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Cover page of the Journal of Health Sciences

 Table of Contents  
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 131-136

Performing tracheostomy on COVID-19 pediatric patients at intensive care unit: Our experiences

Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission03-Oct-2020
Date of Acceptance26-Nov-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘O’ Anusandhan University, Kalinga Nagar, Bhubaneswar 51 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_356_20

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Background: The novel coronavirus disease-2019 (COVID-19) is posing unprecedented challenges among health-care workers for managing the pediatric tracheostomy. Tracheostomy and posttracheostomy care are considered as high-risk procedures for contamination of health-care workers and other patients of the intensive care unit (ICU) in COVID-19 pandemic.
Objective: The objective of this retrospective study is to evaluate the details of pediatric tracheostomy including patients' profile, surgical steps, complications, and precautions by health-care workers at the ICU of the specially assigned hospital for COVID-19 patients.
Materials and Methods: This is a descriptive retrospective study in which 18 COVID-19 pediatric patients underwent bedside surgical tracheostomy at the ICU. Clinical patient's profiles such as age, sex, comorbidities, complication of the tracheostomy, ventilator withdrawal after tracheostomy, and nosocomial infections of the health-care professionals related to tracheostomy were analyzed.
Results: Of the 18 patients with COVID-19 infections who underwent tracheostomy, there were 11 male (61.11%) and 7 female (38.88%) with a male-to-female ratio being 17:1. The age ranged from 4 years to 18 years, with a mean age of 11.45 years. The mean duration from the day of the orotracheal intubation to the day of tracheostomy was 12 days.
Conclusion: Performing surgical tracheostomy on COVID-19 pediatric patients is a high-risk aerosol-generating procedure for health-care professionals. It should be performed with close association with pediatric otolaryngologists, anesthesiologists, and pediatric intensive care physicians along with adequate personal protective equipment for smooth and safe execution of the procedure.

Keywords: COVID-19 infection, intensive care unit, pediatric tracheostomy

How to cite this article:
Swain SK, Sahu A. Performing tracheostomy on COVID-19 pediatric patients at intensive care unit: Our experiences. Indian J Health Sci Biomed Res 2021;14:131-6

How to cite this URL:
Swain SK, Sahu A. Performing tracheostomy on COVID-19 pediatric patients at intensive care unit: Our experiences. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Apr 16];14:131-6. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/131/308966

  Introduction Top

The novel coronavirus disease-2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome corona-virus-2 (SARS-CoV-2) virus.[1] This virus is found in high abundance at the mucosa of the upper and lower respiratory tract.[2] The COVID-19 infection spreads from person to person through respiratory droplets or contact. The common symptoms of COVID-19 patients are fever, cough, fatigue, and dyspnea. Many times, the individuals are asymptomatic carriers. Currently, the hospitals and intensive care units (ICUs) are facing a surge of the COVID-19 patients requiring urgent care or invasive ventilation. Tracheostomy is one of the oldest surgical procedures performed among the critical ill patients for prolonged ventilation.[3] The patients may be in any age group, i.e., from young children to elderly persons. For several different reasons, children require tracheostomy those are at airway compromise. Although the tracheostomy is a life-saving surgical procedure, it is more challenging surgery in the pediatric age group than the adult age group. The pediatric tracheostomy may be associated with higher chances of morbidity and mortality. The chances of complications associated with pediatric tracheostomy are more in comparison to the adult or elderly age group.[2] In comparison to the adult age group, the indications for the tracheostomy remain the same for the years. However, the increased number of corvid-19 patients with compromised airway required intubation with a ventilator. The most common indication for pediatric tracheostomy includes prolonged ventilations and obstruction of the airway.[3] Till date, the profile of the pediatric trachesotomy in the COVID-19 pandemic is not reported adequately in medical literature. This study aims to evaluate the clinical profile of surgical tracheostomy on pediatric COVID-19 patients at the ICU.

