key: cord-263214-h6lkvlj3 authors: Bassi, Massimiliano; Anile, Marco; Pecoraro, Ylenia; Ruberto, Franco; Martelli, Sabina; Piazzolla, Mario; Pugliese, Francesco; Venuta, Federico; De Giacomo, Tiziano title: BEDSIDE TRANSCERVICAL-TRANSTRACHEAL POST-INTUBATION INJURY REPAIR IN A COVID-19 PATIENT date: 2020-04-22 journal: Ann Thorac Surg DOI: 10.1016/j.athoracsur.2020.04.009 sha: doc_id: 263214 cord_uid: h6lkvlj3 Abstract SARS-Co-2 disease 2019 (COVID-19) has rapidly spread worldwide since December 2019. A relevant rate of patients develops an acute respiratory distress syndrome that require hospitalization. Among them, a non-negligible rate (9.8%-15.2%) requires tracheal intubation for invasive ventilation. We report the case of a COVID-19 patient developing pneumomediastinum and subcutaneous emphysema secondary to post-intubation tracheal injury. The management of COVID-19 patient can be challenging due to the risk of disease transmission to caregivers and epidemic spread. We performed a bedside tracheal injury surgical repair, after failure of conservative management, with resolution of pneumomediastinum and subcutaneous emphysema and improvement of patient’s conditions. Since the first reported case in Wuhan, China (1), novel coronavirus disease 2019 (COVID-19) has quickly spread worldwide. Most of patients are asymptomatic or complain mild respiratory influenza-like symptoms. However, some patients need hospitalization for respiratory support and a relevant rate (ranging between 9.8 and 15.2%) requires oro-tracheal intubation (OTI) for invasive ventilation. On April 3rd, 28741 patients in Italy are hospitalized for COVID-19. Among them, 4068 (14,2%) need intensive care support and most of them are intubated for mechanical ventilation support. OTI could rarely lead to tracheal injury particularly under emergency or in patient with documented difficulty airway management. We present a case of a COVID-19 patient who develops massive pneumomediastinum and subcutaneous emphysema for post-intubation tracheal injury. Considering the hemodynamic and respiratory instability after conservative management, a bedside surgical tracheostomy with primary suture of the tracheal lesion was performed. A 72-year-old man was admitted to our hospital complaining fever (38°C) and cough. In his medical history, the patient reported systemic hypertension and an epidemiological link with family members returned from northern Italy. At the admission, temperature was 37.8°C, oxygen saturation 95% and laboratory tests showed an enhanced C-reactive protein (3,02 mg/dL) and normal leukocytes count with lymphopenia (870 cells per μL). A computed tomography (CT) scan was performed, showing multiple ground glass opacity extensively involving the lungs bilaterally with associated mild pericardial effusion. The nasopharyngeal swab PCR-test confirmed the infection by SARS-Co-2 allowing the diagnosis of COVID-19. The patient was immediately isolated in a dedicated COVID-19 ward and was given supplemental oxygen, antiviral and anti-rheumatic drugs as protocol in our institute (lopinavir/ritonavir, hydroxychloroquine). However, the day after the patient developed progressive dyspnea, persistent fever and deterioration of hemogas oxygenation requiring c-PAP by helmet (PEEP 10 FiO 2 0.5→1). On day 4 th , the rapid worsening of respiratory conditions leads to OTI in emergency. A fast track intubation was performed using a 8 mm single-lumen oro-tracheal tube with the support of videolaringoscope. Thus, the patient was transferred to a dedicated COVID-19 intensive care unit. Immediately, the patient presented progressive subcutaneous emphysema. A flexible bronchoscopy was performed, revealing a level II tracheal laceration of about 1 cm in the membranous wall, about 2 cm distally to the vocal cords. Considering the dimension and characteristics of the rupture, a conservative management was firstly considered convenient. The oro-tracheal tube was endoscopically positioned with the cuff located distally to the lesion. Nevertheless, the subcutaneous emphysema continued to worsen (Figure1), reaching zygomatic and periorbital region, the whole chest bilaterally and the arms, accompanied by atrial fibrillation and hemodynamic instability. On day 7 th , surgical repair of the tracheal injury with tracheostomy was planned. In order to reduce the risk of epidemic spread and avoid transporting, in absence of a COVID-19 dedicated operating room, the procedure was performed bedside. Under total endovenous general anesthesia (TIVA), a transverse cervical incision of about 4 cm was performed. Meticulously