Post-Extubation Stridor in COVID-19 Pneumonia: A Case for Rigid Tracheoscopy Over Bronchoscopy to Avert Airway Compromise

Introduction: Post-extubation stridor, or inspiratory noise following extubation, is frequently observed in patients post-extubation, due to laryngeal edema secondary to airway manipulation. Post-extubation stridor is of increasing concern during the COVID-19 pandemic, as risk for re-intubation and consequent poor outcome is high. We present a case of post-extubation stridor due to tracheal mucus plugging in the setting of COVID-19 pneumonia. Case Presentation: A 61-year-old female diagnosed with COVID-19 pneumonia, right lower lobe pulmonary embolus, and left lung pneumothorax with chest tube experienced a nontraumatic intubation and 13 days of ventilatory support due to respiratory failure. Four days following extubation patient developed stridor and increased oxygen requirement. Patient was given racemic epinephrine 0.5mL x two doses and IV solumedrol 40mg BID x four doses, maintaining oxygen saturation >91% on BiPAP. Direct visualization under flexible laryngoscopy showed small granulation tissue in posterior commissure and concretions and dried mucus in the trachea. The following day, patient displayed worsening stridor, hoarseness, and respiratory difficulty. Bronchoscopy versus tracheoscopy was considered. CT chest displayed moderate debris within the proximal trachea. Due to concern for airway compromise with bronchoscopy, patient underwent laryngoscopy and tracheoscopy with tracheal plug removal by airway forceps. Stridor and hoarseness improved following procedure;oxygen requirements declined in following two-three days leading to discharge. Discussion: Post-extubation stridor can occur in nearly 10% of intensive care unit patients, frequently due to laryngeal edema. In the present case, our patient underwent steroid and racemic epinephrine therapy to address this possible cause with no clinical improvement. Chest CT was performed for further characterization, which discovered moderate debris within the proximal trachea. We hypothesize the tracheal debris accumulation was due to illness with COVID-19, prolonged intubation, and a weak cough unable to clear airway secretions. Previous studies have shown that COVID-19 pneumonia causes bilateral diffuse alveolar damage with fibromyxoid exudates leading to excessive airway mucus. This excess mucus leads to increased airway resistance and decreased alveolar gas exchange. Weakness after critical illness and prolonged intubation likely contributed to our patient's inability to clear these secretions, leading to tracheal accumulation, increased oxygen requirement, and stridor. Bronchoscopy and/or intubation in patients with tracheal debris may be detrimental due to endotracheal tube obstruction or mucus plug mobilization into distal bronchi and subsequent respiratory failure. Therefore, it is important to maintain a broad differential diagnosis while assessing stridor after extubation, particularly in patients with COVID-19 pneumonia.