  Materials and Methods Top

This a descriptive retrospective study and was done at the tertiary care teaching hospital of eastern India which attached to a 1000-bedded COVID hospital with 125-bedded ICU. This COVID hospital is one of the largest designated hospitals assigned by the state government to treat the COVID-19 patients. We retrospectively analyzed the hospitalized COVID-19 pediatric patients between March 2020 and September 2020 who underwent tracheostomy. Ethical clearance for our study was obtained from Institutional Ethical Committee, IMS&SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneswar with Ref no IEC/IMS/SOA/13/14.03.2020, dated 14.03.2020. Written informed consent was waived the ethics committee of our hospital owing to the rapid emergence of the disease. Here, all the COVID-19 pediatric patients were admitted on the basis of the positive reverse transcription–polymerase chain reaction (RT-PCR) test of the nasopharyngeal swab specimens. The age range of these pediatric COVID-19 patients who underwent tracheostomy at the ICU was from 4 years to 18 years. Before performing tracheostomy, RT-PCR was again advised to know the infectivity of the COVID-19 pediatric patients. At the time of treatment, the discussion was not done with parents or guardian for describing the risks and benefits of tracheostomy. In this study, we describe the surgical tracheostomy on ICU COVID-19 pediatric patients with ventilators. All were elective tracheostomy and done for prolonged ventilation. All were done at the bedside of these pediatric patients in the ICU of the COVID hospital. During the past 6 months, we performed 18 surgical tracheostomies on pediatric patients because of the COVID-19 infections with acute respiratory distress syndrome (ARDS) for prolonged ventilations. For performing open or surgical tracheostomy, the department of otolaryngology had established a COVID airway team constituted by three skilled otolaryngologists without involving any residents. The trachesotomy was performed with wearing adequate personal protective equipment (PPE) [Figure 1]. All the tracheostomies were done after 7 days with ventilators. In all the cases of the elective trachesotomy, the cuffed and nonfenestrated tracheostomy tubes were used for limiting the diffusion of the virus. Before performing surgical tracheostomy on COVID-19 pediatric patients, adequate sedation was given to paralyze the patient for eliminating the risk of coughing during the surgery. Initial advancement of the endotracheal tube was done prior to the window made on the anterior wall of the trachea. Ventilation was ceased before inserting the tracheostomy tube. Before inserting the tracheostomy, the cuff should be checked for any leak. All efforts were made for not piercing the cuff of the tracheostomy tube during the surgical procedure. All the surgeries were performed by senior author/consultant surgeon, a scrub nurse, and with the presence of one intensivist/anesthetist with adequate PPE to avoid transmission of the infections and also to complete the surgery in less time at the uncomfortable ICU setting. In this study, all the data were recorded and analyzed by using the Statistical Package for the Social Sciences software, v20 (IBM, Armonk, New York, USA).
Figure 1: Surgeon with personal protective equipment before performing tracheostomy

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  Results Top

The study included 18 pediatric COVID-19 patients who underwent tracheostomy where 11 males (61.11%) and 7 females (38.88%) were present with a male-to-female ratio of 1.7:1. The age ranges from 4 years to 18 years, with a mean age of 11.45 years. All of them underwent bedside surgical tracheostomy at COVID-19 hospital ICU. The mean time between the intubation and performing tracheostomy date was 12 days. Of 18 children, 4 (22.22%) were associated with comorbidities such as acute myeloid leukemia (AML) and nephrotic syndrome. Four (22.22%) of them had a history of recurrent cold/allergic rhinitis throughout the year before COVID-19 infections. Two children (11.11%) had habit of the chronic smoking. Of the four comorbid diseases, two of them were undertreatment for AML and two children were with nephritic syndrome [Table 1]. The details of the trachesotomy of this study including techniques and precautions by health-care workers and comparison with others are described in [Table 2].
Table 1: Clinical profile of coronavirus disease-2019 pediatric patients who underwent tracheostomy

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Table 2: Different case series of open tracheostomies done at the time of coronavirus disease-2019 pandemic

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The prerequisites toward for personal protections to perform the tracheostomy on study patients are given in [Table 3]. Mean time of our study pediatric patients in ICU was 23 days. No tracheostomy was done within 7 days of COVID-19 pediatric patients at the ICU with mechanical ventilation. Three patients (16.66%) presented with complications such as bleeding during the surgery as they were with therapeutic anticoagulation. In this study, except one, none of the health-care workers associated with tracheostomy and tracheostomy care were infected with COVID-19 infections. Of 18 patients who underwent trachesotomy, 8 (44.44%) died at the ICU during posttracheostomy care. The causes of the death were not related to the complications of the tracheostomy. Of 10 alive pediatric patients, one was faced weaning failure because of the deterioration of their poor cognitive status. Among the alive pediatric patients, the mean time between tracheostomy and decannulation was 23.5 days (with minimum 16 days and maximum of 31). Among dead pediatric patients, the mean time between the intubation and death was 23 days and the mean time between the tracheostomy and death was 14.6 days.
Table 3: Requisites for performing tracheostomy on coronavirus disease-2019 patients

