Early treatment of acute laryngeal injury in patients who have been intubated could limit their risk of long-term physiological impairment, researchers found.
Their retrospective cohort study, published in JAMA Otolaryngology–Head & Neck Surgery, found that early intervention was associated with a decreased duration of tracheostomy dependence, a higher rate of decannulation, and fewer surgical procedures in these patients, compared with late intervention.
According to Anne S. Lowery, BA, Vanderbilt University School of Medicine, Nashville, and colleagues, these findings could be relevant for the management of patients who are intubated for prolonged periods as a result of Covid-19 infection.
Millions of patients are intubated in intensive care units each year, putting them at risk for acute laryngeal injury. In fact, studies have shown that up to 57% of patients intubated more than 12 hours show evidence of acute laryngeal injury after extubation.
According to Lowery and colleagues, acute laryngeal injury can result in worse patient-reported breathing and vocal symptoms compared with patients without acute laryngeal injury. Furthermore, it presents a significant clinical challenge, since patients often present to otolaryngologists late in the disease course.
“Occasionally, however, patients may be referred while still in the acute phase of disease, when there is evolving mucosal ulceration or granulation tissue that may be amenable to endoscopic interventions to minimize the full progression of disease,” the authors observed. Therefore, in this study, Lowery and colleagues set out to compare the functional outcomes of an early intervention — 45 of fewer days after the inciting injury — as opposed to a later intervention for an intubation-related laryngeal injury.
The study included 29 patients who had an intubation-related laryngeal injury after endotracheal intubation. Ten patients with intubation injury to the posterior glottis who received early treatment were compared with 19 patients presenting with posterior glottic stenosis who received late treatment.
Surgical treatments for early intervention included removal of granulation and necrotic tissue, corticosteroid injection, and balloon dilation, while procedures for mature laryngeal injuries (later intervention) included cordotomy or total arytenoidectomy, extended cricotracheal resection, tracheoplasty, or laryngotracheal reconstruction.
Almost all patients — 9 of 10 patients in the early treatment group and all 19 patients treated late — required a tracheostomy at some point during their disease course. The mean (SD) time from initial intervention to decannulation was 54.1 days for patients who received early treatment compared to 154.9 days for patients who received later treatment.
Patients who received early treatment required fewer total interventions (mean of 2.2. interventions) than patients with mature lesions (11.5 interventions) — and none of those patients who received early treatment underwent an open procedure, compared to 17 patients (90%) with mature lesions.
The study’s finding “suggest that more focus should be placed on timely diagnosis and intervention of acute airway injuries after intubation,” wrote Lowery and colleagues. “Future studies should explore the utility of formalized screening protocols for high-risk patients with significant comorbid illness, prolonged intubation, or extended dyspnea after extubation.”
In a commentary accompanying the study, Molly N. Huston, MD, Washington University School of Medicine in St Louis, and Matthew R. Naunheim, MD, of the Massachusetts Eye and Ear Infirmary and Harvard Medical School, commended Lowery and colleagues for “bringing attention to an element often dismissed in the throes of an acute hospitalization: otolaryngology consultation.”
According to Huston and Naunheim, otolaryngologists are typically not actively involved in following patients who are able to successfully manage their airways in the aftermath of extubation, even in cases of prolonged intubation.
This approach, as illustrated in the current study, could have “dire” consequences, they pointed out, adding that otolaryngologists “are the vanguard for airway protection, and the authors rightly suggest a more proactive role.”
“This article serves as a reminder that we often rely on our colleagues to identify acute laryngeal injury, but perhaps a more standard visualization and treatment of the airway for those at risk, as described in this article, could improve long-term functional outcomes for acutely ill patients,” they concluded.
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Early treatment of acute laryngeal injury as a result of intubation is associated with a decreased duration of tracheostomy dependence, a higher rate of decannulation, and fewer surgical procedures than seen in patients with later treatment.
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The results of this trial are particularly relevant considering the number of patients who are intubated for prolonged periods because of Covid-19 infection.
Michael Bassett, Contributing Writer, BreakingMED™
The study authors and editorialists had no relationships to disclose.
Cat ID: 570
Topic ID: 569,570,254,728,791,570,730,192,925
