COVID-19 patients receiving prolonged, invasive mechanical ventilation are much more likely than non-COVID patients on ventilators to develop tracheal complications, a new cohort study shows. Nearly half of COVID-19 patients in the study developed full-thickness tracheal lesions (FTTLs) or tracheoesophageal fistulas (TEFs), versus 2.2% of a control group of mechanically ventilated patients without the infection, Dr. Giacomo Fiacchini of the University of Pisa, in Italy, and colleagues report in JAMA Otolaryngology-Head and Neck Surgery. "Our work is mainly addressed to the 'actors' of the airway-team who manage COVID-19 patients, i.e. anesthesiologists, otolaryngologists, thoracic surgeons and bronchoscopists," Dr. Fiacchini told Reuters Health by email. "If they are faced with major complications such as pneumomediastinum and pneumothorax in COVID-19 patients, a full-thickness tracheal lesion should be suspected and eventually confirmed with bronchoscopy." Dr. Fiacchini and his team conducted the retrospective study after observing an "unprecedented increase" in FTTLs and TEFs in COVID-19 patients. They compared 30 patients with COVID-19 who received invasive ventilation for at least 14 days to a control group of 45 patients without the infection. Among the COVID-19 patients, 10 had FTTLs (33%) and four had TEFs (13%), while one patient in the control group developed a FTTL (2.2%), a highly significant difference. Presentations included pneumomediastinum in 10 patients (71%), pneumothorax in six (43%) and/or subcutaneous emphysema in 13 (93%). The authors make the following recommendations for preventing and managing tracheal complications in ventilated COVID-19 patients: * Performing periodic bronchoscopy for early detection of tracheal and endobronchial lesions. * Using high steroid doses (intravenous methylprednisolone, 80 mg) with caution. * Monitoring cuff pressure to prevent hypoperfusion and pressure sores in the tracheal mucosa, especially in patients with a nasogastric tube. * Clinical and radiologic follow-up with patients after prolonged mechanical ventilation. "The Covid-19 outbreak has been a shock for all health systems and for doctors who have had to face a completely new disease, which has proved to be a multi-organ pathology rather than a disease of infectious and virologic relevance only," Dr. Fiacchini said. "For this reason, we believe that by combining the knowledge and skills of several medical-surgical specialties we will be able to treat better and reduce the number of complications. Together as a team." At his center, Dr. Fiacchini noted, mechanically ventilated patients now undergo periodic bronchoscopy, and cuff pressure is carefully monitored, especially during pronation maneuvers. "It must be said that the therapeutic protocols adopted in the second wave are very different from those of the first wave, in terms of both pharmacological treatments and ventilation protocols," he added. "As a matter of fact, most of the COVID-19 patients who come to the emergency room today are patients who were already undergoing home therapy, so their average condition is certainly better than seen in the first wave. Furthermore, there is no longer the rush to mechanically ventilate these patients, so the number of intubated patients who need many days of invasive mechanical ventilation has also been reduced." —Anne Harding Source
