COVID-19 Patients Presenting with Post-Intubation Upper Airway Complications: A Parallel Epidemic?

Abstract

During the current pandemic, we witnessed a rise of post-intubation tracheal stenosis (PITS) in patients intubated due to COVID-19. We prospectively analyzed data from patients referred to our institution during the last 18 months for severe symptomatic post-intubation upper airway complications. Interdisciplinary bronchoscopic and/or surgical management was offered. Twenty-three patients with PITS and/or tracheoesophageal fistulae were included. They had undergone 31.85 (±22.7) days of ICU hospitalization and 17.35 (±7.4) days of intubation. Tracheal stenoses were mostly complex, located in the subglottic or mid-tracheal area. A total of 83% of patients had fracture and distortion of the tracheal wall. Fifteen patients were initially treated with rigid bronchoscopic modalities and/or stent placement and eight patients with tracheal resection-anastomosis. Post-treatment relapse in two of the bronchoscopically treated patients required surgery, while two of the surgically treated patients required rigid bronchoscopy and stent placement. Transient, non-life-threatening post-treatment complications developed in 60% of patients and were all managed successfully. The histopathology of the resected tracheal specimens didn't reveal specific alterations in comparison to pre-COVID-era PITS cases. Prolonged intubation, pronation maneuvers, oversized tubes or cuffs, and patient- or disease-specific factors may be pathogenically implicated. An increase of post-COVID PITS is anticipated. Careful prevention, early detection and effective management of these iatrogenic complications are warranted.

Keywords: COVID-19; airway complications; intubation; tracheal stenosis; tracheoesophageal fistula; tracheostomy.

Figure 1

CT of the thorax depicting upper trachea stenosis with posterior wall thickening (a), anterior wall cartilage fracture (b) and tracheoesophageal fistula (c).

Figure 2

Bronchoscopic view of severe complex upper trachea stenosis (a–c) and tracheoesophageal fistula (d).

Figure 3

Bronchoscopic view of complicated tracheal stents with obstruction due to biofilm and thick purulent mucous accumulation (a), removal of sticky secretions making use of cryoprobe (b) and peripheral stent migration (c).

Figure 4

Histogram depicting the multi-disciplinary management of our patients and their long-term outcome.

Figure 5

Histological section of the trachea with fibrosis and plasma cell infiltration (hematoxylin-eosin; ×20 magnification). Upper row: Representative histological micrographs comparing the lateral part of subglottic tracheal stenosis between a patient with post-COVID stenosis (A,B) and a patient with non-COVID stenosis (C,D) (hematoxylin-eosin staining; ×20 magnification). The findings are similar. (A). Squamous metaplasia, thickening, and scarring of submucosa, considerable interstitial fibrosis. (B). Submucosal vessels dilatation, hyperemia, and granulation tissue proliferate. (C,D). Degeneration and ischemic necrosis of the cartilaginous tracheal rings. Lower row: on immunohistochemistry, plasma cells are mainly IgG-secreting elements, with a low tissue density of IgG4 subclass (IHC ×20 objective). The findings are similar between post-COVID (E,F) and non-COVID patients (G,H). Immunohistochemical stains show abundant IgG+ plasma cells, some of which are also IgG4+. The IgG4+ plasma cells exhibit a patchy distribution (IgG4, immunoperoxidase, original magnification ×200). A definite histopathologic diagnosis of IgG4-RD is not proven. Abbreviation: IgG, IgG4, immunoglobulin G and immunoglobulin G4.