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Necrotizing tracheobronchitis with endotracheal tube obstruction in COVID-19 patients
Traqueobronquitis necrosante con obstrucción del tubo endotraqueal en pacientes COVID-19
G. Pérez Acosta, L. Santana-Cabrera
Corresponding author
Servicio de Medicina Intensiva, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Las Palmas, Spain
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Pérez Acosta, L. Santana-Cabrera" "autores" => array:2 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Pérez Acosta" ] 1 => array:4 [ "nombre" => "L." "apellidos" => "Santana-Cabrera" "email" => array:1 [ 0 => "lsancabx@gobiernodecanarias.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Las Palmas, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Traqueobronquitis necrosante con obstrucción del tubo endotraqueal en pacientes COVID-19" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">COVID-19 is an infection caused by the SARS-CoV-2 virus that can cause severe or fatal complications in high-risk patients. Though rare, we have observed several cases of necrotizing tracheobronchitis, which causes airway obstruction, with necrotic and hemorrhagic debris that obstruct the trachea and bronchi.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This problem has already been described in infections caused by the H1N1 flu virus, bacterial infections, and diseases such as rheumatoid arthritis or ulcerative colitis. It is associated with the formation of bronchial blood clots, bronchial hypersecretion, and presence of bacterial lung infection.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> Said clots provoke severe obstruction of the bronchial lumen, leading to an increase in airway pressure and making ventilation impossible. In many cases, it is necessary to exchange the endotracheal tube urgently.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This complication, which we believe may influence a patient's prognosis, entails an increase in risk of contagion by healthcare personnel; it is one of the procedures classified as of greatest risk for viral transmission from patients to healthcare personnel, along with bronchoscopy, aerosol therapy, nebulization, and aspiration of secretions. The aim of our study is to analyze the prognosis of patients with COVID-19 who have undergone an episode of endotracheal tube obstruction that made exchanging it necessary.</p><p id="par0020" class="elsevierStylePara elsevierViewall">During the period from February to April 2020, 26 patients were hospitalized in our ICU: 22 (84.7%) required invasive mechanical ventilation (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Of those, 16 (72.7%) presented with at least one episode of endotracheal tube obstruction that required an exchange. What's more, none of these incidents occurred before the seventh day mechanical ventilation, with a mean day of onset of 10.5 days. Some patients even required a tube exchange on more than one occasion. The mean number of exchanges was 1.46.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">If we compare patients who had endotracheal tube obstruction and tube exchange (which we will group together in the first group) with those who did not need it (the second group), we can observe that there are significant differences in the days they required mechanical ventilation (21.6 vs. 17.5 days). Therefore, a greater number of patients in the first group required a tracheotomy before proceeding to be weaned off of mechanical ventilation (81.2% vs. 18.7%).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Eleven patients developed respiratory superinfection as a complication during hospitalization, eight of which (72.7%) were among those who presented with endotracheal tube obstruction.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In regard to treatment received, it should be noted that 100% of patients who did not present with obstruction received treatment with azithromycin, in contrast to the first group, in which only 56.2% did.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Lastly, five patients died: Three (60%) in the first group, a greater proportion than in the second group, which did not have obstruction.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our experience with patients diagnosed with pneumonia due to COVID-19 is that they present with an elevated frequency of necrotizing tracheobronchitis after the first week of mechanical ventilation, causing a sudden obstruction of the endotracheal tube that requires its immediate exchange due to hypoxemia and the inability to ventilate the patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In this disease, an increase in the immune response is described, with a generalized migration of proinflammatory cytokines and an increase in fibrin deposits observed in the pulmonary area due to deregulation between the coagulation and fibrinolytic systems.