Post-intubation tracheal stenosis in COVID-19 patients
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LETTER TO THE EDITOR
Post‑intubation tracheal stenosis in COVID‑19 patients Francesco Mattioli1 · Alessandro Marchioni2 · Alessandro Andreani2 · Gaia Cappiello2 · Matteo Fermi1 · Livio Presutti1 Received: 18 May 2020 / Accepted: 23 September 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Benign subglottic/tracheal stenosis (SG/TS) is a debilitating and potentially life-threatening condition that is commonly caused by iatrogenic events as a result of endotracheal intubation or tracheostomy. It has long been known that ischemia caused by prolonged intubation is a source of initial injury leading to scar formation, especially in obese patients [1]. In December 2019, a novel coronavirus causing severe acute respiratory disease occurred in China. The World Health Organization (WHO) considered it a public health emergency of international concern on January 31, 2020. The most common and severe complication in patients with COVID-19 is an acute respiratory distress syndrome (ARDS), requiring oxygen and ventilation therapies. Current evidence from China suggests that between 9.8 and 15.2% of patients required invasive mechanical ventilation (IMV) [2]. It has been demonstrated that COVID-19 patients had a median duration of ventilation of 17 days and high frequency of re-intubation [3, 4]. In addition, over-cuffed intubation and prone position ventilation might contribute to the mechanism underlying the stenosis. Lastly, several authors have demonstrated the correlation between COVID-19 patients requiring IMV and obesity, which is a proven risk factor also for SG/TSs [5]. It can be postulated that a certain amount of these patients will develop a SG/T cicatricial concentric stenosis after extubation. A respiratory distress syndrome in these patients might be misdiagnosed, thus we believe that HRCT plays a significant role in differential diagnosis of SG/ TS with other tracheobronchial or pulmonary diseases. The management of SG/TS is still controversial and there is no consensus about the best treatment strategy. At present, there * Matteo Fermi [email protected] 1
Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Modena, Via Largo del Pozzo 71, Modena, Italy
Bronchoscopy and Respiratory Diseases Department, University Hospital of Modena, Via Largo del Pozzo 71, Modena, Italy
2
are no experiences reported about this topic in COVID-19 scenario. The primary aim of the treatment consists in maintaining the patency of the patient’s airway, preserving voice and swallowing. Open surgical approaches, such as tracheal resection-anastomosis, should be avoided as primary choice treatment in COVID-19 population. This strategy is more common in the setting of previous prolonged intubation or tracheostomy, since external or internal trauma to the airway is associated with cartilage injury and the potential loss of structural support. However, these approaches should be selected for patients with no comorbidities, which is not the case of the vast majority of
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