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Airway Injuries and Tracheotomies After COVID-19

Photos show posterior glottic stenosis from long-term intubation, treated with laser excision, dilation and steroid injection. The glottic opening (on right) is much better after treatment.

Airway Injuries and Tracheotomies After COVID-19

Johns Hopkins laryngeal surgeon Simon Best sees many patients who underwent prolonged intubation from COVID-19 and who have resulting laryngeal or tracheal injuries. He also sees patients who had a tracheotomy placed, but are now recovered from COVID-19, and are eager to have their tracheotomy removed.

Early in the pandemic — between March and May of 2020 — he says, clinicians were reluctant about converting to tracheotomy in hospitalized patients with the coronavirus. “They were hesitant to perform the aerosol-generating procedure that could spread the virus to providers when they couldn’t confirm its benefits for the patient,” says Best. “At the time, we did not know if tracheotomy was the best course of treatment.”

As a result, a large number of patients hospitalized with pneumonia from COVID-19 were intubated for more than 10 days. “It’s well-known that if an endotracheal tube is in long enough, there’s going to be a percentage of people who will have damage to the trachea,” says Best. “We’ve seen this in many patients who had breathing tubes for COVID-19 in those first months.” Injuries include granulation tissue that can be removed with laser surgery and steroid injections, glottic stenosis treated with dilation or stents, as well as critical tracheal stenosis that requires tracheal resection, he says.

While shortness of breath can be a residual symptom from a respiratory illness, breathing issues can also be due to any of these types of injuries, says Best. For patients who have breathing difficulties a month or more after extubation, Best performs an airway assessment using a flexible laryngoscopy to look for upper airway damage.


“There may be an anatomic reason, separate from the lungs, as to why patients have shortness of breath after having endotracheal tubes in the hospital for COVID-19,” says Best.

By June 2020, a panel of experts from the American College of Chest Physicians, the American Association for Bronchology and Interventional Pulmonology, and the Association of Interventional Pulmonology Program Directors published recommendations for performing tracheotomies in patients with COVID who were expected to require prolonged mechanical ventilation. Since then, some of the worst airway injuries have been avoided, but now Best and colleagues have been seeing a cohort of recovered COVID patients with tracheotomies.

“We have the range of expertise needed to safely remove a tracheotomy and to work with these patients for successful decannulation,” he says.

Because the aim of removal is to ensure the patient will be able to breathe well without the tracheotomy, Best evaluates the airway to confirm normal anatomy or to identify any damage to the vocal cords or trachea. If there is damage, the team addresses it beforehand.

The Johns Hopkins tracheotomy team includes otolaryngologists–head and neck surgeons, nurse practitioners, nurses, speech and swallowing pathologists, respiratory care practitioners, and other health care professionals and educators. Together, the team takes a multidisciplinary approach to ensure patients with a tracheotomy receive comprehensive care.

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