10.14639/0392-100X-N1952
Objective. The COVID-19 pandemic was an extraordinary challenge for the global health-care system not only for the number of patients affected by pulmonary disease, but also for the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) repre-sents one of the most common complications of invasive ventilation. Methods. A case series of patients who underwent tracheal resection and anastomosis (TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021. Results. Among 14 patients included, 50% had diabetes and 64.3% were obese. During intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10 patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31 days. According to the European Laryngological Society classification, 13 patients (92.9%) had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according to the authors’ classification. No major perioperative complications were reported and at the last follow-up all patients were asymptomatic. Conclusions. With the appropriate indications, TRA represents an effective treatment in post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in order to reduce the incidence of airway injury.
text/xml
1827-675X
1952
en
Giorgio Peretti
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
tracheostomy
Post-COVID-19 airway stenosis treated by tracheal  resection and anastomosis: a bicentric experience
Text.Serial.Journal
https://www.actaitalica.it/
42
COVID-19
2022-05-16
2021-12-03
2022-05-23
2022-05-23
99-105
1
Giorgio Peretti
2022/05/16
10.14639/0392-100X-N1952
99
Unit of Otorhinolaryngology – Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, School of Medicine, Genoa, Italy
1827-675X
tracheostomy
en
105
Post-COVID-19 airway stenosis treated by tracheal  resection and anastomosis: a bicentric experience
https://www.actaitalica.it/article/download/1952/784
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:99-105; doi: 10.14639/0392-100X-N1952




COVID-19


Post-COVID-19 airway stenosis treated by tracheal
resection and anastomosis: a bicentric experience
Stenosi tracheali post-COVID-19 trattate con resezione e anastomosi tracheale:
l’esperienza di due centri
Cesare Piazza1, Davide Lancini1, Marta Filauro2, Claudio Sampieri2, Paolo Bosio1, Gabriele Zigliani1, Alessandro Ioppi2,
Alberto Vallin2, Alberto Deganello1, Giorgio Peretti2
1
  Unit of Otorhinolaryngology – Head and Neck Surgery, ASST Spedali Civili di Brescia, Department of Medical and Surgical
Specialties, Radiological Sciences, and Public Health, University of Brescia, School of Medicine, Brescia, Italy; 2 Unit of
Otorhinolaryngology – Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Department of Surgical Sciences and
Integrated Diagnostics, University of Genoa, School of Medicine, Genoa, Italy


