key: cord-0799671-k0r81ev9
authors: Matsumoto, Haruko; Hanada, Shigeo; Yamamoto, Kazumasa; Takaya, Hisashi
title: Endotracheal granulation after tracheostomy in acute respiratory distress syndrome from COVID‐19
date: 2021-05-26
journal: Respirol Case Rep
DOI: 10.1002/rcr2.787
sha: 4de2beb886d0ae101260bbc613c02a155c395e3a
doc_id: 799671
cord_uid: k0r81ev9

Granulation tissue formation is one of the late complications of tracheostomy. It can cause stomal stenosis secondary to chondritis because of disproportionate excision of the anterior cartilage. Clinicians should carefully determine the incision point, which is typically located half way between the cricoid cartilage and the sternal notch.

Granulation tissue formation is one of the late complications of tracheostomy. It can cause stomal stenosis secondary to chondritis because of disproportionate excision of the anterior cartilage. Clinicians should carefully determine the incision point, which is typically located half way between the cricoid cartilage and the sternal notch.

A 59-year-old man with acute respiratory distress syndrome (i.e. coronavirus disease (COVID-19)) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection underwent percutaneous tracheostomy and mechanical ventilation for three weeks. He was readmitted six months after decannulation with dyspnoea, productive cough, and hoarseness. Computed tomography (CT) revealed a lesion protruding into the tracheal lumen at the tracheostomy site ( Fig. 1A) . Fibre-optic bronchoscopy revealed stomal granulation tissue development in the subglottic airway ( Fig. 2A ). At readmission, his symptoms were mild and his oxygen saturation was 99% while he was breathing ambient air at rest. A treatment with inhaled glucocorticoid and two bronchodilators (long-acting β2-agonist plus a longacting muscarinic antagonist) was provided. His symptoms were carefully observed without performing an interventional bronchoscopic procedure and were improved at four weeks after treatment (Figs 1B, 2B) . Tracheostomy requires an incision between the cricoid cartilage and sternal notch in critically ill patients who require an extended period of mechanical ventilation. This procedure can potentially increase the availability of intensive care unit beds in the COVID-19 era [1] . Granulation tissue formation can cause stomal stenosis secondary to chondritis because of the disproportionate excision of the anterior cartilage [2] . Here, CT imaging showed partial destruction of the cricoid cartilage, which is suggestive of chondritis and may lead to airway stenosis. In case of suspicion of tracheal stenosis after imaging screening, bronchoscopy should be performed to define the exact site and cause of stenosis and the length of the involved trachea. A CT scan before decannulation or immediately after decannulation before closing of the tracheostomy is the preferred way to assess airway stenosis based on the strategies to minimize aerosol generation by bronchoscopy.

Appropriate written informed consent was obtained for publication of this case report and accompanying images.

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance

Tracheostomy tube placement: early and late complications

All authors directly provided patient care. Haruko Matsumoto and Shigeo Hanada drafted and edited the manuscript and images. All authors revised the manuscript.

 Figure 2 . Fibre-optic bronchoscopy imaging findings reveal a white elevated lesion arising from the left side of the trachea with significant narrowing of the airway (A). Bronchoscopic findings markedly improved after a four-week treatment with combination of inhaled glucocorticoid and two bronchodilators (long-acting β2-agonist plus a long-acting muscarinic antagonist) (B).

H. Matsumoto et al.