ABSTRACT
AIM: We aimed to characterise a large population of coronavirus disease 2019 (COVID-19) patients with moderate-to-severe hypoxaemic acute respiratory failure (ARF) receiving continuous positive airway pressure (CPAP) outside the intensive care unit (ICU), and to ascertain whether the duration of CPAP application increased the risk of mortality for patients requiring intubation. METHODS: In this retrospective, multicentre cohort study, we included adult COVID-19 patients, treated with CPAP outside ICU for hypoxaemic ARF from 1 March to 15 April, 2020. We collected demographic and clinical data, including CPAP therapeutic goal, hospital length of stay and 60-day in-hospital mortality. RESULTS: The study included 537 patients with a median (interquartile range (IQR) age of 69 (60-76) years. 391 (73%) were male. According to the pre-defined CPAP therapeutic goal, 397 (74%) patients were included in the full treatment subgroup, and 140 (26%) in the do not intubate (DNI) subgroup. Median (IQR) CPAP duration was 4 (1-8) days, while hospital length of stay was 16 (9-27) days. 60-day in-hospital mortality was 34% (95% CI 0.304-0.384%) overall, and 21% (95% CI 0.169-0.249%) and 73% (95% CI 0.648-0.787%) for full treatment and DNI subgroups, respectively. In the full treatment subgroup, in-hospital mortality was 42% (95% CI 0.345-0.488%) for 180 (45%) CPAP failures requiring intubation, and 2% (95% CI 0.008-0.035%) for the remaining 217 (55%) patients who succeeded. Delaying intubation was associated with increased mortality (hazard ratio 1.093, 95% CI 1.010-1.184). CONCLUSIONS: We described a large population of COVID-19 patients treated with CPAP outside ICU. Intubation delay represents a risk factor for mortality. Further investigation is needed for early identification of CPAP failures.
ABSTRACT
BACKGROUND The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic is still to be determined, and the complication rate of the tracheostomy in COVID-19 patients is still unknown. Postintubation tracheal stenosis is a well-known risk of prolonged endotracheal intubation, but it is too early to define the existence of any difference among the COVID-19 cohort of patients and non-COVID-19 patients. This report is of 2 cases of COVID-19 pneumonia that required tracheostomy and prolonged endotracheal intubation, which were followed by delayed tracheal stenosis. CASE REPORT Case 1. A 54-year-old male was admitted to our hospital (Biella, Italy) for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The patient underwent orotracheal intubation, progressively improving his breathing function, and was discharged after 20 days. Ten days later, the patient presented with severe respiratory distress. Computed tomography (CT) scan and bronchoscopy showed signs of tracheal stenosis. We administered intravenous steroids for 10 days. The patient showed increasing improvement in his breathing function and was discharged with no other signs of respiratory distress. Case 2. A 43-year-old male was admitted to our hospital for SARS-CoV-2 infection. The patient underwent orotracheal intubation, progressively improving his breathing function, and was discharged after 25 days. Eighteen days later, the patient came to our emergency room with severe respiratory distress. CT scan and bronchoscopy showed signs of tracheal stenosis. The patient had to undergo tracheal resection. CONCLUSIONS The 2 cases presented in this report have shown that even when patients recover from severe COVID-19 pneumonia requiring tracheostomy and mechanical ventilation, tracheal stenosis should be recognized as a potential complication and careful follow-up is required.