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  Discussion Top

The coronavirus disease-2019 (COVID-19) is an infectious disease caused by SARS-CoV-2 which originated in Wuhan, China, in December 2019.[7] The COVID-19 pandemic is currently causing an untold disruption in all over the world where majority of the countries are facing the burden irrespective of their strength of their health care system. The common clinical presentations of the COVID-19 patients are cough, fever, fatigue, anosmia, taste disturbances, and dyspnea.[8] The pediatric patients often present with diseases related to the upper airway such as sinonasal infections, tonsillitis, pharyngitis, nasal foreign body, airway foreign body, otitis media, and adenoid infections. There is a disproportionately high number of clinicians specifically otolaryngologists who have been infected with COVID-19 during their patient care specifically the pediatric age group.[9] Asymptomatic pediatric patients have a high risk for viral shedding. These asymptomatic children are considered as silent carriers in this pandemic. This infection is contaminated mainly via the respiratory airway through droplets, secretions, and direct contact.[10]

SARS-CoV-2 often affects the lower respiratory airway and leads to pneumonia.[11] In the hospital setting, pediatric patients of COVID-19 infections may land in respiratory failure where he or she requires ventilatory support with orotracheal intubation and changed to tracheostomy in case of prolonged ventilation. In this study, 18 children were included who underwent trachesotomy for prolonged ventilation. There are several noninvasive methods for ventilations such as continuous positive airway pressure, bi-level positive airway pressure, and high-flow nasal oxygen therapy which are useful to correct hypoxemia and avoid the endotracheal intubation or may delay the intubation with potential complications. However, in this study, the invasive mechanical ventilation by endotracheal tube was done in all of our cases with ARDS, followed by tracheostomy. In COVID-19 patient, early intubation may be better than late .This is because late intubation of a sick child in emergency situation may result in rapid deterioration and also associated with higher risk of transmission of infection to both the health-care professionals and other patients.[12] In all cases of this study, tracheostomy was done after 7 days of intubation.

Tracheostomy is a high-risk surgical procedure during the present COVID-19 pandemic. Tracheostomy generates aerosols which easily transmits the virus to the health-care professionals and other patients.[13] The elective tracheostomy can be delayed until active COVID-19 infections have passed with consideration of the current guidelines.[14] In pediatric COVID-19 patients, tracheostomy is often required in acute respiratory failure, especially when the clinicians predict for prolonged ventilation. Health-care workers are at high risk for getting infections during this surgical procedure at the ICU. Currently doing tracheostomy on the COVID-19 patients is challenging for otolaryngologists and associated health workers at the ICU because high chance of spread of SARS-CoV-2 virus to the surrounding and also for the other patients.[15] Tracheostomy provides several advantages such as less requirements of sedations, less medical support, and also decreases the dead space of the airway. The overall surgical procedure for tracheostomy should thoroughly and appropriately planned, explained to all concerned health-care staff and executed in order for ensuring the safety of the staff and patients.[16]

Before performing surgical tracheostomy on COVID-19 pediatric patients, adequate sedation should be provided to the intubated child even paralyze for eliminating the risk of coughing during the procedure. During performing the surgical tracheostomy, there is high chance of spreading of the aerosols to the surrounding persons including surgeon so to avoid such aerosol, the endotracheal tube should be little pushed down beyond the location chosen for the tracheal stoma. The endotracheal tube should go lower down and reaches near the carina, so the cuff will be distal to the tracheostomy site. Before making an opening on trachea, pushing of the endotracheal tube lower down in trachea and the cuffed it at the site of the carina may prevent spread of the aerosol(after making opening on trachea) which provides an extra security for the health care professionals during performing the tracheostomy from high risk generating aerosol.[17] Before making an opening on the trachea, 5cc of lidocaine (5%) can be injected intratracheally through the tracheal wall for reducing the cough reflex.

The surgeon and assisting health-care professionals should remove the bracelets and other jewellery before scrubbing for the tracheostomy. The surgeon and assisting staff should wear adequate PPE with FFP3 or N95 mask, head shield, and goggles. The double gown is preferred along with gloves during surgical tracheostomy. The head protection with a hood cap is better than a simple cap to prevent any skin exposure. A full-face shield/visor or airtight protective glasses are helpful for preventing the contamination to the health-care professionals. The headlight should be covered by a head cap. An impermeable protective apron or an overcoat must be worn under the surgical gown as it is not sterile. The surgical team for the pediatric tracheostomy must ensure all the required equipments such as suction catheter, cannula, and all surgical instruments required for surgery along with cuffed appropriate size for pediatric tracheostomy tube. The use of the electrocoagulation should be minimized as it can generate the aerosolization of the virus when the trachea is open to outside.[18] A sterile transparent interface between the patient and surgeon can be used for restricting the risk of contamination. Ventilation should be paused once the opening is made on the trachea and anytime the ventilation circuit is disconnected. A nonfenestrated cuffed tracheostomy tube is helpful for preventing the spread of infections. The cuff must be inflated for limiting the spread of the virus via the upper airway. Health-care professionals or nursing staffs should perform tracheostomy suctioning by using a closed suction system with a viral filter. Heat moisture exchanger (HME) device should be used instead of tracheostomy collar during weaning for preventing the spread of the viral infections of the patients. Changing of the tracheostomy tube is avoided until the viral load is as low as possible. The tracheostomy tube is usually sutured if a prone position for patient is planned. The detail of our study is compared with other studies in terms of techniques and precautions [Table 2].[4],[5],[6]

