Endotracheal Tube Obstruction Among Patients Mechanically Ventilated for ARDS Due to COVID-19: A Case Series

Background: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing endotracheal tube (ETT) obstruction that has not been previously described in patients with ARDS due to other causes. The purpose of this report is to describe a case series of patients with COVID-19 and ARDS in which ETT occlusion resulted in significant clinical consequences and to define the pathology of the obstructing material. Methods: Incidents of ETT occlusion during mechanical ventilation of COVID-19 patients were reported by clinicians and retrospective chart review was conducted. Statistical analysis was performed comparing event rates between COVID-19 and non-COVID 19 patients on mechanical ventilation over the predefined period. Specimens were collected and submitted for pathological examination. Findings: Eleven COVID-19 patients experienced endotracheal tube occlusion over a period of 2 months. Average age was 69 (14.3, range 33-85) years. Mean APACHE III score was 73.6 (17.3). All patients had AKI and cytokine storm. Nine exhibited biomarkers for hypercoagulability. Average days on mechanical ventilation before intervention for ETT occlusion was 14 (5.18) days (range of 9 to 23 days). Five patients were discharged from the ICU, and 4 expired. Average documented airway resistance on admission was 14.2 (3.0) cm H2O/L/sec. Airway resistance before tube exchange was 28.1 (8.0) cm H2O /L/sec. No similar events of endotracheal tube occlusion were identified in non-COVID patients on mechanical ventilation during the same time period. Microscopically, the material consisted of mucin admixed with necrotic cell debris, variable numbers of degenerated inflammatory cells, oral contaminants and red blood cells. Interpretation: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing ETT obstruction due to deposition of a thick, tenacious material within the tube that consists primarily of mucin and cellular debris. Clinicians should be aware of this dangerous but treatable complication.

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Prone Position after Liberation from Prolonged Mechanical Ventilation in COVID-19 Respiratory Failure

Critical Care Research and Practice ◽

10.1155/2020/6688120 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Andrei Karpov ◽

Anish R. Mitra ◽

Sarah Crowe ◽

Gregory Haljan

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Respiratory Failure ◽

Respiratory Rate ◽

Prolonged Mechanical Ventilation ◽

Case Series ◽

Prone Positioning ◽

Retrospective Case ◽

Number Of Patients

Objective and Rationale. Prone positioning of nonintubated patients has prevented intubation and mechanical ventilation in patients with respiratory failure from coronavirus disease 2019 (COVID-19). A number of patients in a recently published cohort have undergone postextubation prone positioning (PEPP) following liberation from prolonged mechanical ventilation in attempt to prevent reintubation. The objective of this study is to systematically search the literature for reports of PEPP as well as describe the feasibility and outcomes of PEPP in patients with COVID-19 respiratory failure. Design. This is a retrospective case series describing the feasibility and tolerability of postextubation prone positioning (PEPP) and its impact on physiologic parameters in a tertiary intensive care unit during the COVID-19 pandemic. Setting and Patients. This study was conducted on patients with COVID-19 respiratory failure hospitalized in a tertiary Intensive Care Unit at Surrey Memorial Hospital during the COVID-19 pandemic. Measurements and Results. We did not find prior reports of PEPP following prolonged intubation in the literature. Four patients underwent a total of 13 PEPP sessions following liberation from prolonged mechanical ventilation. Each patient underwent a median of 3 prone sessions (IQR: 2, 4.25) lasting a median of 1.5 hours (IQR: 1.2, 2.1). PEPP sessions were associated with a reduction in median oxygen requirements, patient respiratory rate, and reintubation rate. The sessions were well tolerated by patients, nursing, and the allied health team. Conclusions. The novel practice of PEPP after liberation from prolonged mechanical ventilation in patients with COVID-19 respiratory failure is feasible and well tolerated, and may be associated with favourable clinical outcomes including improvement in oxygenation and respiratory rate and a low rate of reintubation. Larger prospective studies of PEPP are warranted.

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Protective effect of HTK solution on postoperative pulmonary function in infants with CHD and PAH

Bioscience Reports ◽

10.1042/bsr20170984 ◽

2017 ◽

Vol 37 (6) ◽

Cited By ~ 3

Author(s):

Jindong Li ◽

Yanhong Wu ◽

Xudong Tian ◽

Jiantang Wang ◽

Mingfeng Dong ◽

...

