Post COVID-19 tracheitis contributing to tracheal wall tear: the missed and underdiagnosed

• Main Authors: Bahruddin, Nur Azilah, Abdul Rahim, Shahir Asraf, Abdul Rahman, Ruhana, Oh, Yin Lin, Mat Nor, Mohd Basri
• Format: Article
• Language: English
• Published: Kugler Publications 2023
• Subjects: RC82 Medical Emergencies, Critical Care, Intensive Care, First Aid; RD81 Anesthesiology
• Online Access: http://irep.iium.edu.my/115883/13/115883_Post%20COVID-19%20tracheitis%20contributing%20to%20tracheal%20wall%20tear.pdf; http://irep.iium.edu.my/115883/; https://www.myja.pub/index.php/myja/issue/view/6/6
• Institution: Universiti Islam Antarabangsa Malaysia

Introduction Iatrogenic tracheal wall tear is a rare but devastating complication post tracheostomy. Its incidence is estimated from 0.05% to 0.37% of orotracheal intubations, with overall mortality rate of 22%.(1) This case report aims to aid clinicians in identifying patients who are at risk and to enforce the appropriate prevention steps to reduce this complication. Case Report A 38 year old ASA 1 lady with recurrent COVID 19 infection presented with progressive respiratory muscle weakness, eye ptosis, diplopia and fever. After few hours of admission, she became lethargic and tachypneic, hence was electively intubated with no difficulties for anticipated respiratory muscle weakness following the diagnosis of Guillain Barre Syndrome. In view of slow neurological recovery, surgical tracheostomy was performed on day 25 of ventilation after resolution of hospital acquired pneumonia (HAP) and catheter associated urinary tract infection (CAUTI). Endoscopic guidance was used to insert the tracheostomy tube after multiple failed insertion attempts due to false tracts. Postoperatively, she developed massive subcutaneous emphysema. CT neck and thorax revealed a left posterolateral trachea wall defect associated with left pneumothorax, extensive pneumomediastinum, pneumoperitoneum, and extensive subcutaneous emphysema required multiple chest tubes insertion. Examination under anaesthesia confirmed a trachealis muscle tear with unhealthy and malacic posterior tracheal mucosa. She was reintubated, tracheostomy removed and packed, and the tip of endotracheal tube positioned beyond the defect. Intraoperative tracheal wall tissue cultures grew pseudomonas aeruginosa, confirming the diagnosis of infectious tracheitis. Reinsertion of tracheostomy tube performed 2 weeks later revealed healed posterior tracheal wall tear with improved tracheomalacia. Discussion/ Conclusion Iatrogenic tracheal wall tear has been associated with multiple causes, namely intubation, tracheostomy, bronchoscopy, placement of stents and esophagectomy. The exact mechanism remains uncertain with most tears occurring longitudinally at pars membranosa , the posterior tracheal part that lacks cartilaginous support.(1) The risk factors of iatrogenic tracheal wall tear in this patient are multiple attempts at tracheostomy insertion, female gender and infectious tracheitis from Pseudomonas and post COVID 19 infection. Pseudomonas Aeruginosa accounts for 75% of the nosocomial tracheitis.(2) COVID 19 virus has a high affinity for the upper respiratory tract with a study reported 30% incidence of presumed severe tracheobronchitis in COVID 19 patients.(3) Post mortem examination of COVID 19 patients revealed incidence of severe mucous tracheitis in 29% patients.(4) Infectious tracheitis is a significant respiratory infection as the progression of ventilator associated tracheobronchitis (VAT) to ventilator associated pneumonia (VAP) was significantly increased when patients with VAT were given inappropriate or no antibiotics.(5) Despite clinical, radiological and microbiological criteria as a guide, there is no consensus on gold standard in diagnosing VAT. Nevertheless, l ack of lung infiltrates in portable chest X ray has been concluded as a common feature.(6) Infectious tracheitis is often missed and underdiagnosed because of concomitant pneumonia or hospital acquired infection, the non specific clinical signs, and the need of endoscopic examination for diagnosis confirmation. High index of clinical suspicion of infectious tracheitis, early antimicrobial therapy and risk reduction strategies of modifiable risk factors must be advocated to minimize complications in susceptible patients.