Intubation of critically ill patients: A pilot study of minute-by-minute physiological changes within an Australian tertiary intensive care unit.

BACKGROUND: There are no published minute-by-minute physiological assessment data for endotracheal intubation (ETT) performed in the intensive care unit (ICU). The majority of physiological data is available from Europe and North America where etomidate is the induction agent administered most commonly. AIMS: The aim of this study was to describe the feasibility of obtaining minute-by-minute physiological and medication data surrounding ETT in an Australian tertiary ICU and to assess its associated outcomes. METHODS: We performed a single-centre feasibility observational study. We obtained minute-by-minute data on physiological variables and medications for 15 min before and 30 min after ETT. We assessed feasibility as enrolled to screened patient ratio and completeness of data collection in enrolled patients. Severe hypotension (systolic blood pressure < 65 mmHg) and severe hypoxaemia (pulse oximetry saturation < 80%) were the secondary clinical outcomes. RESULTS: We screened 43 patients and studied 30 patients. The median age was 58.5 (interquartile range: 49-70) years, and 18 (60%) were male. Near-complete (97%) physiological and medication data were obtained in all patients at all times. Overall, 15 (50%) ETTs occurred after hours (17:30-08:00) and 90% were by video laryngoscopy with a 90% first-pass success rate. Prophylactic vasopressors were used in 50% of ETTs. Fentanyl was used in all except one ETT at a median dose of 2.5 mcg/kg. Propofol (63%) or midazolam (50%) were used as adjuncts at low dose. Rocuronium was used in all but one patient. There were no episodes of severe hypotension and only one episode of short-lived severe hypoxaemia. CONCLUSION: Minute-by-minute recording of ETT-associated physiological changes in the ICU was feasible but only fully available in two-thirds of the screened patients. ETT was based on fentanyl induction, low-dose adjunctive sedation, and frequent prophylactic vasopressor therapy and was associated with no severe hypotension and a single short-lived episode of severe hypoxaemia.

Analysis of preoperative and postoperative blood gas indices and airflow dynamics with tracheal stenosis undergoing tracheal reconstruction.

Prolonged ventilation remains the most common cause of tracheal stenosis. Tracheal reconstruction is the gold standard treatment in these cases. The success of surgery is based on results of the pulmonary function test (PFT) which relies on patients' performance and their cooperation. The objective of the study was to investigate the impact of tracheal reconstruction in cases of tracheal stenosis on blood gas indices as well as airflow indices and whether arterial blood gas (ABG) can be a better surrogate of adequacy of tracheal reconstruction. This was a retrospective observational study of 61 patients with tracheal stenosis between the ages of 21 and 65 years who underwent tracheal reconstruction. The preoperative and postoperative values of various blood gas indices like partial pressure of oxygen (pO2), partial pressure of carbon dioxide (pCO2), and potential of hydrogen (pH) and airflow indices like forced expiratory volume in 1 s (FEV1) and peak expiratory flow (PEF) were evaluated and found that all the parameters showed significant improvement after tracheal reconstruction with P < 0.0001. Tracheal reconstruction resulted in improvement of oxygenation and airflow parameters which led to relief of symptoms. Hence, ABG can be used as a surrogate marker for denoting the success of the surgery.

Machine learning approach for predicting post-intubation hemodynamic instability (PIHI) index values: towards enhanced perioperative anesthesia quality and safety.

BACKGROUND: Adequate preoperative evaluation of the post-intubation hemodynamic instability (PIHI) is crucial for accurate risk assessment and efficient anesthesia management. However, the incorporation of this evaluation within a predictive framework have been insufficiently addressed and executed. This study aims to developed a machine learning approach for preoperatively and precisely predicting the PIHI index values. METHODS: In this retrospective study, the valid features were collected from 23,305 adult surgical patients at Peking Union Medical College Hospital between 2012 and 2020. Three hemodynamic response sequences including systolic pressure, diastolic pressure and heart rate, were utilized to design the post-intubation hemodynamic instability (PIHI) index by computing the integrated coefficient of variation (ICV) values. Different types of machine learning models were constructed to predict the ICV values, leveraging preoperative patient information and initiatory drug infusion. The models were trained and cross-validated based on balanced data using the SMOTETomek technique, and their performance was evaluated according to the mean absolute error (MAE), root mean square error (RMSE), mean absolute percentage error (MAPE) and R-squared index (R2). RESULTS: The ICV values were proved to be consistent with the anesthetists' ratings with Spearman correlation coefficient of 0.877 (P < 0.001), affirming its capability to effectively capture the PIHI variations. The extra tree regression model outperformed the other models in predicting the ICV values with the smallest MAE (0.0512, 95% CI: 0.0511-0.0513), RMSE (0.0792, 95% CI: 0.0790-0.0794), and MAPE (0.2086, 95% CI: 0.2077-0.2095) and the largest R2 (0.9047, 95% CI: 0.9043-0.9052). It was found that the features of age and preoperative hemodynamic status were the most important features for accurately predicting the ICV values. CONCLUSIONS: Our results demonstrate the potential of the machine learning approach in predicting PIHI index values, thereby preoperatively informing anesthetists the possible anesthetic risk and enabling the implementation of individualized and precise anesthesia interventions.

