Complex Post-intubation Tracheal Stenosis in Covid-19 Patients

Abstract

Management of tracheal complications due to endotracheal intubation in patients with coronavirus disease-2019 (COVID-19) is an important concern. This study aimed to present the results of patients who had undergone tracheal resection and reconstruction due to COVID-19-related complex post-intubation tracheal stenosis (PITS). We evaluated 15 patients who underwent tracheal resection and reconstruction due to complex PITS between March 2020 and April 2021 in a single center. Seven patients (46.6%) who underwent endotracheal intubation due to the COVID-19 constituted the COVID-19 group, and the remaining 8 patients (53.4%) constituted the non-COVID-19 group. We analyzed the patients’ presenting symptoms, time to onset of symptoms, radiological and bronchoscopic features of stenosis, bronchoscopic intervention history, length of the resected tracheal segment, postoperative complications, length of hospital stay, and duration of follow-up. Six of the patients (40%) were female, and 9 (60%) were male. Mean age was 43.3 ± 20.5. We found no statistically significant difference between the COVID-19 and non-COVID-19 PITS groups in terms of presenting symptoms, time to onset of symptoms, stenosis location, stenosis severity, length of the stenotic segment, number of bronchoscopic dilatation sessions, dilatation time intervals, length of the resected tracheal segment, postoperative complications, and length of postoperative hospital stay. Endotracheal intubation duration was longer in the COVID-19 group than non-COVID-19 group (mean ± SD: 21.0 ± 4.04, 12.0 ± 1.15 days, respectively). Tracheal resection and reconstruction can be performed safely and successfully in COVID-19 patients with complex PITS. Comprehensive preoperative examination, appropriate selection of surgery technique, and close postoperative follow-up have favorable results.

Management of COVID-19 related tracheal stenosis: The state of art

“…The raw incidence of TS seems to be higher in COVID-19 patients than in pre-COVID-19 era ( 11 ), and the medical community has been alerted to the possibility of an unprecedented surge in TS ( 12 ), despite the limited number of cases in literature does not allow to draw definitive conclusions in this regard. The mean age ranges from 50 ( 13 – 15 ) to 60 ( 8 , 11 , 16 ) years old, and males seem to be more prone to develop this disease, with approximately prevalence of 60%–70% ( 8 , 11 , 13 , 14 , 16 , 17 ).…”

“…Symptoms can widely vary depending on site and extension of airway stenosis ( 8 ): occlusive TS localized within 2–3 cm from vocal cords will occur during the hospitalization with difficulties in extubating the patient or weaning tracheostomy; whereas progressive TS localized beyond 3 cm from vocal cords will show up with progressive shortness of breath after discharging. Manifestations will also depend on the degree of obstruction, which in turn influences airflow rate and pressure changes ( 8 , 17 ): mild stenosis (<50%) will be broadly asymptomatic since the pressure at the stenosis is comparable to that at the glottic plane; moderate stenosis (51%–70%) will result in fluctuating symptoms, based on significant pressure drop manifesting under exertion or other contexts requiring higher airflow rate; severe stenosis (>71%) will produce symptoms even at rest, due to massive pressure drop. The typical presentation consists of dyspnea, wheezing and stridor on physical examination occurring after several days from extubating ( 8 , 9 , 14 ).…”

“…TS at the stomal site could be more subtle and less rapidly progressive, leading to functional impairment up to years or even decades later ( 8 ). COVID-19-related TS has more severe clinical presentations than other TS because of more complex stenotic airway segments ( 11 ) and delayed diagnosis, since symptoms of TS could be initially misdiagnosed as post-COVID-19 respiratory symptoms ( 16 , 17 ). Whatever the symptoms, without proper management, TS can lead to life-threatening situations due to impaired respiratory function ( 22 ).…”

“…Clinically, TS are divided into simple (or web-like) and complex stenosis: the formers are less than 1 cm long circumferential stenosis, without any cartilage involvement; the latters are more than 1 cm long articulated and mixed stenosis, with involvement of cartilage ( 17 ). TS could potentially affect each segment of the trachea.…”

“…TS could potentially affect each segment of the trachea. The majority of COVID-19-related TS is complex ( 8 , 13 , 16 ), with higher incidence of associated tracheomalacia, vocal cord paralysis and tracheoesophageal fistula ( 13 ), and localized in the upper third segment ( 8 , 13 , 14 , 17 ). The stenotic segment is highly variable in extension, but it is most reported as around 2 cm long ( 8 , 11 , 13 , 16 ).…”