Long-term intubation and high rate of tracheostomy in COVID-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society

Abstract

Introduction: The novel Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, may need intensive care unit (ICU) admission in up to 12% of all positive cases for massive interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy. The most common airway-related complications of such ICU maneuvers are laryngotracheal granulomas, webs, stenosis, malacia and, less commonly, tracheal necrosis with tracheo-esophageal or tracheo-arterial fistulae.

Materials and methods: This paper gathers the opinions of experts of the Laryngotracheal Stenosis Committee of the European Laryngological Society, with the aim of alerting the medical community about the possible rise in number of COVID-19-related laryngotracheal stenosis (LTS), and the aspiration of paving the way to a more rationale concentration of these cases within referral specialist airway centers.

Results: A range of prevention strategies, diagnostic work-up, and therapeutic approaches are reported and framed within the COVID-19 pandemic context.

Conclusions: One of the most important roles of otolaryngologists when encountering airway-related signs and symptoms in patients with previous ICU hospitalization for COVID-19 is to maintain a high level of suspicion for LTS development, and share it with colleagues and other health care professionals. Such a condition requires specific expertise and should be comprehensively managed in tertiary referral centers.

Keywords: Airway team; COVID-19; European laryngological society; Intubation injuries; Laryngotracheal stenosis; Prevention; Tracheostomy.

Fig. 1

Different patterns of LTS associated with endotracheal intubation and tracheostomy placement. a Bilateral vocal fold immobility caused by still inflamed posterior glottic web. b Same condition due to a mature posterior glottic and inter-arytenoid stenosis. c Cicatricial stenosis at the junction between the cricoid and trachea due to long-term intubation and tracheostomy. d Tracheostomy-related suprastomal collapse. e Suprastomal contracture and tracheal stenosis (so called “lambdoid deformity”). f, g Tracheal stenoses resulting from tracheostomy cuff injury at different levels of the airay. h Complete (grade IV) LTS