Extensive Tracheal Injuries: A Reasoned Multistep Approach to Guarantee Mechanical Ventilatory Support Developed During the COVID-19 Pandemic

The COVID-19 pandemic has notably increased the need for prolonged mechanical ventilation (MV) in patients with respiratory failure. This has increased the risk of extensive tracheal injury (ETI) associated with life-threatening complications in complex cases. Furthermore, tracheal injury treatment in patients with COVID-19 has not been described yet. Three patients with COVID-19 and ETI who required MV between April and November 2020 were included. A multistep approach was performed to restore tracheal integrity with a custom-remodeled stent and tracheostomy tube placement to allow ventilatory support. Efficient MV with no residual air leaks was obtained in all cases. One patient died 6 weeks after the procedure due to COVID-19 lung damage. Two patients have completely been weaned from MV. This multistep procedure could be used to maintain ventilatory support in the case of ETI, working as a bridge to subsequent surgery when clinical conditions improve.

Endobronchial valve positioning for alveolar-pleural fistula following ICU management complicating COVID-19 pneumonia.

BACKGROUND: The main clinical consequences of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection are pneumonia and respiratory failure even requiring mechanical ventilation. In this context, the lung parenchyma is highly prone to ventilator-related injury, with pneumothorax and persistent air leak as the most serious adverse events. So far, endobronchial valve (EBV) positioning has proved efficacious in treating air leaks with a high success rate. CASE PRESENTATION: We report, for the first time, two cases of patients affected by SARS-CoV-2-related pneumonia complicated with bacterial super-infection, experiencing pneumothorax and persistent air leaks after invasive mechanical ventilation. Despite the severity of respiratory failure both patients underwent rigid interventional bronchoscopy and were successfully treated through EBV positioning. CONCLUSIONS: Persistent air leaks may result from lung tissue damage due to a complex interaction between inflammation and ventilator-related injury (VILI), especially in the advanced stages of ARDS. EBV positioning seems to be a feasible and effective minimally invasive therapeutic option for treating this subset of patients.

Spontaneous Breathing and Evolving Phenotypes of Lung Damage in Patients with COVID-19: Review of Current Evidence and Forecast of a New Scenario.

The mechanisms of acute respiratory failure other than inflammation and complicating the SARS-CoV-2 infection are still far from being fully understood, thus challenging the management of COVID-19 patients in the critical care setting. In this unforeseen scenario, the role of an individual's excessive spontaneous breathing may acquire critical importance, being one potential and important driver of lung injury and disease progression. The consequences of this acute lung damage may impair lung structure, forecasting the model of a fragile respiratory system. This perspective article aims to analyze the progression of injured lung phenotypes across the SARS-CoV-2 induced respiratory failure, pointing out the role of spontaneous breathing and also tackling the specific respiratory/ventilatory strategy required by the fragile lung type.