Incidence and types of laryngotracheal sequelae of prolonged invasive ventilation in COVID-19 patients

Risk of Post-Intubation Laryngotracheal Stenosis With Respect to COVID-19 Status in a Large Multicenter Cohort Cross-Sectional Study

OBJECTIVES

Occurrence of post-intubation laryngotracheal stenosis (LTS) with respect to COVID-19 status.

DESIGN

Retrospective cross-sectional inpatient database.

SETTING

Eleven Midwest academic and community hospitals, United States.

PATIENTS

Adults, mechanically ventilated, from January 2020 to August 2022, who were subsequently readmitted within 6 months with a new diagnosis of LTS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Six thousand eight hundred fifty-one COVID-19 negative and 1316 COVID-19 positive patients were intubated and had similar distribution by age (median 63.77 vs. 63.16 yr old), sex (male, 60.8%; n = 4173 vs. 60%; n = 789), endotracheal tube size (≥ 7.5, 75.8%; n = 5192 vs. 75.5%; n = 994), and comorbidities. The ICU length of stay (median [interquartile range (IQR)], 7.23 d [2.13-16.67 d] vs. 3.95 d [1.91-8.88 d]) and mechanical ventilation days (median [IQR], 5.57 d [1.01-14.18 d] vs. 1.37 d [0.35-4.72 d]) were longer in the COVID-19 positive group. The occurrence of LTS was double in the COVID-19 positive group (12.7%, n = 168 vs. 6.4%, n = 440; p < 0.001) and was most commonly diagnosed within 60 days of intubation. In multivariate analysis, the risk of LTS increased by 2% with each additional ICU day (hazard ratio [HR], 1.02; 95% CI, 1.02-1.03; p < 0.001), by 3% with each additional day of ventilation (HR, 1.03; 95% CI, 1.02-1.04; p < 0.001), and by 52% for each additional reintubation (HR, 1.52; 95% CI, 1.36-1.71; p < 0.001). We observed no significant association COVID-19 status and risk of LTS.

CONCLUSIONS

The occurrence of post-intubation LTS was double in a COVID-19 positive cohort, with higher risk with increasing number of days intubated, days in the ICU and especially with the number of reintubations. COVID-19 status was not an independent risk factor for LTS.

Laryngotracheal Complications after Intubation for COVID-19: A Multicenter Study

Many of the patients with COVID-19 have suffered respiratory distress requiring prolonged endotracheal intubation (ETI) resulting in laryngotracheal complication with an impact on breathing, phonation, and swallowing. Our aim is to describe laryngeal injuries diagnosed after ETI in patients with COVID-19 in a multicentre study.

METHODS

A prospective descriptive observational study was conducted from January 2021 to December 2021, including COVID-19 patients with laryngeal complications due to ETI diagnosed in several Spanish hospitals. We analyzed the epidemiological data, previous comorbidities, mean time to ICU admission and ETI, need for tracheostomy, mean time on invasive mechanical ventilation until tracheostomy or weaning, mean time in ICU, type of residual lesions, and their treatment.

RESULTS

We obtained the collaboration of nine hospitals during the months of January 2021 to December 2021. A total of 49 patients were referred. Tracheostomy was performed in 44.9%, being late in most cases (more than 7-10 days). The mean number of days of ETI until extubation was 17.63 days, and the main post-intubation symptoms were dysphonia, dyspnea, and dysphagia, in 87.8%, 34.7%, and 42.9%, respectively. The most frequent injury was altered laryngeal mobility, present in 79.6%. Statistically, there is a greater amount of stenosis after late ETI and after delayed tracheostomy, not observing the data with the immobility alterations.

CONCLUSION

The mean number of days of ETI was long, according to the latest guidelines, with the need for several cycles of pronation. This long ETI may have had an impact on the increase of subsequent laryngeal sequelae, such as altered laryngeal mobility or stenosis.

Fatal Asphyxia Potentially Caused by COVID-19-Induced Exacerbation of Pre-existing Tracheal Stenosis

We report a case of cardiac arrest due to asphyxia caused by coronavirus disease 2019 (COVID-19) in a patient with no history of tracheal intubation but with a history of subglottic stenosis. A 54-year-old man suffered a cardiac arrest at home. The patient had tracheal stenosis; therefore, it was difficult to intubate. The patient had COVID-19, which was presumed to have aggravated the existing tracheal stenosis and caused asphyxiation. The patient died seven days later. This is, to our knowledge, the first report of a patient with subglottic stenosis potentially aggravated by COVID-19, resulting in asphyxia-related cardiopulmonary arrest. The patient could not be saved, but emergency physicians should be aware that airway obstruction can be caused by viral infections, including severe acute respiratory syndrome coronavirus 2 infections. Physicians should consider the difficulty in performing oral intubation and cricothyrotomy and be aware of alternative methods to secure the airway.