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> This entails a problem that can affect biosecurity when it comes to management by healthcare personnel, as it requires immediate intervention. In other infections, upon histopathological examination of the trachea and bronchial samples, mononuclear cell infiltration has been seen in the mucosa and submucosa with desquamation of the bronchial epithelium accompanied by congestion, hemorrhage, and necrosis in the tracheobronchial area.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">It is necessary to study the protective association of the use of azithromycin in this problem associated with COVID-19—a drug has also been used in other clinical entities—due to its anti-inflammatory and immunomodulating effect.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez Acosta G, Santana-Cabrera L. Traqueobronquitis necrosante con obstrucción del tubo endotraqueal en pacientes COVID-19. Rev Clin Esp. 2020;220:531–533.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">ICU: intensive care unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total <span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Endotracheal obstruction <span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16 (72.7%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No endotracheal obstruction <span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6 (27.2%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">63.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Males (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (59.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (56.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (66.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Duration of mechanical ventilation (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tracheotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (72.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (81.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (18.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean number of days on which endotracheal tube obstruction occurred \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.5 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean number of occasions in which endotracheal tube exchange was required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 times \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Development of respiratory superinfections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (50%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (72.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (17.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Use of azithromycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (68.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (60%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (40%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stay in the ICU (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (22.72%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (60%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (40%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2531996.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Differences between patients with COVID-19 according to whether they presented with endotracheal tube obstruction due to necrotizing tracheobronchitis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Necrotizing tracheobronchitis causing airway obstruction complicated by pandemic 2009 H1N1 influenza: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 24 | 0 | 24 |
| 2024 September | 22 | 1 | 23 |
| 2024 August | 18 | 0 | 18 |
| 2024 July | 15 | 1 | 16 |
| 2024 June | 8 | 1 | 9 |
| 2024 May | 19 | 0 | 19 |
| 2024 April | 20 | 0 | 20 |
| 2024 March | 11 | 0 | 11 |
| 2024 February | 9 | 0 | 9 |
| 2024 January | 12 | 2 | 14 |
| 2023 December | 13 | 0 | 13 |
| 2023 November | 28 | 1 | 29 |
| 2023 October | 15 | 0 | 15 |
| 2023 September | 17 | 1 | 18 |
| 2023 August | 15 | 1 | 16 |
| 2023 July | 23 | 4 | 27 |
| 2023 June | 17 | 1 | 18 |
| 2023 May | 19 | 3 | 22 |
| 2023 April | 14 | 0 | 14 |
| 2023 March | 18 | 7 | 25 |
| 2023 February | 8 | 1 | 9 |
| 2023 January | 18 | 3 | 21 |
| 2022 December | 18 | 5 | 23 |
| 2022 November | 17 | 1 | 18 |
| 2022 October | 15 | 5 | 20 |
| 2022 September | 13 | 12 | 25 |
| 2022 August | 13 | 5 | 18 |
| 2022 July | 23 | 6 | 29 |
| 2022 June | 14 | 2 | 16 |
| 2022 May | 20 | 7 | 27 |
| 2022 April | 25 | 8 | 33 |
| 2022 March | 24 | 7 | 31 |
| 2022 February | 23 | 8 | 31 |
| 2022 January | 20 | 7 | 27 |
| 2021 December | 16 | 3 | 19 |
| 2021 November | 6 | 3 | 9 |
| 2021 October | 2 | 7 | 9 |
| 2021 September | 1 | 3 | 4 |
| 2021 August | 3 | 9 | 12 |
| 2021 July | 3 | 5 | 8 |
| 2021 June | 3 | 7 | 10 |
| 2021 May | 1 | 3 | 4 |
| 2021 April | 2 | 6 | 8 |
| 2021 March | 4 | 3 | 7 |
| 2021 February | 7 | 3 | 10 |
| 2021 January | 9 | 6 | 15 |
| 2020 December | 14 | 7 | 21 |
| 2020 November | 4 | 13 | 17 |
| 2020 October | 9 | 11 | 20 |
| 2020 September | 17 | 10 | 27 |
| 2020 August | 12 | 12 | 24 |
| 2020 July | 24 | 8 | 32 |
| 2020 June | 62 | 8 | 70 |
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