CA N'EST PAS DU GÂTEAU: CHALLENGES OF MECHANICAL VENTILATION IN A PATIENT WITH ARDS DUE TO COVID-19 INFECTION AND TRACHEOMEGALY

Khalid, Faiza; Josan, Enambir; Tarabichi, Yasir; Kourouni, Ismini

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Mechanical ventilation for Covid-19 – acute respiratory distress syndrome (ARDS) is challenging due to poor lung compliance and high airway pressures for a prolonged period. Under these circumstances, physicians have limited means to control air leaks when they occur. We discuss a case of severe Covid-19 ARDS complicated by early air-leak which was attributed to idiopathic tracheomegaly, and the associated challenges in the patients' care. CASE PRESENTATION: 60-year-old African American man with polymyositis and diabetes mellitus was intubated with a size 8.0 endotracheal tube (ET) for hypoxemic respiratory failure due to Covid-19 infection. Lung protective ventilation was utilized. He was extubated on day three, but he required re-intubation the following day for worsening mental status and hypoxemia. A significant cuff leak (> 400 ml) on a PEEP of 5 cm H2O was noted. Ppeak and Pplat were 42cm H20 and 39 cm H2O respectively. Arterial blood gas: pH 7.129, PCO2 79.6, PaO2 72. The air leak only resolved when cuff pressures exceeded 70 cm H2O. A chest x-ray confirmed adequate ET tube positioning. Tube exchange with another size 8.0 tube was performed, but the balloon was found to be intact. The ET tube was upsized to size 9.0, yet cuff-pressures as high as 70-80 cm H2O were needed to maintain a leak of < 200ml. Considering focal tracheomalacia, the ET tube was bronchoscopically repositioned at different lengths of the airway, without effect. Extended tracheostomy was technically unfeasible due to the severity of the respiratory failure. A computed tomography (CT) of the neck was pursued for airway injury following re-intubation. Image review suggested tracheomegaly with a tracheal diameter of 29 mm (average 21-25 mm in men);Left and Right mainstem measured 18.11 mm and 21mm respectively. (Figure 1). Size 9.0 ET tube failed to prevent air-leak and lung de-recruitment. In the absence of alternative adult airway products, and with the reassurance obtained from the CT neck, the cuff pressure was deliberately kept at 80 mm Hg to maintain adequate ventilation. DISCUSSION: Risk factors for tracheomalacia include prolonged ventilation, high cuff pressure(>35cm H2O) and airway pressures, steroid use, connective tissue diseases, and systemic shock. Our patient had a history of polymyositis but no other risk factors for early tracheomalacia. This case highlights the challenge of overcoming a life-threatening air leak that was likely exacerbated by elevated airway pressures in a patient with idiopathic tracheomegaly. The cuff leak improved after one week with the recovery of lung compliance. After 45 days in the medical intensive care unit, the patient was discharged to an LTACH with a size 8.0 Shiley tube. CONCLUSIONS: Developing alternative endotracheal airway products should be considered to account for these rare patients. REFERENCE #1: Everson DM. Tracheobronchomegaly causing endotracheal tube cuff leak. Trends in Anaesthesia and Critical Care. 2019;25:46-7. DISCLOSURES: No relevant relationships by Enambir Josan, source=Web Response No relevant relationships by Faiza Khalid, source=Web Response No relevant relationships by Ismini Kourouni, source=Web Response No relevant relationships by Yasir Tarabichi, source=Web Response