Tracheostomy in Mechanically Ventilated Patients With SARS-CoV-2-ARDS: Focus on Tracheomalacia

Abstract

BACKGROUND:The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. The aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence. METHODS: This retrospective, single-center study was performed in an Italian teaching hospital. All adult subjects admitted to the ICU between February 24, 2020, and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, whereas information regarding airway management was collected daily. RESULTS: A total of 151 subjects were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 40%. A tracheostomy was performed in 73 ( 48%), open surgical technique in 54 (74%), and percutaneous Ciaglia technique in 19 (26%). Subjects who had a tracheostomy performed had, compared to the other subjects, a longer duration of mechanical ventilation and longer ICU and hospital stay. Tracheomalacia was diagnosed in 8 (5%). The factors associated with tracheomalacia were female sex, obesity, and tracheostomy. CONCLUSIONS: In our population, approximately 50% of subjects with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized subjects had a longer ICU and hospital stay. In our population, 5% were diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature, and the underlying mechanisms are not fully understood.

Traqueomalacia en la unidad de cuidados críticos. Reporte de 2 casos

“…Un estudio observacional de pacientes con distrés respiratorio en ventilación mecánica invasiva, reportó que aproximadamente el 5% de ellos son diagnosticados con traqueomalacia, ocasionada muchas veces por un pequeño estrechamiento en la luz de la tráquea, causando disminución significativa del flujo de entrada de aire (10).…”

Acquired Tracheomalacia Requiring Urgent Tracheostomy Exchange in Patients With COVID-19

“…One study identified 8 of 151 patients (5.3%) developing tracheomalacia after prolonged intubation for COVID-19. 3 The mean time to diagnosis of tracheomalacia was 27 days after intubation, and all were treated with tracheostomy. The patients in our case series developed the need for emergent tracheostomy at a mean of 23 days after intubation, which may reflect similar pathology.…”

Moisture-Associated Skin Damage

“…24 Evidence concerning the frequency of tracheostomy creation is not known, but the available research strongly suggests that intentional tracheostomy is the most frequent scenario underlying irritant contact dermatitis due to respiratory secretions. [25][26][27] For example, Fischler and colleagues 25 evaluated 90,412 patients receiving care for a combined 243,921 days in intensive care units (ICUs). They found that 10% of patients who required ventilation for more than 24 hours underwent tracheostomy.…”

“…[28][29][30] For example, Pereira and colleagues 28 examined residents of 33 skilled nursing facilities and reported that 3.36% had longterm tracheostomies. Guarnieri and colleagues 27 evaluated 209 patients with amyotrophic lateral sclerosis and reported that 16% had a tracheostomy. Similarly, Branco's group 30 reviewed medical records of 5265 patient with cervical spinal cord injuries and reported that 20.6% required long-term tracheostomy for ventilatory support.…”

“…Tracheostomy is a surgically created ostomy (stoma) connecting the trachea directly to the skin 24. Evidence concerning the frequency of tracheostomy creation is not known, but the available research strongly suggests that intentional tracheostomy is the most frequent scenario underlying irritant contact dermatitis due to respiratory secretions 25–27. For example, Fischler and colleagues25 evaluated 90,412 patients receiving care for a combined 243,921 days in intensive care units (ICUs).…”