SUMMARY
Objective. The COVID-19 pandemic was an extraordinary challenge for the global health-
care system not only for the number of patients affected by pulmonary disease, but also for
the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) repre-
sents one of the most common complications of invasive ventilation.
Methods. A case series of patients who underwent tracheal resection and anastomosis
(TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021.
Results. Among 14 patients included, 50% had diabetes and 64.3% were obese. During
intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10
patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31
days. According to the European Laryngological Society classification, 13 patients (92.9%)
had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according
to the authors’ classification. No major perioperative complications were reported and at the
last follow-up all patients were asymptomatic.
Conclusions. With the appropriate indications, TRA represents an effective treatment in         Received: December 3, 2021
                                                                                                Accepted: January 19, 2022
post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in
order to reduce the incidence of airway injury.
                                                                                                Correspondence
KEY WORDS: airway stenosis, COVID-19, tracheal resection, tracheal intubation,                  Davide Lancini
tracheostomy                                                                                    Unit of Otorhinolaryngology – Head and Neck
                                                                                                Surgery, ASST Spedali Civili di Brescia, piazza
                                                                                                Spedali Civili 1, 25123 Brescia, Italy
RIASSUNTO                                                                                       Tel. +39 030 3995319. Fax +39 030 3996142
Obiettivo. La pandemia da COVID-19 ha rappresentato una sfida straordinaria, sia per il         E-mail: lancinidavide@gmail.com
numero di pazienti colpiti, che per l’incidenza di sequele. Tra queste, la stenosi laringo-
tracheale (LTS) è tra le complicanze più comuni dopo ventilazione invasiva.                       How to cite this article: Piazza C, Lancini D,
Metodi. È stata raccolta una casistica di pazienti sottoposti a resezione-anastomosi trache-      Filauro M, et al. Post-COVID-19 airway ste-
ale (TRA) per LTS post-COVID-19 dal Giugno 2020 al Settembre 2021.                                nosis treated by tracheal resection and anas-
Risultati. Tra i 14 pazienti inclusi, il 50% era affetto da diabete ed il 64,3% da obesità.       tomosis: a bicentric experience. Acta Otorhi-
Durante la degenza in terapia intensiva, la durata media di intubazione orotracheale (OTI)        nolaryngol Ital 2022;42:99-105. https://doi.
è stata di 15,2 giorni e 10 pazienti (71,4%) sono stati sottoposti a tracheotomia, mantenuta      org/10.14639/0392-100X-N1952
in 7 di loro per una media di 31 giorni. Secondo la classificazione della Società Europea
di Laringologia, 13 pazienti avevano una LTS di grado IIIa ed uno di grado IIIa+. Tutti         © Società Italiana di Otorinolaringoiatria
                                                                                                e Chirurgia Cervico-Facciale
i pazienti sono stati sottoposti a TRA di Tipo A secondo la classificazione proposta dagli
autori. Non ci sono state complicanze perioperatorie e all’ultimo follow-up tutti i pazienti
                                                                                                               OPEN ACCESS
sono asintomatici.
Conclusioni. Con le giuste indicazioni, la TRA è un trattamento efficace in pazienti affetti    This is an open access article distributed in accordance with
                                                                                                the CC-BY-NC-ND (Creative Commons Attribution-Non-
da LTS post-COVID-19. Un’OTI breve ed un’attenta tecnica tracheotomica sono necessa-            Commercial-NoDerivatives 4.0 International) license. The
rie per ridurre l’incidenza di lesioni tracheali.                                               article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: stenosi tracheale, COVID-19, resezione tracheale, intubazione                    only in the original version. For further information: https://
tracheale, tracheotomia                                                                         creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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Introduction                                                     the unpredictable course of the infection did not allow to
                                                                 foresee the patients’ time of recovery. Moreover, the fear of
Clinical management of patients affected by symptomatic          contamination of health care workers during invasive and
SARS-CoV-2 infection has proven to be complicated and            aerosol generating manoeuvers such as tracheostomy of-
shaded by an unpredictable viral infection course. The cor-      ten led to the use of larger than normal tubes, maintenance
