In This Article
- Reports show that up to 5% of the patients who underwent prolonged invasive mechanical ventilation during treatment for COVID-19 later present with chronic airway problems or some degree of post-intubation tracheal stenosis
- Several weeks following extubation and recovery of the initial illness, patients at risk of tracheal stenosis begin to exhibit signs of airway problems
- Patients with suspected or confirmed post-intubation tracheal stenosis can undergo tracheal resection and reconstruction surgery to correct the narrowing of the airway, which typically produces excellent results in the vast majority of patients
Prolonged breathing assistance, administered by endotracheal intubation and mechanical ventilation, is a procedure that has been used extensively in the treatment of critically ill patients during the COVID-19 pandemic. Though an effective treatment for many patients with COVID-19, it has long been recognized to result in injuries of the subglottic larynx and trachea.
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Reports show that up to 5% of the patients who underwent prolonged invasive mechanical ventilation during treatment for COVID-19 later present with chronic airway problems or some degree of post-intubation tracheal stenosis. Tracheal stenosis is a narrowing or constriction of the trachea.
"The pathophysiology of post-intubation stenosis is a result of the pressure of the balloon in the tracheal tube, which creates a seal between the endotracheal tube and trachea. The balloon gets inflated and sits against the tracheal wall, exerting pressure on it and, thereby, preventing blood flow to the mucosa and the wall of the trachea," says Harald Ott, MD, director of Thoracic Robotics at the Massachusetts General Hospital Division of Thoracic Surgery.
When done for over 16 days—which is the average intubation period of COVID patients—the body produces an inflammatory response in that region because the tissue is damaged, which ultimately can lead to stenosis of the airway, he says.
If a patient is expected to be intubated longer than eight to 10 days, there are standards of care commonplace in reducing the risk of post-intubation complications (e.g., placing a tracheostomy tube to prevent any sort of complication that can result in tracheal stenosis). However, in the management of critically ill patients with COVID-19, these standards of care have shifted as clinicians learn that many patients require longer and more invasive intubation.
"Many patients do not undergo tracheostomy placement, mainly because of the risks related to COVID-19," says Dr. Ott.
Other preventative measures to take in the care of intubated patients being treated for COVID-19 include:
- Reducing the pressure the balloon exerts on the trachea
- Preventing reflux of acidic gastric content into the trachea
Patient Evaluation and Presentation of Symptoms
As a relatively rare condition with symptoms similar to other airway complications, Dr. Ott says that a thorough understanding of tracheal stenosis and its presentation is critical to proper diagnosis.
Several weeks following extubation and recovery of the initial illness, patients at risk of tracheal stenosis begin to exhibit signs of airway problems. Symptoms of this condition include:
- Shortness of breath
- Wheezing, or raspy, noisy breathing
- A bluish tint to skin color
- Severe coughing or coughing up blood
- Respiratory distress
Due to the similarity of the symptoms of tracheal stenosis and other airway conditions, many patients are incorrectly diagnosed with either a lung or pulmonary condition, such as asthma.
"It is important that patients and providers are aware of this condition, recognize these symptoms and investigate how they could be related to the trachea," says Dr. Ott. "What we don't want are patients struggling with breath, having difficulty walking up the stairs, and thinking to themselves, 'You know what, I was really sick and this is just something I have to live with now.'"
Post-Intubation Tracheal Stenosis Management
Patients with suspected or confirmed post-intubation tracheal stenosis can undergo tracheal resection and reconstruction surgery to correct the narrowing of the airway, which typically produces excellent results in the vast majority of patients. First, the patient is evaluated with a CT scan of the neck and chest and, a same-day procedure, flexible and rigid bronchoscopy for better characterization and measurement of the airway.
If the diagnosis is severe, the patient is strongly recommended to stay at the hospital. If less severe, the patient can return later for the definitive repair.
During the surgery, the patient undergoes resection of the stenotic segment of the airway with end-to-end anastomosis for reconstruction. The surgical team makes a low-collar incision, similar in size and characteristics to an incision for a thyroid operation. Then, the surgeon dissects down to the trachea and removes that segment of tracheal stenosis, connecting the two ends back together—healthy trachea to healthy trachea.
For recovery, the patient stays at the hospital for a week's time to heal. After one week has passed, the care team performs another bronchoscopy to make sure the trachea and airway has healed.
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Refer a patient to the Division of Thoracic Surgery