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How to: Post-COVID-19 Airway Stenosis: Tracheal Resection-Anastomosis Using The Tritube Ventilation

by Gabriele Molteni, MD, PhD, Virginia Dallari, MD, Erika Segato, MD, and Francesco Mattioli, MD, PhD •

INTRODUCTION

As reported in the literature, up to 12% of all COVID-19 patients may need intensive care unit admission for severe interstitial pneumonia, with possible long-term endotracheal intubation for mechanical ventilation and subsequent tracheostomy (Eur Arch Otorhinolaryngol. 2021;278:1–7). As is now known, prolonged endotracheal intubation can lead to mucosal injury and inflammation, granulation tissue formation, perichondritis, and subsequent stenotic scar tissue development. Moreover, tracheostomy may add trauma to the already damaged tracheal lumen, for example tracheal ring fracture, collapse, necrosis, malacia, and superinfection (Acta Otorhinolaryngol Ital. 2022;42:99–105).

In this setting, laryngotracheal stenosis represents one of the most common complications of invasive ventilation and tracheostomy. In addition, the absence of accurate monitoring of the cuff pressure or the need to maintain it above 50 mmHg for clinical reasons and prone position ventilation might contribute to the mechanism underlying the stenosis (Acta Otorhinolaryngol Ital. 2022;42:99–105; Respir Med. 2018;13:34).

As predicted by the European Laryngological Society, the incidence of laryngotracheal stenosis in post-COVID-19 patients may increase and should not be underestimated (Eur Arch Otorhinolaryngol. 2021;278:1–7; Acta Otorhinolaryngol Ital. 2022;42:99–105). After intensive care unit discharge, patients with breathing difficulties must receive a targeted evaluation aimed at ruling out the possibility of iatrogenic laryngotracheal stenosis, because a respiratory distress syndrome might be misdiagnosed in these cases (Acta Otorhinolaryngol Ital. 2022;42:99–105).

Regarding the treatment, Piazza et al state that tracheal resection and anastomosis represent an effective treatment in post-COVID-19 laryngotracheal stenosis patients (Acta Otorhinolaryngol Ital. 2022;42:99–105). Indeed, this strategy is common in the setting of previous prolonged intubation or tracheostomy, since external or internal trauma to the airway is associated with cartilage injury and the potential loss of structural support (Respir Med. 2018;13:34).

The purpose of the present paper is, therefore, to show step by step the tracheal resection anastomosis type A1, according to the University of Brescia classification (Acta Otorhinolaryngol Ital. 2022;42:99–105), in a post-COVID-19 patient. In addition, on the day of the surgery, the airway was managed with a new device, the Tritube with an outer diameter of only 4.4 mm. Here, we report the clinical case of a 62-year-old patient who presented to our attention for significant exertional dyspnea, cough, and sometimes dyspnea at rest.

Surgical Technique

The patient had been intubated for 21 days for severe COVID-19 interstitial pneumonia. Then, he had undergone a percutaneous tracheotomy for difficult weaning from ventilation in January 2021. The patient recovered in February 2021 with removal of the endotracheal cannula. The patient otherwise had no major comorbidities.