COVID-19 News: How Pediatric Tracheostomy Management Helped Adult COVID-19 Patients

The pediatric tracheostomy care program developed by Susannah E. Hills, MD, in 2018 proved to be invaluable during the pandemic when Dr. Hills and her colleagues quickly transitioned their services to help the large number of hospitalized adults needing breathing support.

The creation of a tracheostomy care program for children, one of only a few such comprehensive tracheostomy programs in the country, established a standardized and consistent way to manage patients with tracheostomies in the hospital and to ensure follow-up and close monitoring after their return home. Tracheostomy can be an intermittent treatment for children until they outgrow ventilator dependence or undergo surgical correction of an anatomic obstruction to breathing. For others, tracheostomy may be a long-term part of life. 

Dr. Hills, assistant professor of otolaryngology/head & neck surgery, specializes in endoscopic airway surgery, airway reconstruction, and tracheostomy care. The program at NewYork-Presbyterian’s Morgan Stanley Children’s Hospital provides patients and their families with a support system that features a comprehensive team of specialists to promote optimal breathing, feeding, and speech/language development. A tracheostomy care coordinator helps families bridge the transition from inpatient to outpatient care.

The hospital protocols Dr. Hills and her team established for nurses, respiratory therapists, and physicians on management of pediatric tracheostomy provided a template for addressing adult COVID-19 patient care. “When the pandemic hit, we performed over 170 tracheostomies; that’s almost as many as we would do in the adult hospital in a typical year,” says Dr. Hills. “The COVID-19 pandemic demanded and inspired a team-oriented response. We came together from across our hospital system to form a tracheostomy care team in expectation of the dozens—possibly hundreds—of patients we would need to care for.”

The team included ENT surgeons, thoracic surgeons, critical care surgeons, anesthesiologists, intensive care doctors, speech and language pathologists, and respiratory therapists.

Dr. Hills led a team in postoperative management of the hospital’s tracheostomy patients, the Safe Tracheostomy Aftercare Team (STAT). “Once we had the tracheostomies in place, the challenge was keeping those patients safe.” A rotating team, including Dr. Hills, an attending surgeon, a lead physician assistant, and five volunteer medics from military special operations forces, oversaw post-tracheostomy care and developed a protocol to help patients decannulate in a safe but expedited way.

“On a typical day amid this outbreak, the rotating surgical and anesthesia teams would go from patient to patient at bedside—sometimes as many as seven or eight—surgically entering the airway and placing the tracheostomy tube,” says Dr. Hills. “The STAT team would go from bed to bed, checking on the patients that already underwent surgery, making sure their tubes were secure and that they had the supplies they need nearby.”

As patients were well enough to have their tracheostomy tubes removed, the STAT team initiated afternoon decannulation rounds, and over 60% of the COVID tracheostomy patients from the spring were able to leave the hospital breathing on their own, without a tracheostomy tube.

Dr. Hills and her team continue to follow these COVID tracheostomy patients, even months after their discharge. “We’re seeing some patients do really, really well: They’re at home, living their lives. Some are even back to work. But many others are still struggling with fatigue, shortness of breath, weak voice, neuropathy, and anxiety. It’s going to be a long road for many of them.

“Our goal was to keep patients safe after surgery and then to discharge them either to their home or more often to a rehabilitation facility without the trach tube,” says Dr. Hills. “All of our efforts on the pediatric and the adult side stem from our desire to give our patients the very best care that we possibly can and to keep them safe during their hospital stay. But we’re also striving to address all of the important issues that persist when they leave—quality-of-life issues, such as swallowing and voice and working towards decannulation—when it’s possible. Families need to be empowered with resources and education so that they don’t feel alone. If we can provide this kind of support to our patients, then I’ll consider our program a success.”