The complications of the pediatric tracheostomy are classified into perioperative and early and late postoperative complication. The complications those are occurring in the 1st postoperative week is called as early complications and those are occurring after the 1st week is called as late complications. Some patients with tracheostomy during COVID-19 pandemic may develop complications like ulcers in the pharynx and bleeding from the stoma or tracheostomy tube which need further care by otolaryngologists. In this study, 3 pediatric patients (16.66%) developed bleeding during the surgery. Tracheostomy should be avoided or delayed even beyond 2 weeks because of the high chance of the infections during the procedure and subsequent tracheostomy care.[19] When the acute phase of infection is subsided or the likelihood of the recovery of infection is high, tracheostomy can be done for less likelihood of infection transmission. Early tracheostomy should be avoided in case of COVID-19 patients because of the higher viral load. Early tracheostomy is not related to the improved mortality or less ICU stay.[20] In all of the study cases, tracheostomies were done after 7 days of orotracheal intubation. After tracheostomy, the tube changes should be delayed till infectivity of the patient ceases.

The crust formation inside the tracheostomy tube can be minimized by doing humidification via the tube. Clinician should carefully judge the selection of the proper method of the humidification and a HME which represents an alternative to the wet circuit and may reduce the aerosol generation. Nebulizers may be avoided and the spacers with a metered dose inhaler often give an alternative technique for medication delivery to the respiratory airway. Unlike to the adult patients, pediatric tracheostomy tube has no inner cannula for removal, so without doing humidification is likely to cause occlusion of the tracheostomy tube. The occluded tracheostomy tube may disrupt the circuit at the time of the emergency and enhances chances of aerosol spread. Majority of the COVID-19 patients in ICU receive high dose of heparin infusion, so there is a high chance of bleeding during and tracheostomy.[21] In this study, children presented with bleeding during tracheostomy as they were with therapeutic anticoagulation. During the study period, we performed 18 surgical tracheostomies on the pediatric COVID-19 patients where the median timing for tracheostomy was 12 days after intubation. As the surgical/open tracheostomy is an aerosol-generating procedure and carries a high risk for contamination through exposing the airway secretions to the health-care staffs, so this surgical procedure should require a thorough plan and proper execution to ensure the safety of the staff and patient.[21] Early tracheostomy is often avoided in COVID-19 patients because of the high viral load. Early tracheostomy is also not associated with lowered mortality or reduced the stay period at the ICU.[22]

  Conclusion Top

Health-care workers are currently facing the greatest challenge to the COVID-19 infections. In the current global COVID-19 pandemic, ARDS and respiratory failure in the pediatric age group require mechanical ventilation. Prolonged ventilation is the common indications for tracheostomy at COVID-19 ICU. Tracheostomy in pediatric patients is a relatively uncommon procedure. The most common indication for pediatric tracheostomy is prolonged ventilation in the ICU of the COVID-19 hospital. Tracheostomy is considered a high-risk aerosol-generating surgical procedure because of the exposure to droplet and aerosol leakage which is infected with SARS-CoV-2 during performing this procedure. An increasing number of tracheostomy is expected because of the increased number of the COVID-19 pediatric patients globally with acute respiratory distress. The otolaryngologists and intensivists should pay meticulous attention to infection control to reduce the cross-contamination and their own risk for contracting the infection. Pediatric tracheostomy with adequate PPE helps to reduce the droplet and aerosol exposure to the surgeon and other health-care workers.

Study limitation

This study has a relatively small sample size due to the rarity of pediatric tracheostomy in COVID-19 infections which may limit the outcome of the above interpretation. Although the sample size is small, the result of this study is an important message for the public health point of view to prevent transmission of the SARS-CoV-2 infection to the health-care workers and other patients at the ICU. However, the development of the protocol and profile for tracheostomy in COVID-19 pediatric patients in this study will surely give awareness among the clinicians, pediatricians, otolaryngologists, and intensivists.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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