dissection of the cervical fascia, platysma and pre-tracheal muscles allowed the visualization of the anterior tracheal wall. A reverse "U" shaped tracheal incision was performed and the tracheal injury identified and repaired using a 4/0 absorbable running suture. The tracheotomy was then used to insert a 8 mm cuffed tracheostomy cannula. The procedure, from tracheotomy to cannula insertion, has been rapidly performed in apnea to reduce the aerosol contamination, with anesthesiologist constantly monitoring the vital signs. By day 9, the patient conditions started to improve, with reducing in subcutaneous emphysema, increasing in gasses exchange and hemodynamic parameters and no novel episodes of tachycardia or atrial fibrillation. The patient was progressively weaned from mechanical ventilation with the improvement of oxygenation and general conditions. The incidence of airways injury due to OTI is reported approximately to 0,005% with a single-lumen tube and occurs more often in patient with difficult airway management or when performed under emergency (2). However, some author believes that it is probably underestimated as these injuries are often unrecognized and underreported (3) . Pneumomediastinum and subcutaneous emphysema are the most common clinical manifestation, however it can lead to more sever conditions like bilateral pneumothorax, hemodynamic 5 instability, mediastinitis and sepsis. The treatment options include non-invasive interventions such positioning the tracheal tube cuff distal to the lesion and observation. Surgery is indicated in case of large tracheal ruptures, type III A-B lesions (4), ventilatory instability, mediastinitis or a progressive increase in subcutaneous emphysema (3) . For injuries of the proximal one-third of the trachea, a transcervical approach, firstly proposed by Angelillo-Mackinlay, is preferred over traditional right thoracotomy because of its less invasiveness. More recently, a transcervical-transtracheal approach that includes a T-shaped tracheotomy, has been proposed for post-intubation tracheal injury (5). Management of COVID-19 patients represents a challenge especially during invasive airways interventions (2) . A negative-pressure operating room, adequate protective equipment and an experienced team is mandatory for minimalize the risk of contagion. In this case, the precautions used to minimalize the epidemic spread were: 1) Bedside approach. The choice for a bedside approach avoids patient transport and disconnection/reconnection to ventilators. Transferring of COVID-19 patients must be always considered a risk of contamination and avoided if possible. The bedside approach avoid risks related to transport and the requirement of a dedicated operating room as previously demonstrated during SARS and MERS outbreak (6). 2) Time of aerosol exposure. Intraoperatively, some tricks have been adopted to reduce the time of respiratory secretion exposure. First of all, the patient remain ventilated through oro-tracheal tube, connected to a closed viral-filtered system, until the reverse "U" shaped tracheal incision was performed. The adequate length of tracheotomy for surgical repair and subsequent tracheostomy cannula insertion, has been checked in this phase. Second, the ventilation was stopped and the tube withdrawn to visualize the tracheal injury. Third, the repair was rapidly performed during patient's apnea. This was possible since the lesion was small; however, an on-field 5 mm tracheal tube was available if ventilation was needed. No suction was needed. 3) General anesthesia. TIVA, with infusion of propofol, sufentanyl and rocuronium, guarantees deep curarization to prevent cough or reflexes during the procedure. Unquestionably, this technique present some limitations, mainly related to the impossibility in treating large injuries or lesion of the lower-third of the trachea. Moreover, the bedside approach present some considerations related to the limited space, suboptimal positioning of the patient and the movement of essential surgical instruments (6) . However, these difficulties can be overpassed with a rigorous preoperative planning and an experienced team. A Novel Coronavirus from Patients with Pneumonia in China The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice Treatment of Tracheobronchial Injuries: A Contemporary Review Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment Surgical approaches to membranous tracheal wall lacerations Surgical Considerations for Tracheostomy During the COVID-19 Pandemic: Lessons Learned From the Severe Acute Respiratory Syndrome Outbreak