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Lais G, Piquilloud L. Tracheostomy: update on why, when and how. Curr Opin Crit Care 2025; 31:101-107. [PMID: 39588741 DOI: 10.1097/mcc.0000000000001224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2024]
Abstract
PURPOSE OF REVIEW The aim of this review is to summarize available data, including the most recent ones, to help develop the best possible strategy regarding the use of tracheostomy in ICU patients requiring prolonged mechanical ventilation or who experience loss of airway-protecting mechanisms. RECENT FINDINGS Tracheostomy facilitates the weaning process by reducing the patient's work of breathing and increasing comfort. It thus allows for a reduction in sedation levels. It also helps with secretions clearance, facilitates disconnection from the ventilator, and enables earlier phonation, oral intake, and mobilization. Despite these advantages, tracheostomy does not reduce mortality and is associated with both early and late complications, particularly tracheal stenosis. The timing of tracheostomy remains a subject of debate, and only a personalized approach that considers each patient's specific characteristics can help find the best possible compromise between avoiding unnecessary delays and minimizing the risks of performing a needless invasive procedure. In the absence of contraindications, the percutaneous single dilator technique under fibroscopic guidance should be the first choice, but only if the team is properly trained. SUMMARY A step-by-step individualized approach based on the available evidence allows identifying the best strategy regarding the use of tracheostomy in ICU patients.
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Affiliation(s)
- Giulia Lais
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, and Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
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Nisa L, Leroyer H, Sandu K. Open airway surgery for post-COVID laryngotracheal stenosis. Eur Arch Otorhinolaryngol 2024; 281:2531-2538. [PMID: 38407612 PMCID: PMC11024014 DOI: 10.1007/s00405-024-08533-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/05/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION This study reports our experience with open reconstructive surgery in patients with laryngotracheal stenosis (LTS) following prolonged intubation and/or tracheostomy in the context of COVID-19. METHODS All patients underwent a preoperative endoscopic airway assessment. Posterior glottic lesions were graded according to the Bogdasarian classification, subglottic-tracheal lesions according to the Cotton-Myers classification and postoperative complications reported by the Clavien-Dindo classification. We report postoperative outcomes and functional results in this patient subset. RESULTS We include 14 patients diagnosed to have post COVID LTS, one female and 13 males. This group was compared with a control group, diagnosed with LTS following prolonged intubation. In the COVID group, mean age of patients at the time of the airway surgery was 52.1 ± 16.8 years (range: 13.7-76.3). More than half the patients were multi-morbid with hypertension and obesity being the most common conditions. Eleven patients had multi-site stenoses. Open surgical interventions performed were tracheal resection and anastomosis, laryngotracheal reconstruction and extended cricotracheal resection, and postoperative complications were seen in 12 (85.6%) patients. 70% patients with pre-existing tracheostomy were decannulated. Oral swallowing was not tolerated in one-fifth of the patients and a significant number of them have poor voice quality. CONCLUSION Post-COVID pandemic, airway surgeons are seeing an increased number of patients with complex LTS, and we report significant postoperative complications in this patient subset. Decannulation rates, voice and swallowing results are poor in patients with glottic involvement as compared to isolated tracheal stenosis.
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Affiliation(s)
- Lluís Nisa
- Department of Otorhinolaryngology, Head and Neck Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Hajdi Leroyer
- Department of Otorhinolaryngology, Head and Neck Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Kishore Sandu
- Department of Otorhinolaryngology, Head and Neck Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland.
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Mangiameli G, Perroni G, Costantino A, De Virgilio A, Malvezzi L, Mercante G, Giudici VM, Ferraroli GM, Voulaz E, Giannitto C, Acocella F, Onorati I, Martinod E, Cariboni U. Analysis of Risk Factors for Tracheal Stenosis Managed during COVID-19 Pandemic: A Retrospective, Case-Control Study from Two European Referral Centre. J Pers Med 2023; 13:jpm13050729. [PMID: 37240899 DOI: 10.3390/jpm13050729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/08/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION Benign subglottic/tracheal stenosis (SG/TS) is a life-threatening condition commonly caused by prolonged endotracheal intubation or tracheostomy. Invasive mechanical ventilation was frequently used to manage severe COVID-19, resulting in an increased number of patients with various degrees of residual stenosis following respiratory weaning. The aim of this study was to compare demographics, radiological characteristics, and surgical outcomes between COVID-19 and non-COVID patients treated for tracheal stenosis and investigate the potential differences between the groups. MATERIALS AND METHODS We retrospectively retrieved electronical medical records of patients managed at two referral centers for airways diseases (IRCCS Humanitas Research Hospital and Avicenne Hospital) with tracheal stenosis between March 2020 and May 2022 and grouped according to SAR-CoV-2 infection status. All patients underwent a radiological and endoscopic evaluation followed by multidisciplinary team consultation. Follow-up was performed through quarterly outpatient consultation. Clinical findings and outcomes were analyzed by using SPPS software. A significance level of 5% (p < 0.05) was adopted for comparisons. RESULTS A total of 59 patients with a mean age of 56.4 (±13.4) years were surgically managed. Tracheal stenosis was COVID related in 36 (61%) patients. Obesity was frequent in the COVID-19 group (29.7 ± 5.4 vs. 26.9 ± 3, p = 0.043) while no difference was found regarding age, sex, number, and types of comorbidities between the two groups. In the COVID-19 group, orotracheal intubation lasted longer (17.7 ± 14.5 vs. 9.7 ± 5.8 days, p = 0.001), tracheotomy (80%, p = 0.003) as well as re-tracheotomy (6% of cases, p = 0.025) were more frequent and tracheotomy maintenance was longer (21.5 ± 11.9 days, p = 0.006) when compared to the non-COVID group. COVID-19 stenosis was located more distal from vocal folds (3.0 ± 1.86 vs. 1.8 ± 2.03 cm) yet without evidence of a difference (p = 0.07). The number of tracheal rings involved was lower in the non-COVID group (1.7 ± 1 vs. 2.6 ± 0.8 p = 0.001) and stenosis were more frequently managed by rigid bronchoscopy (74% vs. 47%, p = 0.04) when compared to the COVID-19 group. Finally, no difference in recurrence rate was detected between the groups (35% vs. 15%, p = 0.18). CONCLUSIONS Obesity, a longer time of intubation, tracheostomy, re-tracheostomy, and longer decannulation time occurred more frequently in COVID-related tracheal stenosis. These events may explain the higher number of tracheal rings involved, although we cannot exclude the direct role of SARS-CoV-2 infection in the genesis of tracheal stenosis. Further studies with in vitro/in vivo models will be helpful to better understand the role of inflammatory status caused by SARS-CoV-2 in upper airways.