Voice Restoration after Traumatic Subglottic Tracheal Stenosis.

Tracheal stenosis post intubation is one of the most common complication for which resection and anastomosis is done. Here we present a 21 year male patient who was intubated post organophosphorous poisoning. Diagnosed with tracheal stenosis post intubation and managed with tracheal resection and anastomosis with uneventful recovery. Post intubation tracheal stenosis is one of the serious complications and requires a multidisciplinary team and high volume centre for adequate management. Considering the fact that this case report has tracheal stenosis of grade IV type with resected length of tracheal cartilage of more than 3 cm and trachea- tracheal anastomosis makes this a rare case report.

Airway collapse hinders recovery in bronchoscopy therapy for postintubation tracheal stenosis patients.

BACKGROUND: Expiratory central airway collapse (ECAC) following postintubation airway stenosis (PITS) is a rare phenomenon. The impact of airway malacia and collapse on the prognosis and the success rate of bronchoscopic interventional therapy in patients with PITS had been inadequately investigated. OBJECTIVE: The aim of this research was to assess the influence of airway malacia and collapse on the efficacy of bronchoscopic interventional therapy in patients with PITS. DESIGN: This retrospective analysis examined the medical documentation of individuals diagnosed with PITS who underwent bronchoscopic intervention at the tertiary interventional pulmonology center of Emergency General Hospital from 2014 to 2021. MAIN OUTCOME MEASURES: Data pertaining to preoperative, perioperative, and postoperative stages were documented and subjected to analysis. RESULTS: The patients in malacia and collapse group (MC group) exhibited a higher frequency of perioperative complications, including intraoperative hypoxemia, need for reoperation within 24 h, and postoperative intensive care unit admission rate (P < 0.05, respectively). Meanwhile, patients in group MC demonstrated significantly worse postoperative scores (higher mMRC score and lower KPS score) compared to those in pure stenosis group (P < 0.05, respectively), along with higher degrees of stenosis after treatment and a lower success rate of bronchoscopic intervention therapy cured (P < 0.05, respectively). Pearson analysis results showed that these terms were all significantly correlated with the occurrence of airway malacia and collapse in the airway (P < 0.05, respectively). CONCLUSION: The presence of malacia or collapse in patients with PITS was associated with increased perioperative complications following bronchoscopic interventional therapy, and significantly reduced the long-term cure rate compared to patients with pure tracheal stenosis. Trial registration Chinese Clinical Trial Registry on 06/12/2021. REGISTRATION NUMBER: ChiCTR2100053991.

Recurrent Subglottic Stenosis in a 16-Month-Old Male in the Setting of Influenza A, Intubation, and Honey Consumption.

Recurrent episodes of subglottic stenosis are rare in the literature, and the etiologic causes are misunderstood but can be congenital, idiopathic, or iatrogenic in nature. Complications of intubation can result in subsequent inflammation and reactive processes. This case involves a 16-month-old male who suffered from a recurrent episode of subglottic stenosis in the setting of croup, influenza, and honey consumption. He had presented to the emergency department in respiratory distress after ingesting a home remedy of onion juice and honey. He had been discharged one day prior from the pediatric intensive care unit after four days of intubation and a seven-day hospital course with evidence of croup on imaging. He was readmitted, and subglottic edema and narrowing were confirmed via endoscopy, which prompted antibiotic treatment and close monitoring. After three days of monitoring and re-evaluation by bronchoscopy, the patient's condition began to improve, and no intubation was necessary. It is unclear what the cause of recurrent subglottic stenosis is due to the patient's clinical picture being clouded by a potential allergic reaction to honey versus an inflammatory reactive process post-intubation from the previous admission days prior. This case emphasizes the need for further research on the prevalence and etiology of recurrent subglottic stenosis and a deeper understanding of how to optimize diagnosis and treatment.

