A Case Series Demonstrating the Difficulties in Diagnosing COVID-19 Associated Pulmonary Aspergillus.

Many bacterial, viral, and fungal co-infections have been reported with COVID-19-associated acute respiratory distress syndrome (ARDS). Invasive Aspergillosis has been described with COVID-19 ARDS. However, it continues to evade diagnosis in critically ill patients admitted to the intensive care unit (ICU). The difficulty is discerning an actual infection from colonization. Unfortunately, a timely diagnosis is crucial since COVID-19-associated pulmonary Aspergillus (CAPA) has high morbidity and mortality. We present three ICU cases of CAPA to illustrate the difficulty in diagnosing and treating the disease. We hope to bring awareness and improve patient outcomes of CAPA.

Management of blind-end subglottic stenosis following SARS-CoV-2 infection: A case report

Background: Reports identify rates of prolonged intubation as high as 28% in patients who are hospitalized for worsening respiratory status due the SARS-CoV-2 infection. This has placed a toll on healthcare systems around the world. However, we believe we are only seeing the beginnings of complications associated with the COVID-19 pandemic. Subglottic tracheal stenosis is a known complication of prolonged intubation and may therefore be on the rise in the wake of the current pandemic. The European Laryngology Society created the Laryngotracheal Stenosis Committee to alert the international medical community of the rise in airway complications associated with long-Term intubation and high rates of tracheostomy seen in the recent months during the pandemic. Optimal surgical management of the unique features of subglottic stenosis following COVID-19 disease, especially in severely deconditioned patients, has yet to be reported. Case Description: We report the surgical management of blind-end Myer-Cotton Grade IV subglottic stenoses in two patients who required prolonged mechanical ventilatory support for respiratory failure resulting from the SARS-CoV-2 infection with a two stage minimally invasive recanalization strategy. Patients underwent two-step minimally invasive process for recanalization. The first step is to re-establish a patent tracheal lumen under direct visualization utilizing both a rigid bronchoscope from proximally as well as a flexible bronchoscope distal to the stenosis from the tracheostomy stoma. Once the tracheal lumen is re-established, proper dilation of the airway and hemostasis is achieved in standard fashion. Both patients have had roughly 6 months of follow-up and have tolerated their silicone T-Tubes capped at all times. Neither patient currently require any oxygen supplementation and continue to phonate well. While they are not at their baseline in terms of physical activity, they are continuing their rehabilitation process. Conclusions: While the definitive treatment continues to be surgical resection, the endoscopic approach to re-establishing the tracheal lumen is a safe and effective method with little to no morbidity and mortality. This will allow for uninhibited rehabilitation following prolonged mechanical ventilatory support and hospital stay following severe COVID-19 infection. © 2022 Audiology and Speech Research. All rights reserved.

Inflammatory Profiles of Tracheal Biopsies From SARS-CoV-2 Patients.

Purpose: An increasing number of laryngotracheal complications in mechanically ventilated COVID-19 patients has been reported in the last few months. Many etiopathogenetic hypotheses were proposed but no clear explanation of these complications was identified. In this paper we evaluated the possibility that the tracheal mucosa could be a high viral replication site that could weaken the epithelium itself. Methods: Subjects for the COVID-19 group and the control group were selected retrospectively according to specific criteria. Patients' basic and clinical data were recorded and analyzed. Tracheal samples of both groups were collected during surgical tracheostomies and then analyzed from a histological and genetic-transcriptional point of view. Results: Four COVID-19 patients were enrolled in this study and compared with four non-COVID-19 patients. No laryngotracheal complications were identified in both groups. The SARS-CoV-2 was detected in one out of four COVID-19 samples. A subepithelial inflammatory lymphomonocyte infiltrate was observed in all patients but two cases of the COVID-19 group showed vasculitis of small subepithelial vessels associated with foci of coagulative necrosis. Two gene sets (HALLMARK_INFLAMMATORY_RESPONSE and HALLMARK_ESTROGEN_RESPONSE_LATE) were significantly deregulated in COVID-19 patients compared to the control group. Conclusion: The altered inflammatory response of the COVID-19 patients could be another possible explanation of the increasing number of laryngotracheal complications.

Weaning Analgosedation in Patients Requiring Prolonged Mechanical Ventilation.

Although research supports the minimization of sedation in mechanically ventilated patients, many patients with severe acute respiratory distress syndrome (ARDS) receive prolonged opioid and sedative infusions. ICU teams face the challenge of weaning these medications, balancing the risks of sedation with the potential to precipitate withdrawal symptoms. In this article, we use a clinical case to discuss our approach to weaning analgosedation in patients recovering from long-term mechanical ventilation. We believe that a protocolized, multimodal weaning strategy implemented by a multidisciplinary care team is required to reduce potential harm from both under- and over-sedation. At present, there is no strong randomized clinical trial evidence to support a particular weaning strategy in adult ICU patients, but appraisal of the existing literature in adults and children can guide decision-making to enhance the recovery of these patients.

Tracheostomy in patients with COVID-19: predictors and clinical features.

BACKGROUND: Around 20% of patients hospitalized for COVID-19 need mechanical ventilation (MV). MV may be prolonged, thus warranting tracheostomy. METHODS: Observational cohort study enrolling patients admitted due to COVID-19. Demographic and clinical data at hospital and ICU admission were collected. The primary endpoint was to identify parameters associated with a need for tracheostomy; secondary endpoints were to analyze the clinical course of patients who needed tracheostomy. RESULTS: 118 patients were enrolled; 37 patients (31.5%) were transferred to ICU, of which 11 (29.72%) needed a tracheostomy due to prolonged MV. Sequential Organ Failure Assessment (SOFA) score at ICU admission (OR 0.65, 95% CI 0.47-0.92, p 0.015) was the only variable found to be associated with increased risk of the need for tracheostomy, with a cut-off point of 4.5 (sensitivity 0.72, specificity 0.73, positive predictive value 0.57 and negative predictive value 0.85). The main complications were nosocomial infection (100%), supraventricular cardiac arrhythmia (45.5%), agitation (54.5%), pulmonary thromboembolism (9.1%) and depression (9.1%). All patients presented with hypoalbuminemia and significant critical illness polyneuropathy. CONCLUSION: SOFA at ICU admission is associated with an increased risk of tracheostomy in patients with COVID-19. Moreover, they present clinical features similar to those with chronic critical illness and suffer SARS-CoV-2-related complications.

Tracheostomy during novel corona virus pandemic. / Tracheotomia az új típusú koronavírus okozta járvány idején(A COVID-19-pandémia orvosszakmai kérdései).

Recently, 6 percent of COVID-19 patients required prolonged mechanical ventilation due to severe respiratory failure. Early tracheostomy prevents the risk of postintubation upper airway stenosis. In the pandemic, all surgical interventions that generate aerosol increase the risk of contamination of the medical staff, for which reason the "traditional" indications of tracheostomy have to be revised. Authors present their recommendations based on international experiences. Orv Hetil. 2020; 161(19): 767-770.