Increased Risk of Post Extubation Stridor With COVID-19 Pneumonia

Abstract

Background: Severe COVID-19 pneumonia often results in prolonged intubation with both frequent use of prone positioning and increased body mass index found in these patients potentially increasing the risk for post extubation stridor (PES). Previously we reported a PES incidence of 1.4%.¹ This retrospective study examined whether these risk factors in COVID-19 were associated with PES.

Methods: We enrolled 46 intubated subjects with COVID-19 pneumonia that were mechanically ventilated (MV) >48 h, excluding those with tracheostomy. IRB approval was obtained with waiver for consent due to the observational nature of the study. The primary outcome was PES incidence identified by medical record review. Bivariate analysis compared PES risk factors between PES and non-PES subjects. Continuous variables were compared using the Wilcoxon rank sum test, categorical variables using the Chi squared test. All tests were stratified by the presence of PES. Multivariate logistic regression modeling assessed the association between PES risk factors and the incidence of PES. Alpha was set at 0.05.

Results: Nine of 46 subjects (20%) developed PES with 3 (33%) requiring reintubation. Median MV days were significantly greater among PES subjects (22 d [IQR: 6-23] vs. 6 d [IQR: 4-8], P = 0.04). PES subjects also had a tendency towards morbid obesity with median body mass index 35 [IQR: 33-36] vs. 30 [IQR: 26-33], P = 0.06), but did not require more prone positioning (22% vs. 46%, P = 0.19). In multivariate logistic regression modeling adjusted for prone positioning, MV days had the strongest association with PES (OR 1.06, 95%, CI- 0.98 to 1.16, P = 0.14).

Conclusions: COVID-19 pneumonia was associated with a higher risk of PES than both the risk previously observed at our hospital and that reported in the literature (2-16%),² and appeared to reflect both prolonged MV and the presence of morbid obesity in our COVID-19 subjects. References: 1. Kallet RH, Matsushima A, Lipnick MS, et al. Characteristics of patients who develop stridor following extubation. Respir Care 2018;63 (Suppl 10):3007996. 2. Jaber S, Chanques G, Matecki S, et al. Post-extubation stridor in intensive care unit patients. Risk factors, evaluation and importance of the cuff-leak test. Intensive Care Med 2003; 29:69-74.