BackgroundDuring the coronavirus pandemic, our intensive care units were faced with large numbers of patients with an unfamiliar disease. To support our colleagues and to assist with diagnosis and treatment, we developed a specialist team.
MethodsThe acute respiratory disease support team reviewed 44 consecutive patients referred from the intensive care and coordinated therapies for pulmonary hypertension, pulmonary thrombosis, evolving lung fibrosis and large airway intervention.
ResultsThe mortality for this group was significantly lower (34%) than the total group admitted to critical care as a whole (51%) and for those not reviewed by the team (55%; p=0.012). Pulmonary hypertension was present in 84% of the patients and pulmonary thrombosis in 52%. Thirty-two patients received sildenafil therapy and this was associated with improvement in right heart function in survivors. Ten patients with evolving fibrosis and no evidence of sepsis received high-dose steroid therapy with excellent effect. Five patients developed airway complications requiring intervention. Short time on mechanical ventilation was associated with a poorer outcome (p<0.001).
InterpretationA specialised cardiorespiratory team approach contributes significantly to successful management of severely unwell patients with COVID-19 and offers an important platform for continuity of patient care, education and staff well-being.
COVID-19 pneumonia can cause respiratory failure which requires specialist management. However the inflammatory nature of the condition and the interventions necessary to manage these patients such as endotracheal intubation and tracheostomy can lead to large airway pathology which may go unrecognised. We describe five of the 44 (11%) consecutive patients referred to our specialist ARDS team between April and June 2020 with confirmed COVID-19 pneumonia who developed diverse large airway pathology which comprised of: supraglottic oedema, tracheal tear, tracheal granulation tissue formation, bronchomalacia, and tracheal diverticulum. Large airway pathology may be underappreciated in severely ill patients with COVID-19 pneumonia and should be considered in patients with unexplained air leak, prolonged need for mechanical ventilatory support, and repeated failed extubation or decannulation. If suspected, such patients should be managed by a team with expertise in large airway intervention and early specialist advice should be sought.
COVID-19 ARDS has a high mortality and few therapeutic options. We present a preliminary report on our experience using high-dose pulsed methylprednisolone in COVID-19 ARDS and three-month outcomes. We performed a retrospective analysis of all patients treated with high-dose methylprednisolone for COVID-19 ARDS and three-month lung function, 6MWT, and CT findings. 15 patients were treated of which 10 survived to discharge. Reduced DLCO was the commonest abnormality in lung function tests and had the lowest mean value. Parenchymal bands were the commonest CT finding and 50% of patients had fibrosis at three-months. Mean 6MWD was 65.4% predicted and was abnormal in 62.5% of patients. In this cohort of patients with COVID-19 ARDS treated with high-dose methylprednisolone pulses, CT, lung function, and 6MWT abnormalities were unsurprisingly common at three months, although all 10 patients treated early in their disease course survived, a possible therapeutic effect. Further randomised controlled trials are needed to assess the benefits of this treatment.
Introduction: Iatrogenic tracheal tear is a rare complication after intubation and is often associated with use of a bougie. Traditionally tracheal tears have been surgically managed but this is a major intervention available only in specialist centres and may not be suitable for patients with significant medical comorbidities or if the diagnosis has been made late. Given our encouraging experience in managing posterior tracheal tear complicating percutaneous tracheostomy with airway stenting, we wished to apply this technique to selected patients with acute airway tear. Description: We describe two patients successfully managed with tracheal stenting who had developed a posterior tracheal wall tear post intubation. One patient (74-year-old female) had endotracheal intubation electively while the other (70-year-old female) had intubation in an emergency setting. A bougie was used in both patients. Both patients were clinically unwell, mechanically ventilated in the intensive care unit and were not suitable for surgical intervention due to co-morbidities. Each patient had a 4 cm tear in the membranous trachea at 2.5 and 4 cm respectively below the vocal cords. In both cases, a rigid bronchoscopy was performed and a 6 cm x 20 mm covered expandable metallic stent was deployed. This completely sealed the defect. The patients were subsequently weaned from mechanical ventilation. On follow up bronchoscopy, the stent position in the trachea was satisfactory and there was no evidence of metal fatigue or granulation tissue formation. Discussion: Metallic tracheal stenting should be considered in the management of significant post intubation tracheal tears especially in patients who are high surgical risk.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.