Germ Cell Tumor Complicated by Mediastinal Mass Syndrome: A Report of Cardiac Arrest to Full Recovery.

Germ cell tumors (GCTs) are the most common malignancies in men aged 15-35 years. Five percent of malignant GCTs are of extragonadal origin, and the most common extragonadal location for GCTs in adults is the mediastinum. Like other mediastinal tumors, mediastinal GCTs may cause compression or invasion of vital mediastinal structures, resulting in respiratory or hemodynamic compromise. Right ventricular failure following positive pressure ventilation of such patients is called mediastinal mass syndrome (MMS). This report presents a case of a GCT complicated by cardiac arrest shortly after starting positive pressure ventilation, which was successfully resuscitated. Few previous reports demonstrated a successful outcome of MMS. This report highlights the importance of a multidisciplinary approach for such scenarios in light of the scanty literature and lack of clear guidance and the significance of starting chemotherapy in a timely manner.

Incidence of Airway Complications in ICU.

To show the incidence of airway complications in ICU. Endotracheal intubation is an essential skill performed by multiple medical specialists to secure a patient's airway as well as provide oxygenation and ventilation through the oral route or nose. The goal of endotracheal intubation in the emergency setting is to secure the patient's airway and obtain first-pass success. There are many indications for endotracheal intubation, including poor respiratory drive, questionable airway patency, hypoxia, and Hypercapnia. These indications are assessed by evaluating the patient's mental status, conditions that may compromise the airway, level of consciousness, respiratory rate, respiratory acidosis, and level of oxygenation. In the setting of trauma, a Glasgow Coma Scale of 8 or less is generally an indication for intubation. There are many different complications of intubation as hoarseness of voice, dental injuries, arytenoid dislocation, laryngeal stenosis, tracheal stenosis and tracheomalacia. . 150 patients who were sat in the ICU that developed certain complications. 86 patients (57.3%) were sitting in the ICU develoed certain complications. Liver diseases were the main cause of ICU admission 34 (22.7%) patients then shock 32 (21.3%) patients. Blockage of endotracheal tube was the main ICU complications 18 (12%) patients then sinusitis 16 (10.7%) patients. Endotracheal intubation is a lifesaving procedure and its complications are significant problems in ICUs. A successful procedure of intubation avoids complications. Skilled endotracheal intubation in the ICU decreases the complications.

Nasal Septal Cartilage as Anterior Cap-Graft for Open Tracheoplasty in Cases for Laryngotracheal Stenosis: Our Initial Experience.

The aim of our study is to analyze the efficacy of nasal septal cartilage as cap-graft in laryngo-tracheoplasty in cases of Laryngotracheal stenosis. This was a prospective observational study carried out at a tertiary care hospital from March 2020 to March 2023. Total 8 patients who underwent laryngo-tracheoplasty using nasal septal cartilage as anterior Cap-graft were included in the study. Detailed history and clinical evaluation followed by diagnostic Flexible Fiber-optic Laryngoscopy and radiological investigations were done for all patients with post operative follow up for at least 1 year. Our study had maximum patients in age group of 11-30 years with male predominance, unknown compound ingestion being most common cause of intubation which was followed by tracheostomy. All patients had Cotton Mayer Grade III or IV subglottic stenosis. Out of 8 patients, 5 patients are decannulated, 1 patients still have T-tube in-situ whereas 2 patients didn't tolerate decannulation and required re-exploration. No donor site complication was seen during the study period. Nasal septal cartilage is a viable option for being used as anterior cap graft in laryngo-tracheoplasty. It can be a game changer, as can be done by E.N.T surgeon himself. No separate learning skills are required. It's cosmetically better with minimal complications; compared to life threatening complications like pneumothorax on using costal cartilage. Laryngeal framework is preserved as opposed to thyroid alar cartilage graft. Faster healing along with better postoperative donor site recovery are significant advantages.

Factors Associated with Postintubation Hypotension Among Patients with Suspected Sepsis in Emergency Department.

