COVID-19 Patients Presenting with Post-Intubation Upper Airway Complications: A Parallel Epidemic?

Abstract

During the current pandemic, we witnessed a rise of post-intubation tracheal stenosis (PITS) in patients intubated due to COVID-19. We prospectively analyzed data from patients referred to our institution during the last 18 months for severe symptomatic post-intubation upper airway complications. Interdisciplinary bronchoscopic and/or surgical management was offered. Twenty-three patients with PITS and/or tracheoesophageal fistulae were included. They had undergone 31.85 (±22.7) days of ICU hospitalization and 17.35 (±7.4) days of intubation. Tracheal stenoses were mostly complex, located in the subglottic or mid-tracheal area. A total of 83% of patients had fracture and distortion of the tracheal wall. Fifteen patients were initially treated with rigid bronchoscopic modalities and/or stent placement and eight patients with tracheal resection-anastomosis. Post-treatment relapse in two of the bronchoscopically treated patients required surgery, while two of the surgically treated patients required rigid bronchoscopy and stent placement. Transient, non-life-threatening post-treatment complications developed in 60% of patients and were all managed successfully. The histopathology of the resected tracheal specimens didn’t reveal specific alterations in comparison to pre-COVID-era PITS cases. Prolonged intubation, pronation maneuvers, oversized tubes or cuffs, and patient- or disease-specific factors may be pathogenically implicated. An increase of post-COVID PITS is anticipated. Careful prevention, early detection and effective management of these iatrogenic complications are warranted.

Tracheal complications of mechanical ventilation for COVID-19: a plot twist for survivors

“…This number almost doubled after the COVID19 pandemic, with 24 referrals during the 15-month study period. In concurrence with previous studies, we observed a disproportionate number of obese patients, with an even higher incidence of patients with DM (41.7% versus 17.4%) [ 7 ]. Obesity is a well described risk factor for PITS/PTTS in pre-pandemic studies and also complicates the course of acute COVID19 with a higher rate of MV and airway management issues among these patients [ 3 , 8 ].…”

“…The wide time window between extubation, clinical presentation and diagnosis was also almost identical to previous reports [ 7 ]. Interestingly, more patients in our study presented with simple stenosis than in previous reports where complex stenosis was more common [ 7 , 12 ]. Complex stenosis was significantly more common among PTTS patients.…”

“…DM could play an important role in the development of tracheal complications due to the changes in the microvasculature and impaired wound healing [ 3 , 9 , 10 ]. The median and maximum duration of MV, reintubation and tracheostomy rates were similar to other cohorts and higher than in non COVID19 patients [ 7 , 8 , 11 ]. The wide time window between extubation, clinical presentation and diagnosis was also almost identical to previous reports [ 7 ].…”

“…The median and maximum duration of MV, reintubation and tracheostomy rates were similar to other cohorts and higher than in non COVID19 patients [ 7 , 8 , 11 ]. The wide time window between extubation, clinical presentation and diagnosis was also almost identical to previous reports [ 7 ]. Interestingly, more patients in our study presented with simple stenosis than in previous reports where complex stenosis was more common [ 7 , 12 ].…”

A Rare Case of COVID-19 Infection Leading to Colonic Stricture: Case Report and Review of Literature

“…They suggest that steroid intake prolongs the presence of COVID-19 virus in the GI tract, resulting in increased possibility of severe GI manifestation including PI [8]. Interestingly, there are increasing numbers of patients who developed airway strictures after intubation for COVID-19 infection [9], this may prompt further looking into the inflammatory response due to COVID-19 infection, as there might be specific pathways at the molecular level that induce excessive fibrotic and structuring response to COVID-19 infection, whether in the respiratory tract or GI as in our case.…”