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Tracheal Stenosis/Stenosis Symptoms and Treatment Methods After the COVID-19 Pandemic
One of the main problems after the Covid-19 pandemic is tracheal stenosis due to intubation. During the pandemic, patients with severe Covid 19 had respiratory failure; some experienced intubation and mechanical ventilation.

After treatment, patients who went through Covid-19 may develop tracheal obstruction or tracheal stenosis. Tracheal stenosis causes in these Covid-19 patients are as follows;

  • Prolonged intubation time
    • Prolonged insertion of an endotracheal tube (breathing tube) or tracheostomy
    • Tracheal stenosis due to long etching in the intensive care unit usually occurs after three months. However, we had cases where we observed earlier tracheal stenosis in patients with Covid 19.
  • Overinflation of intubation cuffs/balloons during the intubation process
    • For patients who have experienced intubation for a long time, necrosis develops if the tube's balloon is too swollen. Scar/fibrosis tissue occurs, and the tracheal lumen is narrowed
  • High level of infection and inflammation in cases with Covid-19
  • Failure in performing tracheostomies by unexperienced physicians
  • Failure to prefer intubation cannulas suitable for the anatomical structures of these patients
  • The imbalanced pressure of ventilator sets may increase the rate of stenosis.
    We can reduce the risk of tracheal stenosis after intubation with some precautions in patients with Covid-19.

We can reduce the risk of tracheal stenosis after intubation with some precautions in patients with Covid-19.

In cases with Covid -19, the formation of scar tissue, which we call fibrosis in the trachea, and the loss of flexibility of the cartilage in the trachea, called tracheomalacia, is the narrowing and closing of the trachea during breathing. When this narrowing in the trachea exceeds 50 percent, it presents with the following symptoms.

Clinical Symptoms in Covid-19 Tracheal Stenosis

In patients with Covid-19, recovery is slow if the lungs are affected and intubated. However, contrary to the expectation of recovery in some patients, we can observe the following;

  • Breathlessness, which we call dyspnea, is shortness of breath
  • Difficulty in breathing when talking or with exercise
  • wheezing in breathing
  • The high-pitched breathing sound that we call stridor
  • Prominent blue lip, which we call cyanosis

If we expect improvement in a patient with Covid-19, however, if the above symptoms occur, it is necessary to consider whether tracheal stenosis has developed.

How is Tracheal Stenosis Diagnosed in Patients with Covid-19?

  • Physical examination findings and symptoms such as stridor and wheezing are helpful.
  • Thorax CT can show us the stenosis well.
  • Bronchoscopy is considered the "Gold Standard" for diagnosing tracheal stenosis. Here, we can see the stenosis with bronchoscopy in all its details, including the degree of stenosis, length, location, and proximity to the vocal cords. It is crucial in the treatment decision.
  • Rigid bronchoscopy allows the overcoming of stenosis with diagnostic and therapeutic methods, and the patient is relieved. But we observed that patients with Covid -19 developed stenosis again within one month after dilation, so we started to prefer surgery.
  • In rare cases, a thoracic MRI may also be necessary.

1 - Tracheal Stenosis CT Image

2 - Bronchoscopic image in a patient who developed Tracheal Stenosis after Covid -19

Treatment in Covid-19 Tracheal Stenosis Cases

Bronchoscopic Tracheal Dilatation- After thorax CT, first of all, flexible bronchoscopy (FOB) detects tracheal stenosis and determines the diameter of the stenosis, the degree of stenosis, its length, location, and its proximity to the vocal cords. Then, under general anesthesia, narrowing is provided with Rigid bronchoscopy to widen the trachea with surgical instruments called balloons or tracheal dilators, and the patient is temporarily relieved.

In Covid-19 cases, we can repeat this dilatation process several times. If tracheal stenosis recurs despite repeated treatment, we remove the stenosis site and perform an end-to-end anastomosis if the patient is suitable for surgery. If the patient's general condition does not allow surgery, dilatation and a tracheal stent are inserted. In our cases, compared to other patients, we observed that in patients who had covid-19, the patient was relieved after tracheal dilatation. Still, stenosis generally develops in a short time. Therefore, in such cases, surgery is the best alternative after dilatation.

Tracheal Stent - A tracheal stent is a tube made of metal or silicone placed in the airway to help keep the patient's airway open. Stents are both short-term and long-term therapy for stenosis. In our observations, patients with Covid-19 usually develop subglottic stenosis, which means it is very close to the vocal cords, which may not be suitable for stents in general. In this situation, we prefer a surgical method to remove the stenosis and perform the end-to-end anastomosis.

Tracheal Resection and Reconstruction – The narrowed portion of the tracheal stenosis is removed segmentally. Then the upper and lower parts of the trachea are sutured end-to-end. If the stenosis is in the upper trachea, it is made with an incision in the neck; if it is in the lower part of the trachea, we do a right thoracotomy. This surgery is a special operation. Due to the technical difficulties during the procedure, you must have a good anesthesia team and an excellent intensive care unit.

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