Clinical Scorecard: Management of Tracheal Stenosis through Surgical Intervention in the Context of Covid-19: Insights from a Single-Center Study

At a Glance

Key Highlights

• Prolonged (>14 days) invasive mechanical ventilation is the main cause of acquired tracheal stenosis.
• Covid-19 ICU patients often require longer ventilatory support and have increased incidence of post-IMV tracheal stenosis.
• Surgical resection with primary end-to-end anastomosis is performed after failure of conservative endoscopic treatments.

Guideline-Based Recommendations

Diagnosis

• Perform fiberoptic bronchoscopy to assess stenosis features including morphology, location, length, lumen, and cartilaginous involvement.
• Conduct neck and thorax CT scan with multiplanar reconstructions to evaluate anatomical relationships.
• Exclude patients with tracheo-esophageal fistula from standard surgical analysis due to complexity.

Management

• Primary endoscopic treatments (laser disobstruction, balloon dilation, stent placement) may be attempted initially.
• Surgical intervention involves tracheal resection and primary end-to-end anastomosis under general anesthesia with intraoperative bronchoscopy.
• Post-Covid-19 patients should be clinically healed and PCR negative before surgery; ideally wait at least 2 months post-IMV when possible.
• Use synthetic monofilament absorbable sutures for anastomosis; place chest-to-chin stitches to avoid neck extension.

Monitoring & Follow-up

• Perform fiberoptic bronchoscopy immediately post-surgery and on postoperative days 3 and 7 or as clinically indicated.
• Assess anastomosis patency intraoperatively and postoperatively via bronchoscopy.
• Avoid chronic steroid therapy postoperatively; short-term high-dose corticosteroids may be used selectively.

Risks

• Potential for anastomotic complications requiring close bronchoscopic monitoring.
• Increased complexity and risk in patients with tracheo-esophageal fistula (excluded from this study).

Patient & Prescribing Data

Patients undergoing surgery for benign tracheal stenosis during the Covid-19 pandemic, including post-Covid-19 and non-Covid-19 groups

Surgical outcomes analyzed retrospectively; post-Covid-19 patients require careful timing and multidisciplinary evaluation before surgery.

Clinical Best Practices

• Multidisciplinary preoperative assessment involving thoracic surgeon, bronchial endoscopist, anesthesiologist, and pneumologist.
• Use intraoperative fiberoptic bronchoscopy to guide intubation and confirm stenosis margins.
• Extubate patients immediately after surgery and monitor airway patency closely with scheduled bronchoscopies.
• Place chest-to-chin stitches to prevent neck extension and protect anastomosis integrity.
• Delay surgery post-Covid-19 infection until clinical healing and negative PCR testing to reduce complications.

References

• Richards-Belle et al., 2020
• General knowledge on tracheal stenosis pathophysiology and management