstrated a relative risk of 2.87 for developing severe COVID-19 infections. ¹⁵ Additionally, multisystem inflammatory syndrome in children (MIS-C) is a growing concern. In 186 children with MIS-C, cardiovascular (80%) and respiratory (70%) symptoms were most common. ¹⁶ Intensive care was required for 80%, with 20% receiving mechanical ventilation and 4% needing ECMO. ¹⁶ The index patient required ECMO and CRRT highlighting her critical condition.

The only series of pediatric tracheostomy for COVID-19 reports 18 patients from India. ¹⁷ Similar to this case, all patients had multiple comorbidities, surgeries were performed without trainees at the bedside and an experienced team ensured a safe and rapid procedure. Notably, 44% of patients died of nontracheostomy-related causes. ¹⁷ This emphasizes the need for more studies regarding the safe practices of tracheostomies in this population.

Several groups have offered strategies for pediatric tracheostomy during COVID-19. This includes draping the surgical field, stoma maturation, stay sutures, ¹⁸ and establishing a dedicated tracheostomy team. ^19,20 Techniques also included avoiding electrocautery, using closed-circuit suctioning, minimizing stoma dressing changes, and performing the first tracheostomy tube change after 10 days. ¹⁹ One group suggested multidisciplinary discussions prior to tracheostomy. ²⁰ Other management decisions include avoiding routine tracheostomy tube changes and careful use of suctioning. ²¹ We incorporated many of these steps and would add that a dual cannula tube was ideal for reducing frequent exchanges. Lastly, we advocate for a dedicated and experienced team responsible for tracheostomy care. This maintains consistency, maximizes patient safety, and minimizes staff exposure.