Purpose: Postintubation hypotension (PIH) is a recognized complication that increases both in-hospital mortality and hospital length of stay. Sepsis is reportedly a factor associated with PIH. However, no study to date has examined which factors, including the intubation method, may be clinical predictors of PIH in patients with sepsis. This study aims to investigate factors associated with the occurrence of PIH in patients with suspected sepsis in emergency department. Patients and Methods: This retrospective cross-sectional study was performed over a 5-year period (January 2013-December 2017) and involved patients with suspected sepsis who underwent endotracheal intubation in the emergency department of Ramathibodi Hospital. The patients were divided into those with and without PIH, and factors associated with the occurrence of PIH were analyzed. PIH was defined as any recorded systolic blood pressure of <90 mmHg within 60 minutes of intubation. Results: In total, 394 patients with suspected sepsis were included. PIH occurred in 106 patients (26.9%) and was associated with increased in-hospital mortality (43.00% in the PIH group vs 31.25% in the non-PIH group, P = 0.034). Multivariable logistic regression showed that the factors associated with PIH were an age of ≥61 years (adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 1.14-4.43; P = 0.019) and initial serum lactate concentration of >4.4 mmol/L (aOR 2.00; 95% CI 1.16-3.46; P = 0.013). Rapid sequence intubation and difference types of induction agents was unrelated to PIH. Conclusion: Monitoring the development of PIH in patients with sepsis is essential because of its correlation with higher in-hospital mortality. This is particularly critical for older individuals and those with severe infections and high initial lactate concentrations.

A Nomogram Model for Post-Intubation Hypotension in Patients with Severe Pneumonia in the Emergency Department.

Background: Post-intubation hypotension (PIH) frequently occurs in the management of critically ill patients and is associated with prognosis. The study aimed to construct a prediction model for PIH events by analyzing risk factors in patients with severe pneumonia in the emergency department. Methods: We retrospectively enrolled 572 patients with severe pneumonia diagnosed in the emergency department of West China Hospital of Sichuan University. Five hundred patients with severe pneumonia who underwent endotracheal intubation were included in the study. All patients were randomized according to 7:3 and divided into a training cohort (n=351) and a validation cohort (n=149). Risk factors for PIH were analyzed using Least Absolute Shrinkage and Selection Operator (LASSO) and multivariable logistic regression. Calibration curves, receiver operating characteristic (ROC) curve, and decision curve analysis were applied to assess the predictive model's fitness, discrimination, and clinical utility. Results: A total of 500 patients with severe pneumonia who underwent endotracheal intubation were enrolled in this study, and PIH occurred in 234 (46.8%) of these patients. Age, heart rate, systolic blood pressure, chronic obstructive pulmonary disease, acute physiology and chronic health evaluation II score, and induction agent use were identified as significant risk factors for the occurrence of PIH. Additionally, the body mass index was the opposite of the above. The area under the ROC curve (AUC) for the model was 0.856 (95% CI, 0.818-0.894) in the training cohort and 0.849 (95% CI, 0.788-0.910) in the validation cohort. The nomogram model was validated and demonstrated good calibration and high net clinical benefit. Finally, to facilitate application by clinicians, an online server has been set up which can be accessed free of charge via the website https://chinahospitals.shinyapps.io/DynNomapp/. Conclusion: The nomogram is used for individualized prediction of patients with severe pneumonia prior to intubation and is simple to perform with high clinical value.

A Prospective Institutional Study on Aetiopathogenesis, Management and Complications of Laryngotracheal Stenosis.

The main purpose of this study is to evaluate and understand the clinical profile of patients presenting to an Indian tertiary care referral centre with Laryngotracheal Stenosis (LTS) and also to emphasise on the outcomes after treatment in these patients. This is a prospective observational study conducted at a tertiary care referral centre which included 18 patients diagnosed with LTS. All patients were evaluated clinically and radiologically to evaluate the degree of stenosis, site and length of the stenotic segment involved, intervened surgical procedure, intraoperative and postoperative complications following the procedure were all documented and taken into consideration. The data collected was analysed. The most common etiological cause of LTS was post intubation (77.8%). 61.5% among the 13 intubated patients had a history of intubation for more than 10 days. 83.3% of the cases had stenosis at the level of the subglottis and cervical trachea level. Post intubational airway stenosis is the most common cause of LTS. A precise assessment of the laryngotracheal complex is the cornerstone of LTS management. The choice of treatment depends on the location, severity, and length of stenosis, as well as on the patient's comorbidities, history of previous interventions, and on the expertise of the surgical team. Application of topical Mitomycin c during surgery reduces the incidence of granulations. Close postoperative follow up for a long time and the necessity of more than one intervention improves results and can spare patients the morbidity and mortality associated with acute airway obstruction.