Keyword(s):

Mechanical Ventilation ◽

Inflammatory Cells ◽

Pathological Examination ◽

Control Group ◽

Lung Protection ◽

Arterial Perfusion ◽

Icu Stay ◽

Htk Solution ◽

Pulmonary Arterial ◽

Postoperative Mechanical Ventilation

Objective: In the present study, we aimed to investigate the effect of pulmonary arterial perfusion (PAP) with Histidine–tryptophan–ketoglutarate (HTK) on lung protection in infants with congenital heart disease (CHD) and pulmonary arterial hypertension (PAH) after cardiopulmonary bypass (CPB). Methods: Fifty infant patients with CHD and PAH at our hospital from January, 2016 to February, 2017 were randomly divided into control group and HTK group. The levels of interleukin-6 (IL-6), malondialdehyde (MDA), and endothelin-1 (ET-1) in serum were detected using ELISA Kit. Oxygen index (OI) and respiratory index (RI) were calculated at each time point. The time of postoperative mechanical ventilation and ICU stay was counted, and the right lower lung tissues in patients were taken for pathological examination. Results: Compared with preanesthesia, the levels of IL-6, MDA, and ET-1 in the two groups were significantly increased after CPB, and their levels in HTK group were significantly lower than that in control group. Moreover, OI in control group decreased markedly and RI in control group increased significantly after CPB. Compared with control group, the postoperative mechanical ventilation time, postoperative ICU stay, and total hospital stay in HTK group were markedly short. In addition, inflammatory cells infiltration decreased and pulmonary interstitial showed mild edema in HTK group. Conclusion: PAP with HTK could effectively reduce CPB-induced lung injury and improve lung function.

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Safety of the endotracheal tube for prolonged mechanical ventilation

Journal of Critical Care ◽

10.1016/j.jcrc.2020.10.018 ◽

2021 ◽

Vol 61 ◽

pp. 144-151

Author(s):

Graeme J. Duke ◽

John L. Moran ◽

John D. Santamaria ◽

Owen Roodenburg

Keyword(s):

Mechanical Ventilation ◽

Endotracheal Tube ◽

Prolonged Mechanical Ventilation

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Protective mechanical ventilation does not exacerbate lung function impairment or lung inflammation following influenza A infection

Journal of Applied Physiology ◽

10.1152/japplphysiol.00393.2009 ◽

2009 ◽

Vol 107 (5) ◽

pp. 1472-1478 ◽

Cited By ~ 13

Author(s):

Graeme R. Zosky ◽

Vincenzo Cannizzaro ◽

Zoltan Hantos ◽

Peter D. Sly

Keyword(s):

Mechanical Ventilation ◽

Lung Injury ◽

Influenza A ◽

Airway Resistance ◽

Inflammatory Cells ◽

Lung Mechanics ◽

Forced Oscillation Technique ◽

Protective Ventilation Strategy ◽

Protective Mechanical Ventilation ◽

Tissue Elastance

The degree to which mechanical ventilation induces ventilator-associated lung injury is dependent on the initial acute lung injury (ALI). Viral-induced ALI is poorly studied, and this study aimed to determine whether ALI induced by a clinically relevant infection is exacerbated by protective mechanical ventilation. Adult female BALB/c mice were inoculated with 104.5 plaque-forming units of influenza A/Mem/1/71 in 50 μl of medium or medium alone. This study used a protective ventilation strategy, whereby mice were anesthetized, tracheostomized, and mechanically ventilated for 2 h. Lung mechanics were measured periodically throughout the ventilation period using a modification of the forced oscillation technique to obtain measures of airway resistance and coefficients of tissue damping and tissue elastance. Thoracic gas volume was measured and used to obtain specific airway resistance, tissue damping, and tissue elastance. At the end of the ventilation period, a bronchoalveolar lavage sample was collected to measure inflammatory cells, macrophage inflammatory protein-2, IL-6, TNF-α, and protein leak. Influenza infection caused significant increases in inflammatory cells, protein leak, and deterioration in lung mechanics that were not exacerbated by mechanical ventilation, in contrast to previous studies using bacterial and mouse-specific viral infection. This study highlighted the importance of type and severity of lung injury in determining outcome following mechanical ventilation.

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Invasive pulmonary aspergillosis in COVID-19. A case series at Gregorio Maranon University General Hospital

Revista Chilena de Anestesia ◽

10.25237/revchilanestv50-03-01 ◽

2021 ◽

Author(s):

Alba Burgos Santamaría ◽

María Lema T. ◽

Ana Gloria Pizarro C.

Keyword(s):

At Risk ◽

General Hospital ◽

Chart Review ◽

Distress Syndrome ◽

Invasive Pulmonary Aspergillosis ◽

Case Series ◽

Retrospective Chart Review ◽

Single Center ◽

Secondary Complications ◽

Pulmonary Aspergillosis

Purpose: Patients with acute respiratory distress syndrome (ARDS) due to viral infection admitted at ICU are at risk for secondary complications like invasive pulmonary aspergillosis. Our study evaluates severe ARDS due to COVID-19 associated invasive pulmonary aspergillosis at a single center in Madrid, Spain. Materials and Methods: A retrospective chart review of patients with COVID-19 associated ARDS admitted to two of the five ICUs that were available at the Gregorio Maranon University General Hospital, Madrid, Spain. Results: COVID-19 associated invasive pulmonary aspergillosis was found in 4 of 79 critically ill patients with severe ARDS. Conclusion: Patients with ARDS triggered by COVID-19 seem to be at risk of developing invasive pulmonary aspergillosis, being necessary the early diagnosis and treatment in order to improve their prognosis.