nerstone of treatment of COVID-19 is represented by res-         of excessively high cuff pressure and delay in tracheotomy
piratory support, which can be administered either through       performance 7. As a consequence, in post-COVID-19 pa-
face/nose masks or via oral/nasal and tracheal intubation 1.     tients, we expected an increased incidence of LTS and rec-
This latter invasive treatment, as reported by Grasselli and     ommended that patients presenting with breathing difficul-
colleagues 2, is administered in nearly all (88%) patients       ties within 6 months after ICU discharge receive a targeted
admitted to the intensive care unit (ICU), with an absolute      evaluation aimed at ruling out the possibility of a iatrogenic
number of hospitalised patients who were intubated dur-          LTS.
ing the pandemic reaching a remarkable rate, as high as          Following the European Laryngological Society (ELS)
33.1% from data collected in New York 3. Notably, of those       warning concerning the possible increased incidence of
patients, the vast majority (72.5%) required prolonged           LTS in post-COVID-19 patients 7, we prospectively col-
endotracheal intubation (>7 days) 3, while it was needed         lected data regarding patients diagnosed with critical air-
in nearly 12% of all patients who were affected by COV-          way after a prolonged intubation due to SARS-CoV-2
ID-19 4,5.                                                       infection and therefore treated in two tertiary referral aca-
As reported in the literature 6, prolonged endotracheal in-      demic centres by tracheal resection and anastomosis (TRA)
tubation may lead to mucosal damage and inflammation,            as the index surgical procedure. The present study reports
granulation tissue formation, perichondritis, chondritis and     our experience in this clinical scenario and outlines critical
subsequent cicatricial stenotic tissue formation. In addi-       issues that increase the patient’s risk of developing post-
tion, tracheostomy can add further damage to the already         intubation/post-tracheotomic LTS.
compromised tracheal lumen (tracheal rings fracture, col-
lapse, necrosis, malacia, and superinfection) 7, while a
number of authors 8,9 reported that the use of a large calibre   Materials and methods
endotracheal tube can increase the risk of airway mucosal        Patient selection and data collection
damage. Moreover, the absence of accurate monitoring             Patients who underwent TRA for LTS as a consequence of
of the cuff pressure or the need to maintain it above 50         invasive ventilation therapy for COVID-19 were selected
mmHg for clinical reasons (such as performance of high           at the Units of Otorhinolaryngology – Head and Neck Sur-
positive pressures ventilation in COVID-19 associated            gery of the Universities of Brescia and Genoa from June
pneumonia) are related to mucosal ischaemia and necrosis,        2020 to September 2021. After approval by the local ethic
which play a fundamental role in establishing the above-         committees (11240, CER Liguria Register N. 63/2021),
mentioned complications 10. Hence, use of the appropriate        data concerning patients demographics, comorbidities,
intubation technique minimising trauma related to aryt-          COVID-19 ventilatory treatment, type of LTS and details
enoid luxation or mucosal tearing, a precise tube calibre        of management were collected, and a dedicated database
selection and the meticulous control of cuff pressure are        completed.
of paramount importance to minimise the risk of ensuing          Demographics included patients age, gender and comor-
laryngo-tracheal stenosis (LTS). The estimated rate of LTS       bidities, with particular attention to metabolic diseases.
due to endotracheal intubation ranges from 10% to 22% 11         Data regarding COVID-19 respiratory support consisted of
if all the aforementioned technical issues are carefully fol-    duration of ICU hospitalisation, time and duration of oro-
lowed. Moreover, only 1-2% of patients affected by this          tracheal intubation (OTI), presence and type of tracheos-
complication will possibly complain of severe dyspnoea,          tomy (i.e., surgical vs percutaneous), duration of tracheal
making post-intubation/post-tracheotomic critical LTS a          intubation through the tracheostomy, time of ventilation
rather rare event, with an estimated incidence of 4.9 pa-        weaning/tracheostomy tube removal, and eventual subse-
tients/1,000,000 people per year 6.                              quent re-intubation. Time elapsed between ICU discharge
In this respect, all due attentions have been commonly rec-      and LTS diagnosis was also registered. Data regarding
ommended and observed during the intubation protocol             LTS features was collected using a standardised diagnos-
and management in the pre-pandemic era, while during             tic work-up, and included length, anatomical subsite and
COVID-19 this was often not achieved for a number of rea-        grade of stenosis, according to the ELS classification 12.
sons. Indeed, especially at the beginning of the pandemic,       Data concerning treatments encompassed the number and



