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Covid Intubation; Stridor, Glottic Stenosis. Misleading Vital Oxygen Readers.

Do you have a loved one struggling after coming home after recovering from a severe case of Covid-19, was Intubated fighting for his/her life and you now notice unusual sounds coming from your loved one?

Perhaps it sounds like a bazaar humming sound or harmonic as time goes by. The noises are becoming longer durations and distressing for your loved one, yet vitals are stable, including O2 oxygen reader…? 

Then this topic may help you or your loved one. Vital O2 oxygen readers can be very misleading and rather confusing when it comes back within normal range, yet your loved one looks to be in distress, trying to breathe? This would include those especially with tracheostomy or post tracheostomy after Covid-19 recovery

What is Stridor Breathing…?

Bilateral vocal cord paralysis is a common cause of stridor in adults. It results from a disruption in nerve function in both of the vocal cords, the two small structures in the throat that vibrate and collide to produce sound, leading to vocal cord tissues blocking the airway. This causes biphasic stridor, which means the symptoms of noisy breathing occur when a person inhales and exhales.

Bilateral vocal cord paralysis can result from being intubated, having a breathing tube inserted. These procedures can cause scar tissue that interferes with breathing.

What is Glottic Stenosis…?

Glottic stenosis describes a fixed narrowing of the upper airway at the level of the glottis. The glottis is the portion of the larynx containing the vocal cords and the glottic opening. Anatomically, the glottis is the part of the larynx extending from the junction between the true and false vocal cords at the apex of the laryngeal ventricle to a line one centimeter below the inferior aspect of the vocal cords. The anterior two-thirds of the glottis is the glottis vocalis, while the posterior third is known as the respiratory glottis.

Acquired glottic stenosis is more common and has multiple factors. The most frequent is trauma secondary to endotracheal intubation, which is thought to occur due to the tube’s pressure effect causing tissue ischemia, inflammation and scarring. The risk of glottic stenosis is related to the duration of the intubation, the size of the endotracheal tube, the number of intubations, and excess movement of the endotracheal tube in agitated patients. Also, prolonged nasogastric intubation causes mucosal ulceration which may progress to posterior stenosis.

Post endotracheal intubation stenosis is the most common type of glottic stenosis.  The risk of developing stenosis in intubated patients has been found to be higher based on two prospective studies realized in the long term intubated patients, particularly in those intubated for five days or longer.

Acquired glottic stenosis thought to be caused by mucosal ulceration which leads to infection, perichondritis, and cartilage necrosis leading to granulation tissue formation over the vocal process of the arytenoid cartilage. Subsequently, scar formation and fibrosis cause contraction and arytenoid fixation.

The clinical presentation of glottic stenosis is variable and depends on the cause and the severity of the stenosis. The most common presentation of laryngeal obstruction is stridor. The level of the airway obstruction determines the nature of the abnormal breathing sounds. Upper airway obstruction results in mostly inspiratory stridor while obstruction in the lower respiratory tract results in expiratory or biphasic stridor.

Acquired glottic stenosis symptoms depend on the severity and location of the stenosis. Respiratory symptoms are the predominant symptoms in posterior glottic stenosis while anterior glottic webs mainly present dysphonia. In general, patients may present with respiratory distress. Other symptoms include hoarseness, alteration of voice, and aphonia. Dysphagia and aspiration may also be present.

History needs to concentrate on the assessment of dyspnoea and stridor, the onset and severity of the symptoms as well as the aggravating and relieving factors. Also, the voice should be thoroughly assessed. Finally, history should focus on previous episodes of intubation, trauma, infectious and inflammatory processes as well as co-morbidities.

Lastly, when in doubt and you feel something alarming going on with your love one, keep on track getting the best care and don’t settle on an ER Band-Aid treatment. Keep going until you find answers.

This especially true to those who had intubation for extended period of time due to Covid-19, those with healing trach wounds from previous Tracheostomy and removed post Covid-19.

Marsha B