Predictors of post-intubation hypotension in trauma patients following prehospital emergency anaesthesia: a multi-centre observational study.

BACKGROUND: Post-intubation hypotension (PIH) after prehospital emergency anaesthesia (PHEA) is prevalent and associated with increased mortality in trauma patients. The objective of this study was to compare the differential determinants of PIH in adult trauma patients undergoing PHEA. METHODS: This multi-centre retrospective observational study was performed across three Helicopter Emergency Medical Services (HEMS) in the UK. Consecutive sampling of trauma patients who underwent PHEA using a fentanyl, ketamine, rocuronium drug regime were included, 2015-2020. Hypotension was defined as a new systolic blood pressure (SBP) < 90 mmHg within 10 min of induction, or > 10% reduction if SBP was < 90 mmHg before induction. A purposeful selection logistic regression model was used to determine pre-PHEA variables associated with PIH. RESULTS: During the study period 21,848 patients were attended, and 1,583 trauma patients underwent PHEA. The final analysis included 998 patients. 218 (21.8%) patients had one or more episode(s) of hypotension ≤ 10 min of induction. Patients > 55 years old; pre-PHEA tachycardia; multi-system injuries; and intravenous crystalloid administration before arrival of the HEMS team were the variables significantly associated with PIH. Induction drug regimes in which fentanyl was omitted (0:1:1 and 0:0:1 (rocuronium-only)) were the determinants with the largest effect sizes associated with hypotension. CONCLUSION: The variables significantly associated with PIH only account for a small proportion of the observed outcome. Clinician gestalt and provider intuition is likely to be the strongest predictor of PIH, suggested by the choice of a reduced dose induction and/or the omission of fentanyl during the anaesthetic for patients perceived to be at highest risk.

Effects of Etomidate on Postintubation Hypotension, Inflammatory Markers, and Mortality in Critically Ill Patients with COVID-19: An International, Multicenter, Retrospective Study.

OBJECTIVE: To evaluate the association of etomidate with postintubation hypotension, inflammation, and mortality in critically ill patients with COVID-19. DESIGN: International, multicenter, retrospective study. PARTICIPANTS: Critically ill patients hospitalized specifically for COVID-19 from three major academic institutions in the US and Europe. MAIN OUTCOME AND MEASURES: Patients were allocated into the etomidate (ET) group or another induction agent (OA) group. The primary outcome was postintubation hypotension. Secondary outcomes included postintubation inflammatory status, in-hospital mortality, and mortality at 30 days. RESULTS: 171 patients with a median age of 68 (IQR 58-73) years were included (ET, n = 98; OA, n = 73). Etomidate was associated with lower postintubation mean arterial pressure [74.33 (64-85) mm Hg versus 81.84 (69.75-94.25) mm Hg, p = 0.005] compared to other agents. No statistically significant differences were generally observed in inflammatory markers between the two groups at 7- and 14-days after admission to the intensive care unit. In-hospital mortality [77 (79%) versus 41 (56%), p = 0.003] and mortality at 30-days [78 (80%) versus 43 (59%), p = 0.006] were higher in the ET group. In multivariate logistic regression analysis, only etomidate (p = 0.009) and postintubation mean arterial pressure (p < 0.001) had a statistically significant effect on mortality, in contrast to stress-dose steroids (p = 0.301), after adjusting for creatinine (p = 0.695), blood urea nitrogen (p = 0.153), age (p = 0.055), oxygen saturation of hemoglobin (SpO2) (p = 0.941), and fraction of inspired oxygen (FiO2) (p = 0.712). CONCLUSIONS: Administration of a single-bolus dose of etomidate in critically ill patients with COVID-19 is associated with lower postintubation mean arterial pressure and higher in-hospital and 30-day mortality compared to other induction agents.

Temporary tracheotomy for post-intubation laryngeal edema after lung cancer surgery: a case report.