100
                                                                            Crico-tracheal resection and anastomosis for post-COVID-19 laryngotracheal stenosis




type of endoscopic therapeutic procedures, extension and                            centres complaining of dyspnoea at rest or progressive ex-
type of TRA according to the University of Brescia clas-                            ertional dyspnoea, or the impossibility to be properly de-
sification system 13 (Fig. 1), surgical complications, further                      cannulated. In case of critical LTS at the first counselling,
interventions and postoperative medical therapy. Finally,                           rigid bronchoscopic dilatation was first performed to allow
data concerning surgical outcomes and clinical follow-up                            proper symptom relief before adequate diagnostic work-up.
duration were collected.                                                            If the procedure was not possible, or if it was insufficient
                                                                                    in obtaining an adequate airway, a trans-stenotic tracheos-
Diagnostic work-up and surgery                                                      tomy was performed under local anaesthesia.
All patients included in the present study referred to our                          A standardised diagnostic protocol was then applied to
                                                                                    each patient, as described by Monnier et al. 12. Namely,
                                                                                    each patient underwent awake nasal flexible fibreoptic
                                                                                    laryngoscopy to assess vocal fold mobility and exclude
                                                                                    other potential airway anomalies. If present, laryngoscopy
                                                                                    was carried out also through the tracheostoma in order to
                                                                                    evaluate the distal trachea and subglottic area from below.
                                                                                    When an alteration of the laryngo-tracheal framework was
                                                                                    suspected, radiologic examination by neck and chest CT
                                                                                    was performed. Moreover, a direct laryngoscopy with rigid
                                                                                    instrumentation under general anaesthesia was performed
                                                                                    to assess the length and grade of LTS, and to remove by
                                                                                    transoral carbon dioxide laser and gentle dilatation possible
                                                                                    scar or synechiae, which could interfere with the final TRA
                                                                                    procedure.
                                                                                    After collection of all this information, LTS was classified
                                                                                    according to the ELS proposal 12 and the adequate surgical
                                                                                    treatment planned. In detail, TRA was indicated in case of
                                                                                    high grade mature stenoses (grade III-IV), with cranio-cau-
                                                                                    dal extension > 1 cm (and < 5.5 cm), and/or laryngo-trache-
                                                                                    al framework impairment, or in case of absence of response
                                                                                    to multiple endoscopic procedures. TRA were then catego-
                                                                                    rised according to the University of Brescia classification
                                                                                    as previously described by Piazza et al. 13.

                                                                                    Results
                                                                                    Fourteen patients were treated by TRA for COVID-19 re-
                                                                                    lated LTS at our centres between June 2020 and Septem-
                                                                                    ber 2021. In particular, 9 (64.3%) patients were treated at
                                                                                    the Unit of Otorhinolaryngology – Head and Neck Surgery
                                                                                    of the University of Brescia, and 5 (35.7%) in the Unit of
                                                                                    Otorhinolaryngology – Head and Neck Surgery of the Uni-
                                                                                    versity of Genoa. They represented 43.8% of the overall
                                                                                    number of patients managed in the same time frame by
Figure 1. University of Brescia (C)TRA classification 13. Type A1 refers to         (crico)-tracheal resection and anastomosis [(C)TRA] for
tracheal rings resection with tracheo-tracheal anastomosis; Type A2 is char-        all causes of LTS at both Institutions.
acterised by tracheal rings resection with crico-tracheal anastomosis; Type B
includes tracheal rings resection with anterior cricoid arch removal and sub-       The male to female ratio was 11:3, and mean age was 54
sequent thyro-crico-tracheal anastomosis; Type C encompasses tracheal rings         years (range, 34-67). Twelve (85.7%) patients had at least
removal with anterior cricoid arch resection and posterior cricoid plate reshap-    one comorbidity; in detail, 7 (50%) reported diabetes mel-
ing/partial removal up to the crico-arytenoid joints and subsequent thyro-cri-
                                                                                    litus and 9 (64.3%) obesity. One (7.1%) patient underwent
co-tracheal anastomosis and cricoid plate covering by a mucosal flap of pars
membranacea; Type D is the same of Type C with posterior midline cricoid split      tracheostomy in childhood for respiratory insufficiency due
and cartilaginous graft insertion for massive posterior glottic stenosis.           to viral infection and one (7.1%) presented with tracheo-



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C. Piazza et al.




