SARS-CoV-2 infection and post-extubation laryngeal function

ABSTRACT

Introduction: In critically ill patients with SARS-CoV-2, risk factors for laryngeal complications after endotracheal intubation (ie, diabetes, obesity, prolonged intubation, hypotension, and large endotracheal tube [ETT] size) are common. Given the global impact of the virus, more information is needed regarding the long-term laryngeal effects on both breathing and voice. Method: A retrospective review of patients receiving laryngologic care at a tertiary academic center was compiled, and patient characteristics were abstracted. Postmortem analysis of subglottic tissue in 2 patients with SARS-CoV-2 was performed using in situ hybridization of SARS-CoV-2 RNA and immunohistochemistry (IHC) for CD4 and CD8. Results: Collectively, patients (n = 8) were 55.0 (SD ±14.3) years old with a body mass index of 33.7 (SD ±4.5). Most had type 2 diabetes mellitus (62.5%) and hypertension (50%). The average intubation duration was 15.1 days (SD ±5). Most patients were intubated with an 8.0 ETT. The level of laryngotracheal injury occurred within the posterior glottis (n = 6 [75%]) and subglottis (n = 2 [25%]). Both subglottic specimens tested for SARS-CoV-2 infection were positive for the virus within the mucosal epithelium. IHC demonstrated CD4+ and CD8+ cells indicating an abundant adaptive immune response. At our institution, 1.5% of SARS-CoV-2 patients required intubation. By extrapolating from these data, we estimate roughly 300,000 patients required intubation nationally in 2020 for SARS-CoV-2 infection with more than 225,000 survivors at risk for laryngotracheal complications. Conclusion: Laryngotracheal complications occur frequently after intubation for SARS-CoV-2. Earlier tracheostomy, use of smaller ETTs, and early injury identification through routine screening may limit the impact of functional laryngeal disability.