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Affiliation(s)
- Giuseppe Mangiameli
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
| | - Gianluca Perroni
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Otorhinolaryngology, Head & Neck Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Otorhinolaryngology, Head & Neck Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Luca Malvezzi
- Otorhinolaryngology, Head & Neck Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Giuseppe Mercante
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Otorhinolaryngology, Head & Neck Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Veronica Maria Giudici
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
| | - Giorgio Maria Ferraroli
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Emanuele Voulaz
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
| | - Caterina Giannitto
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, MI, Italy
- Department of Diagnostic Radiology, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
| | - Fabio Acocella
- Department of Veterinary Medicine and Animal Science, University of Milan, Via dell'Università 6, 26900 Lodi, LO, Italy
| | - Ilaria Onorati
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris Seine-Saint-Denis, Hôpital Avicenne, Chirurgie Thoracique et Vasculaire, Université Sorbonne Paris Nord, Faculté de Médecine SMBH, Bobigny, 93000 Paris, France
| | - Emmanuel Martinod
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris Seine-Saint-Denis, Hôpital Avicenne, Chirurgie Thoracique et Vasculaire, Université Sorbonne Paris Nord, Faculté de Médecine SMBH, Bobigny, 93000 Paris, France
| | - Umberto Cariboni
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, MI, Italy
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Orlandi R, Raveglia F, Calderoni M, Cassina EM, Cioffi U, Guttadauro A, Libretti L, Pirondini E, Rimessi A, Tuoro A, Passera E. Management of COVID-19 related tracheal stenosis: The state of art. Front Surg 2023; 10:1118477. [PMID: 36891547 PMCID: PMC9986964 DOI: 10.3389/fsurg.2023.1118477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/24/2023] [Indexed: 02/15/2023] Open
Abstract
Tracheal stenosis (TS) is a debilitating disease promoted by pathologic narrowing of the trachea. The acute respiratory distress syndrome caused by COVID-19 has been demonstrated to trigger enhanced inflammatory response and to require prolonged invasive mechanical ventilation as well as high frequency of re-intubation or emergency intubation, thus increasing the rate and complexity of TS. The standard-of-care of COVID-19-related tracheal complications has yet to be established and this is a matter of concern. This review aims at collecting latest evidence on this disease, providing an exhaustive overview on its distinctive features and open issues, and investigating different diagnostic and therapeutic strategies to handle COVID-19-induced TS, focusing on endoscopic versus open surgical approach. The former encompasses bronchoscopic procedures: electrocautery or laser-assisted incisions, ballooning dilation, submucosal steroid injection, endoluminal stenting. The latter consists of tracheal resection with end-to-end anastomosis. As a rule, traditionally, the endoscopic management is restricted to short, low-grade, and simple TS, whereas the open techniques are employed in long, high-grade, and complex TS. However, the critical conditions or extreme comorbidities of several COVID-19 patients, as well as the marked inflammation in tracheal mucosa, have led some authors to apply endoscopic management also in complex TS, recording acceptable results. Although severe COVID-19 seems to be an issue of the past, its long-term complications are still unknown and considering the increased rate and complexity of TS in these patients, we strongly believe that it is worth to focus on it, attempting to find the best management strategy for COVID-19-related TS.
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Affiliation(s)
- Riccardo Orlandi
- Department of Thoracic Surgery, University of Milan, Milan, Italy
| | - Federico Raveglia
- Department of Thoracic Surgery, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Matteo Calderoni
- Department of Thoracic Surgery, San Gerardo Hospital, ASST Monza, Monza, Italy
| | | | - Ugo Cioffi
- Department of Surgery, University of Milan, Milan, Italy
| | - Angelo Guttadauro
- Department of Medicine and Surgery, School of Medicine and Surgery, Università degli Studi di Milano Bicocca, Monza, Italy
| | - Lidia Libretti
- Department of Thoracic Surgery, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Emanuele Pirondini
- Department of Thoracic Surgery, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Arianna Rimessi
- Department of Thoracic Surgery, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Antonio Tuoro
- Department of Thoracic Surgery, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Eliseo Passera
- Department of Thoracic Surgery, San Gerardo Hospital, ASST Monza, Monza, Italy
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