oesophageal fistula associated with airway stenosis. Addi-                            most common involved site (13 [92.9%] patients), while
tional details on comorbidities are listed in Table I.                                a central tracheal stenosis was reported in one patient
All patients were hospitalised in the ICU for COVID-19:                               (7.1%). Overall, 13 (92.9%) cases were classified as grade
mean OTI duration was 15.2 days (range, 4-24) and 10                                  IIIa stenosis and one (7.1%) as IIIa+ (for the presence of
(71.4%) underwent tracheostomy during ICU stay. In de-                                associated tracheo-oesophageal fistula) according to the
tail, among patients who received tracheostomy, the mean                              ELS classification system 12.
OTI duration was 15.8 days (range, 4-24). Tracheostomy                                All patients arrived at the planned TRA surgical procedure
had been surgically performed in 6 (60%) patients and by                              without major respiratory distress, while in one case an
a percutaneous technique in 4 (40%). Among those who                                  emergency trans-stenotic tracheostomy was required for
underwent tracheostomy, 7 (70%) had the cannula removed                               acute dyspnoea. Two (14.3%) patients underwent glottic
at the end of the hospitalisation, and the average time of                            synechia resection with carbon dioxide laser during
tracheostomy maintenance was 31 days (range, 16-49). In 3                             microlaryngoscopy under general anaesthesia before TRA.
cases, tracheostomy closure was not possible, and the can-                            All patients underwent Type A TRA 15 (5 with tracheo-
nula remained in place until TRA.                                                     tracheal anastomosis or Type A1, and 9 with crico-tracheal
After the first ICU hospitalisation, 2 (14.3%) patients re-                           anastomosis or Type A2) and were extubated immediately
quired further ICU admission for sudden clinical worsen-                              after surgery without the need to perform tracheostomy.
ing. In detail, one patient, who already had the tracheosto-                          Average extension of the resected stenotic tract was 5.5
my closed, was ventilated via OTI for one more day, while                             tracheal rings (range, 4-7). The immediate postoperative
the second, who already received mechanical ventilation                               course was uneventful for all patients, except for minimal
for 13 days, required 5 additional days of OTI support be-                            subcutaneous emphysema in one (7.1%) patient that
fore surgical tracheostomy placement, which was main-                                 resolved spontaneously within 48 hours, and mean
tained for 17 more days.                                                              hospitalisation time was 12.1 days (range, 8-28). After
After ICU discharge and LTS diagnosis, 8 (57.1%) patients                             hospital discharge, one (7.1%) patient developed a late
underwent rigid bronchoscopy dilatation before TRA and,                               circumferential re-stenosis at the anastomotic site, which
among these, in 4 cases multiple endoscopic procedures                                required 3 further bronchoscopic dilatations and prolonged
were performed, with tracheal stent placement in one patient.                         steroid therapy. At the last endoscopic evaluation, this
At preoperative assessment, all patients were affected by                             patient had asymptomatic grade I stenosis. At follow-up, all
purely tracheal stenoses, being the cervical trachea the                              the remaining patients remained asymptomatic and showed


Table I. Patient comorbidities, type of TRA performed, complications, and adjunctive procedures needed to obtain a patent airway.
 Patient no.                           Comorbidities                          Type of TRA            Complications              Adjunctive procedures for
                                                                                                                                obtaining a normal airway
 1                   Type II diabetes mellitus, hypothyroidism, hypertension,          A2          Tracheal stenosis at the    3 bronchoscopic dilatations
                                   tracheostomy during childhood                                       anastomotic site       and prolonged steroid therapy
 2                 Type II diabetes mellitus, critical illness neuropathy, obesity,    A1                   None                           -
                                     tracheo-oesophageal fistula
 3                          Grade A oesophagitis, chronic renal failure                A2        Subcutaneous emphysema                     -
 4                            Hypertension, obesity, adrenal adenoma                   A1                 None                              -
 5                                      Hypertension, obesity                          A1                 None                              -
 6                                              None                                   A2                 None                              -
 7                        Type II diabetes mellitus, hypertension, obesity             A2                 None                              -
 8                   Type II diabetes mellitus, hypertension, bilateral carotid        A1                 None                              -
                                        stenosis, hiatal hernia
 9                           Hypertension, obesity, massive pulmonary                  A1                   None                            -
                      thromboembolism during SARS-CoV-2 hospitalisation
 10                       Type II diabetes mellitus, obesity, hypertension             A2                   None                            -
 11                       Type II diabetes mellitus, obesity, hypertension             A2                   None                            -
 12                                            Obesity                                 A2                   None                            -
 13                       Type II diabetes mellitus, obesity, hypertension             A2                   None                            -
 14                                             None                                   A2                   None                            -




