Posterior glottic stenosis following prolonged intubation for COVID-19

Abstract

Prolonged tracheal intubation (TI) may be necessary in critically ill patients requiring airway protection and ventilatory support. The presence of an endotracheal tube can generate inflammation, fibrosis and scarring resulting in laryngotracheal stenoses including subglottic and posterior glottic stenosis (PGS). If a patient requires continued TI and ventilatory support beyond 7 days, a tracheostomy is often performed to both facilitate weaning from mechanical ventilation and minimize the occurrence of fibrotic laryngotracheal complications. Patients with COVID-19 present a unique challenge, as this population may require TI during a systemic inflammatory process typified by respiratory inflammation, hypoxemia, and acute respiratory distress syndrome. Early tracheostomy has been discouraged in COVID-19 patients given the high potential for aerosolized transmission to health care workers and other patients during these procedures. The advice to continue TI in COVID-19 patients beyond the typical 7-day window is supported by expert consensus and National society recommendations. In this case report, we present a patient who developed PGS following prolonged TI for COVID-19. We suggest that the incidence, severity and complications related to PGS may be amplified in these patients given the underlying proinflammatory nature of COVID-19, society recommendations for delaying tracheostomy, and an increased risk of laryngotracheal stenosis with prolonged TI. This case highlights a unique sub-set of patients,that is, those requiring prolonged mechanical ventilation and TI with COVID-19, which may increase their risk for PGS. This population could benefit from early screening and intervention efforts to prevent long-term morbidity from PGS and other complications of prolonged TI.