BACKGROUND: In the post-intubation period, laryngeal edema is one of the most severe complications, which can cause significant morbidity and even death. Herein, we report a case in which we performed a temporary tracheostomy during surgery because of the risk of postoperative laryngeal edema, successfully avoiding post-intubation laryngeal edema complications. CASE PRESENTATION: A 78-year-old man underwent surgery for left upper lobe lung cancer. He had a history of chemoradiotherapy for laryngeal cancer, bronchial asthma, and chronic obstructive pulmonary disease. He was diagnosed with grade 1 laryngeal edema using computed tomography, and there was a risk of developing post-intubation laryngeal edema. Additionally, there was a decrease in laryngeal and pulmonary functions; therefore, postoperative aspiration pneumonia was judged to be a fatal risk. A temporary tracheostomy was performed during surgery to avoid postoperative intubation laryngeal edema. He was found to have exacerbated laryngeal edema, which is a serious complication of airway stenosis. CONCLUSIONS: Temporary tracheostomy should be considered to avoid airway stenosis due to post-intubation laryngeal edema in patients with laryngeal edema after radiotherapy.

A Comparison of Intubation and Airway Complications Between COVID-19 and Non-COVID-19 Critically Ill Subjects.

Introduction The number of subjects infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the western hemisphere increased exponentially in the later months of 2020. With this increase in infection, the number of subjects requiring advanced ventilatory support increased concomitantly. We decided to compare the survival rates between coronavirus disease 2019 (COVID-19) subjects versus non-COVID-19 subjects undergoing intubation in the intensive care unit (ICU). We hypothesized that COVID-19 subjects would have lower rates of survival post-intubation. Methods We screened all subjects admitted to the adult critical care unit between January 2020 and June 2020 to determine if they met the inclusion criteria. These subjects were required to be spontaneously ventilating upon admission and eventually required intubation. Subjects were selected from our electronic health record (EHR) system EPIC© (Epic Systems, Verona, WI) through a retrospective ICU admission analysis. We identified and included 267 non-COVID-19 subjects and 56 COVID-19 subjects. Our primary outcome of interest was intubation-related mortality. We defined intubation mortality as unexpected death (within 48 hours of intubation). Our secondary outcomes were the length of stay in the ICU, length of time requiring ventilator support, and proportion of subjects requiring tracheostomy placement. Results Compared to non-coronavirus disease (COVID) subjects, COVID subjects were more likely to be intubated for acute respiratory distress. COVID subjects had longer stays in the ICU and longer ventilator duration than non-COVID subjects. COVID-positive subjects had a decreased hazard ratio for mortality (HR = 0.42, 95% CI: 0.20-0.87, P < 0.05) and increased chances of survival compared to non-COVID subjects. Conclusions We showed the rates of intubation survival were no different between the COVID and non-COVID groups. We attribute this finding to intubation preparation, a multidisciplinary team approach, and having the most experienced provider lead the intubation process.

Reintubation in COVID-19 patients: a multicenter observational study in Japan (J-RECOVER study).

BACKGROUND: Reintubation is not an uncommon occurrence following extubation and discontinuation of mechanical ventilation. In COVID-19 patients, the proportion of reintubation may be higher than that of non-COVID-19 patients. Furthermore, COVID-19 patients may have a higher risk for developing laryngotracheal stenosis, along with a higher proportion of reintubation than in non-COVID-19 patients. Our understanding of the proportion of reintubation in COVID-19 patients is limited in Japan. Additionally, the reasons for reintubation have not been adequately examined in previous studies outside of Japan. Thus, the present study aimed to describe the proportion and causes of reintubation among COVID-19 patients in Japan. METHODS: This was a multicenter observational study that included 64 participating centers across Japan. This study included mechanically ventilated COVID-19 patients who were discharged between April 1, 2020 and September 30, 2020. The outcomes examined were the proportion and causes of reintubation. RESULTS: A total of 373 patients were eligible for inclusion in the current analysis. The median age of patients was 64 years and 80.4% were male. Reintubation was required for 35 patients (9.4%) and the most common causes for reintubation were respiratory failure (71.4%; n = 25) and laryngotracheal stenosis (8.6%; n = 3). CONCLUSIONS: The proportion of reintubation among COVID-19 patients in Japan was relatively low. Respiratory failure was the most common cause for reintubation. Reintubation due to laryngotracheal stenosis accounted for only a small fraction of all reintubated COVID-19 patients in Japan.