102
                                                                                  Crico-tracheal resection and anastomosis for post-COVID-19 laryngotracheal stenosis




Table II. Summary of main results.                                                        pressures, and consequent high tube cuff pressure, is the
 ICU stay                                                                                 main factor leading to LTS and airway injuries 18. Moreover,
 Mean OTI duration             15.2 days (4-24)                                           the need for repeated pronation cycles used in intubated
 Tracheostomy                  10 patients (71.4%)                                        patients with COVID-19 could have caused an increase in
                               Surgical tracheostomy 6 (60%)                              airway lesions, due to the possible increase in tube pressure
                               Percutaneous tracheostomy 4 (40%)                          at the anterior/posterior glottic level.
 Mean tracheostomy maintenance 31 days (16-49)                                            Furthermore, among the 14 patients, only 2 had no
 Preoperative treatment
                                                                                          comorbidities, with obesity and diabetes being among
                                                                                          the most common (5 [35.7%] patients had both diabetes
 Endoscopic dilatation                   8 patients (57.1%)
                                                                                          and obesity, 4 [28.6%] only obesity, and 2 [14.2%] only
                                         Single procedure 4 (50%)
                                                                                          diabetes). In particular, type 2 diabetes mellitus is a well-
                                         Multiple procedures 4 (50%)
                                                                                          known predisposing factor for LTS, being probably related
 Emergency tracheostomy                  1 (7.1%)
                                                                                          to different metabolism and fibroblast populations 19.
 Glottic synechiae transoral CO2-        2 (14.3%)                                        On the other hand, in overweight patients, the required
 laser resection
                                                                                          ventilatory pressure is set to higher levels due to their lower
 LTS characteristics
                                                                                          thoracic compliance, and this can therefore contribute to
 Tracheostomy presence                   4 patients (28.6%)                               the ischemic mechanism leading to post-intubation LTS
 LTS ELS grade                           IIIa                                             formation.
                                         IIIa+13 (92.9%)                                  What remains a major concern and doubt, even in the litera-
ICU: Intensive care unit, OTI: Oro-tracheal intubation, LTS: Laryngo-tracheal stenosis,   ture, is the timing of tracheostomy, which, among patients
ELS: European Laryngological Society.
                                                                                          in the present case series, was after 15 days of OTI. Dealing
                                                                                          with post-intubation LTS, Li and coworkers 20 described a
no residual airway stenosis. A summary of main results is                                 significant 3.3 times higher probability of late tracheosto-
reported in Table II.                                                                     my (defined as > 10 days) among patients with post-trache-
                                                                                          ostomy tracheal stenosis. Beyond LTS outcomes, a recent
                                                                                          meta-analysis21 showed that early tracheostomy (< 10 days)
Discussion                                                                                performed in ICU patients was associated with better clini-
As predicted during the first phase of the pandemic by the                                cal outcomes, shorter ICU stays and lower long-term mor-
Laryngotracheal Stenosis Committee of the ELS 7, the wide                                 tality. The same result, in terms of reduced duration of ICU
application of invasive ventilatory support in a considerable                             stay, was also demonstrated in COVID-19 patients who re-
number of COVID-19 patients led to an absolute increase                                   ceived an early tracheostomy 22.
of the number and severity of airway injuries. To the best                                On the other hand, the literature is concordant in finding
of our knowledge, this paper describes one of the largest                                 no major differences in outcomes between surgical and
multicentric case series of patients surgically treated for                               percutaneous tracheostomy when performed in COVID-19
LTS after prolonged invasive ventilation for SARS-CoV-2                                   patients, as also confirmed by our series 23. Naturally, as a
infection 15-17. Such a large number of patients was probably                             rule of thumb, the major concern in tracheostomy prepa-
encountered because Northern Italy was one of the most                                    ration should always be to allow a safe tracheal opening,
affected European areas in the first pandemic wave and our                                without damaging the surrounding laryngotracheal frame-
hospitals are both referral centres for airway diseases.                                  work. The issues of tracheal tube change, correct position-
All patients except one were hospitalised in the ICU for                                  ing and possibility of proper toilette in relation to the type
COVID-19 during the first wave of the pandemic. In fact,                                  of tracheostomy performed and canula applied have been
in the initial phase of SARS-CoV-2 spread, the airway                                     so far scarcely considered, but definitely play a major role
management of affected patients and proper ventilation                                    in airway stenosis formation.
support strategy in the ICUs was debated, due to the lack                                 Concerning treatment outcomes, the present series showed
of knowledge of the clinical behaviour of this new virus,                                 that (C)TRA still represents a sound, definitive and effec-
consequent fear for health care worker contagion, and the                                 tive surgical technique, if applied with the right criteria and
huge and unexpected number of patients requiring rapid                                    indications, even in post-COVID-19 patients, who may be
treatment. Looking at our case series, these problems find an                             affected by long-term airway and systemic sequelae. More-
exact reflection in the heterogeneity of OTI duration (range,                             over, the ELS classification of benign LTS 12 showed a high
4-24 days) and consequent tracheostomy timing. Prolonged                                  reliability in treatment selection also in the present popu-
mechanical ventilation via OTI, using high ventilatory                                    lation, proving high decannulation and low complications



