Post-Extubation Stridor Complicating COVID-19-Associated Acute Respiratory Distress Syndrome: A Case Series

Abstract

Post-extubation stridor is a known complication of mechanical ventilation that affects a substantial number of all critical care patients and leads to increased morbidity and mortality. Common risk factors for the development of post-extubation stridor include female gender, older age, and prolonged length of mechanical ventilation. There may be an increased incidence of post-extubation stridor in patients who require mechanical ventilation to manage the respiratory complications of COVID-19. In this case series, we analyzed nine patients from across our institution who were intubated to manage acute respiratory distress syndrome (ARDS) secondary to COVID-19 and subsequently developed post-extubation stridor. The patients were predominantly females with prolonged intubations and multiple days of prone ventilation. While the patients in this case series possessed some of the well-described risk factors for post-extubation stridor, there may be risk factors specific to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that make these patients more susceptible to the complication. The cuff leak test was performed on the majority of patients in the case series and did not successfully predict successful extubation in this population. Our analysis suggests that prophylactic corticosteroids given in the 24-48 hours prior to elective extubation in female COVID-19 patients who were intubated for more than six days with consecutive days of intermittent prone ventilation may be helpful in reducing the incidence of post-extubation stridor in this population. Overall, this case series elucidates the need for exceptionally close monitoring of COVID-19 patients upon extubation for the development of stridor.

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

“…In a recent laryngological case series [ 24 ], several COVID-19-related upper airway complications, including vocal fold immobility, granulation tissue formation, posterior glottic and subglottic stenosis, and posterior glottic diastasis have been associated with prolonged intubation in prone position and larger (>7.5) caliber orotracheal tubes. High incidence of post-extubation stridor and laryngeal injury among patients who underwent endotracheal intubation and tracheostomy during the COVID-19 pandemic has also been reported in other case series [ 25 , 26 ]. In a number of case reports, it was highlighted that common post-COVID-19 respiratory symptoms, such as cough and dyspnea after discharge from the hospital, were initially misdiagnosed and later attributed to post-intubation tracheal stenosis [ 27 ].…”

“…The true incidence of PITS might be even higher as a number of post-COVID patients may not be referred for dyspnea/tracheal stenosis due to more debilitating COVID-related post-ICU sequelae. Other authors have also observed a similar increase in the incidence of these complications, which could either be attributed to the dramatic increase of intubated patients due to the pandemic or to other factors related to specific patients’ characteristics, to the disease itself, or ultimately to iatrogenic factors related with the hospitalization and the disease management under the current circumstances [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

Postacute COVID‐19 Laryngeal Injury and Dysfunction

“…This aligns with initial guidelines supporting avoidance of early tracheostomy in patients with COVID‐19. This has changed with recent evidence showing benefits and safety of early tracheostomy with standardized protocols and personal protective equipment 24–26 . Thus, patients with extended intubation may be unique to hospitalizations in 2020, though many will require long‐term management for laryngotracheal stenosis.…”

Predictors of post-extubation stridor in patients on mechanical ventilation: a prospective observational study

“…To identify patients at risk of laryngeal edema, airway patency assessment before extubation has been evaluated. Since Miller and Cole evaluated 100 mechanically ventilated patients in 1996, the cuff leak test (CLT) has been widely used because of its noninvasiveness and avoidance of sophisticated equipment 11 – 15 . The cuff leak volume was defined as the tidal volume difference from before to after endotracheal tube (ETT) cuff deflation.…”