Estenosis traqueal postintubación después de neumonía grave por coronavirus / Postintubation Tracheal Stenosis after Severe Coronavirus Pneumonia

Introducción: La rápida propagación del SARS­CoV­2 ha provocado una pandemia mundial. Si bien puede salvar vidas, la intubación traqueal presenta el riesgo inherente de inducir daño en la mucosa traqueal con estenosis, con una incidencia estimada de 4,9 casos por millón cada año. Objetivo: Caracterizar la presentación de una estenosis traqueal por intubación prolongada en un paciente que sufrió neumonía grave por coronavirus. Presentación del caso: Se asiste a un paciente de 55 años que sufrió neumonía grave por coronavirus y necesitó intubación orotraqueal prolongada. Una vez recuperado comienza con disnea de empeoramiento progresivo. Se diagnostica una estenosis traqueal y se decide tratamiento quirúrgico donde se realiza resección y anastomosis. El paciente no presentó complicaciones y evolucionó satisfactoriamente. Conclusiones: La estenosis traqueal debe reconocerse como una complicación potencial, aun cuando los pacientes se recuperan de una neumonía grave por COVID-19. El diagnóstico definitivo de estenosis traqueal se realiza mediante fibrobroncoscopia. La resección traqueal con anastomosis entre tráquea y tráquea es el procedimiento más comúnmente realizado(AU)

Introduction: The rapid spread of SARS-CoV-2 has resulted in a global pandemic. Although tracheal intubation can save lives, it presents the inherent risk of inducing tracheal mucosal damage with stenosis, with an estimated annual incidence of 4.9 cases per million. Objective: To characterize a case of tracheal stenosis due to prolonged intubation in a patient with severe coronavirus pneumonia. Case presentation: A 55-year-old patient who suffered severe coronavirus pneumonia and required prolonged orotracheal intubation was attended. Once recovered, the patient began with progressively worsening dyspnea. Tracheal stenosis was diagnosed and surgical treatment was decided, in which resection and anastomosis were performed. The patient did not present any complications and evolved satisfactorily. Conclusions: Tracheal stenosis should be recognized as a potential complication, even when patients recover from severe COVID-19 pneumonia. A definitive diagnosis of tracheal stenosis is made by fibrobronchoscopy. Tracheal resection with anastomosis between trachea is the most commonly performed procedure(AU)

Glottic and Subglottic Injury and Development of Pediatric Airway Stenosis.

OBJECTIVE: To determine how often children with airway injury at the time of tracheostomy develop airway stenosis. STUDY DESIGN: A 7-year retrospective review of a prospectively maintained database of pediatric patients who underwent endotracheal intubation followed by tracheostomy with concurrent and follow-up direct laryngoscopy. SETTING: Tertiary care hospital. METHODS: Outcomes included glottic or subglottic injury and progression to stenosis. Univariate and multivariate analyses were performed via SPSS. RESULTS: Of the 222 patients (median age at surgery, 0.6 years; 54% male) who met study criteria, 46% had airway injury at the time of tracheostomy. Patients with congenital cardiovascular disease had 2.33-times increased risk of developing airway injury (P = .01). Patients with airway injury on initial direct laryngoscopy developed stenosis significantly more frequently than those without injury (30% vs 12%, P < .01). Risks factors for developing stenosis in children with airway injury include prematurity (P = .02), younger age at time of surgery (P < .01), endotracheal tube size (P < .01), Down syndrome (P = .03), and neonatal (P = .02) and/or congenital cardiovascular (P < .01) diagnosis. However, none of these variables were significant on multivariate analysis. CONCLUSIONS: Intubated patients with evidence of glottic or subglottic injury at the time of tracheotomy are more likely to develop airway stenosis than those without. Congenital heart disease was associated with twice the risk of developing airway injury, while progression to stenosis was associated with younger age, prematurity, and/or comorbid diagnoses.

Post-intubation tracheal lacerations: Risk-stratification and treatment protocol according to morphological classification.

Background: Post-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients. Methods: This retrospective analysis is based on a prospectively collected series (2003-2020) of 62 patients with PITL, staged and treated according to our revised morphological classification. Results: Fifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity. Conclusions: Our previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.