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IDENTIFYING PATIENTS AT RISK FOR PROLONGED MECHANICAL VENTILATION

Critical Care Medicine ◽

10.1097/00003246-199401000-00362 ◽

1994 ◽

Vol 22 (1) ◽

pp. A189 ◽

Cited By ~ 2

Author(s):

Michael G. Seneff ◽

Douglas P. Wagner ◽

Jack E. Zimmerman ◽

Elizabeth A. Draper ◽

William A. Knaus

Keyword(s):

At Risk ◽

Mechanical Ventilation ◽

Prolonged Mechanical Ventilation ◽

Patients At Risk

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Reduced airway resistance and work of breathing during mechanical ventilation with an ultra-thin, two-stage polyurethane endotracheal tube (the Kolobow tube)

Critical Care Medicine ◽

10.1097/00003246-199702000-00014 ◽

1997 ◽

Vol 25 (2) ◽

pp. 276-279 ◽

Cited By ~ 3

Author(s):

Carlos A. Velarde ◽

Billie Lou Short ◽

Oswaldo Rivera ◽

Winslow Seale ◽

Robert Howard ◽

...

Keyword(s):

Mechanical Ventilation ◽

Endotracheal Tube ◽

Airway Resistance ◽

Work Of Breathing ◽

Two Stage

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Effects of Prolonged Mechanical Ventilation with a Closed Suction System on Endotracheal Tube Resistance and its Reversibility by a Closed Suction Cleaning System

Anaesthesia and Intensive Care ◽

10.1177/0310057x1304100607 ◽

2013 ◽

Vol 41 (6) ◽

pp. 728-735 ◽

Cited By ~ 1

Author(s):

N. A. Adi ◽

N. T. Tomer ◽

G. B. Bergman ◽

E. K. Kishinevsky ◽

D. W. Wyncoll

Keyword(s):

Mechanical Ventilation ◽

Endotracheal Tube ◽

Prolonged Mechanical Ventilation ◽

Suction System ◽

Closed Suction ◽

Cleaning System

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Emergency department predictors of tracheostomy in patients with isolated traumatic brain injury requiring emergency cranial decompression

Journal of Neurosurgery ◽

10.3171/2011.7.jns101829 ◽

2011 ◽

Vol 115 (5) ◽

pp. 1007-1012 ◽

Cited By ~ 11

Author(s):

Muhammad Shahzad Shamim ◽

Mohsin Qadeer ◽

Ghulam Murtaza ◽

S. Ather Enam ◽

Najiha B. Farooqi

Keyword(s):

Traumatic Brain Injury ◽

Emergency Department ◽

Mechanical Ventilation ◽

Brain Injury ◽

Chart Review ◽

Prolonged Mechanical Ventilation ◽

Multivariate Logistic Regression Analysis ◽

Retrospective Chart Review ◽

Severe Tbi ◽

Small Cohort

Object Patients with severe traumatic brain injury (TBI) frequently require a tracheostomy for prolonged mechanical ventilation and/or pulmonary toilet. It is now proven that the earlier the procedure is done, the more beneficial it is to the patient. The present study was carried out to determine if the requirement of a tracheostomy can be predicted on arrival of a patient to the emergency department. The prediction can potentially aid in combining the procedure with cranial decompression. In this study, the authors' aim was to determine the emergency department predictors of tracheostomy in patients with isolated TBI requiring emergency cranial decompression. Methods The authors performed a retrospective chart review of all patients who underwent surgery for isolated TBI and required more than 4 days of mechanical ventilation. Multivariate logistic regression analysis was used for predictive indicators. Results In patients with isolated severe TBI, a patient age of 31–50 years, the presence of preexisting medical comorbid conditions, a delay in emergency department arrival exceeding 1.5 hours, an abnormal pupil response on arrival, and a preoperative neurological worsening during hospital stay were independent predictors of the requirement for tracheostomy. These findings were validated in a small cohort of patients and were found to be significant. Conclusions Requirement of a tracheostomy can be predicted in patients with severe TBI on arrival to the emergency department. These results were validated in a small cohort of patients, and it was found that the positive predictive value of requirement of tracheostomy was directly proportional to the number of predictors present. Larger prospective studies with appropriate control groups are further recommended to validate the authors' findings.

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