Not only acute respiratory failure: COVID-19 and the post-intubation/tracheostomy upper airways lesions†

Abstract

BackgroundAn increasing number of patients have been subjected to prolonged invasive mechanical ventilation due to COVID-19 infection, leading to a significant number of post-intubation/tracheostomy (PI/T) upper airways lesions. The purpose of this study is to report our early experience in endoscopic and/or surgical management of PI/T upper airways injuries of patients surviving COVID-19 critical illness.Materials and MethodsWe prospectively collected data from patients referred to our Thoracic Surgery Unit from March 2020 to February 2022. All patients with suspected or documented PI/T tracheal injuries were evaluated with neck and chest computed tomography and bronchoscopy.ResultsThirteen patients (8 males, 5 females) were included; of these, 10 (76.9%) patients presented with tracheal/laryngotracheal stenosis, 2 (15.4%) with tracheoesophageal fistula (TEF) and 1 (7.7%) with concomitant TEF and stenosis. Age ranged from 37 to 76 years. Three patients with TEF underwent surgical repair by double layer suture of oesophageal defect associated with tracheal resection/anastomosis (1 case) or direct membranous tracheal wall suture (2 cases) and protective tracheostomy with T-tube insertion. One patient underwent redo-surgery after primary failure of oesophageal repair. Among 10 patients with stenosis, two (20.0%) underwent primary laryngotracheal resection/anastomosis, two (20.0%) had undergone multiple endoscopic interventions before referral to our Centre and, at arrival, one underwent emergency tracheostomy and T-tube positioning and one a removal of a previously positioned endotracheal nitinol stent for stenosis/granulation followed by initial laser dilatation and, finally, tracheal resection/anastomosis. Six (60.0%) patients were initially treated with rigid bronchoscopy procedures (laser and/or dilatation). Post-treatment relapse was experienced in 5 (50.0%) cases, requiring repeated rigid bronchoscopy procedures in 1 (10.0%) for definitive resolution of the stenosis and surgery (tracheal resection/anastomosis) in 4 (40.0%).ConclusionsEndoscopic and surgical treatment is curative in the majority of patients and should always be considered in PI/T upper airways lesions after COVID-19 illness.

Incidence of Tracheal Stenosis in ICU Hospitalized COVID-19 Patients: Results from a Prospective, Observational, Multicenter Study

“…We have recently reported COVID tracheal stenoses as being more likely to be treated with surgery compared to non-COVID considering their location-usually more distal from the vocal folds-and their trend to involve a greater number of tracheal rings [20]. Several recent surgical series confirm this evidence [23][24][25][26][27][28].…”

Tracheoesophageal Fistula as a Complication of Prolonged Ventilation in COVID-19: Description of Reconstruction and Review of the Literature

“…5 The most common complication among published data is laryngotracheal stenosis (posterior glottic, subglottic, or tracheal), followed by vocal fold immobility, muscle tension dysphonia, laryngotracheal reflux, granulomas, and less commonly TEFs. 1,5,6 Nonmalignant TEFs are most commonly a result of prolonged mechanical ventilation, but the data remain inconclusive on whether they occur in greater incidence in patients with COVID-19 infection compared to patients without. 1 However, laryngotracheal injuries such as TEF can likely be attributed to prone positioning, which increases endotracheal cuff pressure on the tracheal wall, a prothrombic state of infection leading to ischemic injury, and viral replication in the tracheal mucosa weakening the wall.…”

“…5 The most common complication among published data is laryngotracheal stenosis (posterior glottic, subglottic, or tracheal), followed by vocal fold immobility, muscle tension dysphonia, laryngotracheal reflux, granulomas, and less commonly TEFs. 1,5,6…”

“…7 Other less favorable techniques that have been reported in the literature include esophageal reconstruction with full thickness skin graft, cervical esophagostomy, or esophageal diversion/esophagocolonoplasty. 4,6,7,8 TEFs commonly occur at the cervicothoracic junction, 9 and in some cases a sternotomy may be necessary to improve exposure of the carina.…”