                                                                                                                                                               103
C. Piazza et al.




rates for patients categorised as having airway stenosis          Ethical consideration
graded as < IIIb 24,25. This classification, in fact, showed a    This study was approved by the Institutional Ethics Com-
sound result in predicting outcomes of (C)TRA for benign          mittee (CER Liguria). Number of protocol: 63/2021.
LTS, both in adult and paediatric populations 24,25.              The research was conducted ethically, with all study pro-
The most notable limitations of our work are the low num-         cedures being performed in accordance with the require-
ber of included patients, which did not allow to perform          ments of the World Medical Association’s Declaration of
adequate statistical analysis and comparison with other           Helsinki.
clinical conditions such as non-COVID-19 LTS treated by           Written informed consent was obtained from each partici-
similar approaches, and the heterogeneity of ICU manage-          pant/patient for study participation and data publication.
ment, which was due both to the lack of guidelines in the
first pandemic phase and to the difference in therapeutic         References
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                                                                  6
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confirmed to be an effective and resolutive surgical pro-              2021;278:1-7. https://doi.org/10.1007/s00405-020-06112-6
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Conflict of interest statement                                         lation. Crit Care Med 2019;47:1699-1706. https://doi.org/10.1097/
                                                                       CCM.0000000000004015
The authors declare no conflict of interest.                      10
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Funding                                                                multicenter study. Anesth Analg 2010;111:1133-1137. https://doi.
                                                                       org/10.1213/ANE.0b013e3181f2ecc7
This research did not receive any specific grant from fund-
                                                                  11
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Authors’ contributions                                                 classification of benign laryngotracheal stenosis: a consensus paper
                                                                       of the European Laryngological Society. Eur Arch Otorhinolaryngol
Concept: CP, DL, MF, AD, GP. Data collection: CS, PB,                  2015;272:2885-2896. https://doi.org/10.1007/s00405-015-3635-4
GZ, AI, AV. Writing – original draf: DL, MF, PB, CS. Writ-        13
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ing – review and editing: CP, AD, GP DL, PB.                           and cricotracheal resection and anastomosis for inflammatory and




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