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Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Are tracheal complications of invasive mechanical ventilation more frequent in patients with coronavirus disease 2019 (COVID-19)?

Findings  In this cohort study of 98 patients with COVID-19 and severe respiratory failure, the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas after prolonged (≥14 days) invasive mechanical ventilation was significantly higher in patients with COVID-19 (46.7%) than matched controls (2.2%).

Meaning  Among patients with COVID-19, treatment with prolonged invasive mechanical ventilation may be associated with increased risk of full-thickness tracheal lesion and/or tracheoesophageal fistula.

Abstract

Importance  Full-thickness tracheal lesions and tracheoesophageal fistulas are severe complications of invasive mechanical ventilation. The incidence of tracheal complications in ventilated patients with coronavirus disease 2019 (COVID-19) is unknown.

Objective  To evaluate whether patients with COVID-19 have a higher incidence of full-thickness tracheal lesions and tracheoesophageal fistulas than matched controls and to investigate potential mechanisms.

Design, Setting, and Participants  This is a retrospective cohort study in patients admitted to the intensive care unit in a tertiary referral hospital. Among 98 consecutive patients with COVID-19 with severe respiratory failure, 30 underwent prolonged (≥14 days) invasive mechanical ventilation and were included in the COVID-19 group. The control group included 45 patients without COVID-19. Patients with COVID-19 were selected from March 1 to May 31, 2020, while the control group was selected from March 1 to May 31, 2019.

Exposures  Patients with COVID-19 had severe acute respiratory syndrome coronavirus 2 infection diagnosed by nasopharyngeal/oropharyngeal swabs and were treated according to local therapeutic procedures.

Main Outcomes and Measures  The primary study outcome was the incidence of full-thickness tracheal lesions or tracheoesophageal fistulas in patients with prolonged invasive mechanical ventilation.

Results  The mean (SD) age was 68.8 (9.0) years in the COVID-19 group and 68.5 (14.1) years in the control group (effect size, 0.3; 95% CI, −5.0 to 5.6). Eight (27%) and 15 (33%) women were enrolled in the COVID-19 group and the control group, respectively. Fourteen patients (47%) in the COVID-19 group had full-thickness tracheal lesions (n = 10, 33%) or tracheoesophageal fistulas (n = 4, 13%), while 1 patient (2.2%) in the control group had a full-thickness tracheal lesion (odds ratio, 38.4; 95% CI, 4.7 to 316.9). Clinical and radiological presentations of tracheal lesions were pneumomediastinum (n = 10, 71%), pneumothorax (n = 6, 43%), and/or subcutaneous emphysema (n = 13, 93%).

Conclusions and Relevance  In this cohort study, almost half of patients with COVID-19 developed full-thickness tracheal lesions and/or tracheoesophageal fistulas after prolonged invasive mechanical ventilation. Attempts to prevent these lesions should be made and quickly recognized when they occur to avoid potentially life-threatening complications in ventilated patients with COVID-19.

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Article Information

Accepted for Publication: September 23, 2020.

Published Online: November 19, 2020. doi:10.1001/jamaoto.2020.4148

Corresponding Author: Giacomo Fiacchini, MD, Otolaryngology, Audiology and Phoniatric Operative Unit, Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana (AOUP), University of Pisa, Via Paradisa, 2, 56124 Pisa, Italy (g.fiacchini@gmail.com).

Author Contributions: Drs Fiacchini and Tricò had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Fiacchini, Tricò, Ribechini, Forfori, Brogi, Berrettini, Guarracino, Bruschini.

Acquisition, analysis, or interpretation of data: Fiacchini, Tricò, Ribechini, Brogi, Lucchi, Bertini.

Drafting of the manuscript: Fiacchini, Tricò, Ribechini, Brogi, Guarracino.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Tricò, Ribechini, Brogi.

Obtained funding: Ribechini.

Administrative, technical, or material support: Fiacchini, Ribechini, Brogi, Bruschini.

Supervision: Fiacchini, Ribechini, Forfori, Brogi, Lucchi, Berrettini, Bertini, Guarracino, Bruschini.

Conflict of Interest Disclosures: None reported.

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