Question for Dr. Marcus, or any other pulmonologists. I just got an "interesting consult" 59 yo male a couple months post COVID late March, was intubated late March, intubated x 14 days, self-extubated, and has been having SOB since then. He was on CPAP before, says he lost about 40 - 50 pounds post COVID but is still 5'4" and 215#. Pulmonologist scoped him and he has a large granuloma on the left immediately below the posterior aspect of the cord, and another granuloma vs just granulation tissue midline subglottic. Easy enough, but the kicker is that he has extensive tracheomalacia with dynamic collapse extending even into the mainstem bronchi. Pulmonologist sent me a video and it's really impressive. I am a Lolpoor and technologically challenged, not sure I would even know how to post the video.

Question for you is, do you think the tracheomalacia has anything to do with his COVID-19, or just years of being a big, fat fatty McFatface as we say here? He, consistent with his self-extubation, has discontinued his CPAP because he thinks he is "cured" after he lost weight. I can try to post some photos later when I get back to the office and have some time. He's on insulin, a statin, Losartan, Metformin, and - daily prednisone. He says he cannot come off of his prednisone without getting short of breath (which, of course, is exacerbating his diabetes). Ugh.

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big, fat fatty McFatface

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Apt descriptor.

Kool said:

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...or just years of being a big, fat fatty McFatface as we say here?

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I hope this is how it's documented in his PMH.

ICD code for big, fat fatty McFatface? May need to borrow that.
Hate to derail thread but that was funny.
Intersted in hearing answer to the real question.

The fact that the virus didn't kill him tells me all I need to know about this virus....it's ****ing crazy and there is still much to learn about why some people die and others are asymptomatic.

On call at your service sir. IMO - the "granulomas" are secondary to ETT. The tracheomalacia is coincidental to COVID. Long term. Would need to see scans. One would need to consider Mounier-Kuhn syndrome among others at that age. Needs full PFTS, CT chest. If I saw him I would obviously re-bronch.

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One would need to consider Mounier-Kuhn syndrome among others at that age.

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There are just no bland, American disease names. No Bob Jackson disorder or Frank Smith disease.

Kool said:

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Jesus. I don't know how yall do what you do. Glad you do though.

Windy City Ag said:

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One would need to consider Mounier-Kuhn syndrome among others at that age.

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There are just no bland, American disease names. No Bob Jackson disorder or Frank Smith disease.

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Lou Gehrig's disease? Can't get much more American than Lou Gehrig.

Dude. You are so tech savvy. That is a classic post ETT glottic granuloma. Can't tell about trachea given those pics. MK syndrome associated with pits in tracheal wall and bronchiectasis. Also - that is a large ridge of subglottic stenosis. That is why he is dyspneic. Needs laser resection. ENT referral.

i have no idea what i'm reading in this thread (other than the fatty mcfatface comment), but i'm enthralled.

GE said:

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Kool said:

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Jesus. I don't know how yall do what you do. Glad you do though.

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Surprised no ones flagged this yet

I have only a directional understanding that a fat dude has issues with his throat and esophagus and yet this is as someone else said, enthralling.

Knucklesammich said:

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I have only a directional understanding that a fat dude has issues with his throat and esophagus and yet this is as someone else said, enthralling.

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Really fat dude has sleep apnea, high blood pressure, diabetes, and sleep apnea. 'Murca.
Really fat dude gets The COVIDs. Thanks, China.
Really fat dude goes on a ventilator.
Really fat dude yanks the tube out of his trachea himself after two weeks.
Really fat dude "flies" off of the ventilator and gets discharged.
Really fat dude goes home and discovers his really fat dude pants are looser.
Really fat dude decides that means he no longer has sleep apnea.
Really fat dude ditches his CPAP machine. 'Murca.
Really fat dude still can't breathe unless he is taking steroids.
Steroids make really fat dude's blood pressure and diabetes hard to manage.
Really fat dude gets sent to see lung doctor, who sets him up for a "look-see".
Lung doctor does a classic "peek and shriek", calls me up and says, "Tag. You're "it"".

If I wasn't enthralled before, I am now.

Was that your consult note?

Impressive! I have never been privy to two (outstanding AGGIE doctors) discussing a case. I must say besides being very impressed, I am pretty confident that the U.S. medical profession still has great physicians, that care about their patients. Thanks for letting us sit in on your consultation. On a personal note, I hope the fat dude improves.

Marcus Aurelius said:

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Dude. You are so tech savvy. That is a classic post ETT glottic granuloma. Can't tell about trachea given those pics. MK syndrome associated with pits in tracheal wall and bronchiectasis. Also - that is a large ridge of subglottic stenosis. That is why he is dyspneic. Needs laser resection. ENT referral.

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I am the ENT. Staph said they contacted you to give you my contact info, I will forward along his bronch. I found his degree of tracheomalacia to be pretty impressive. Granted, I don't do flex bronchs. IF you know how to post it on the thread, I am OK with that. There is no patient identifying information, no HIPAA concerns. I also have to wonder, with his OSA, just how much the posterior lesion might relate to continual negative intrathoracic pressure and almost certain reflux. I did start PPIs and H2 blockers, Mediterranean diet, alkaline water, all the usual stuff people don't adhere to.

I needed this thread today. Thank you.
'Murcia.

Amazing thread y'all. Thanks for the smiles today.

This thread

Kool said:

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Knucklesammich said:

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I have only a directional understanding that a fat dude has issues with his throat and esophagus and yet this is as someone else said, enthralling.

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Really fat dude has sleep apnea, high blood pressure, diabetes, and sleep apnea. 'Murca.
Really fat dude gets The COVIDs. Thanks, China.
Really fat dude goes on a ventilator.
Really fat dude yanks the tube out of his trachea himself after two weeks.
Really fat dude "flies" off of the ventilator and gets discharged.
Really fat dude goes home and discovers his really fat dude pants are looser.
Really fat dude decides that means he no longer has sleep apnea.
Really fat dude ditches his CPAP machine. 'Murca.
Really fat dude still can't breathe unless he is taking steroids.
Steroids make really fat dude's blood pressure and diabetes hard to manage.
Really fat dude gets sent to see lung doctor, who sets him up for a "look-see".
Lung doctor does a classic "peak and shriek", calls me up and says, "Tag. You're "it"".

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Love the translation...the beginning of it reminded me of Blazing Saddles.

"You said sleep apnea twice."

"I like sleep apnea."

Definitely interesting to listen in on the consultation.

But at the same time, after standing naked in front of my dermatologist and his nurse earlier this week, I'm a little concerned about what my nickname might be...

That is the best HPI I think I have ever read. Accurate, informative, concise and entertaining. True greatness.

Kool said:

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Marcus Aurelius said:

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Dude. You are so tech savvy. That is a classic post ETT glottic granuloma. Can't tell about trachea given those pics. MK syndrome associated with pits in tracheal wall and bronchiectasis. Also - that is a large ridge of subglottic stenosis. That is why he is dyspneic. Needs laser resection. ENT referral.

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I am the ENT. Staph said they contacted you to give you my contact info, I will forward along his bronch. I found his degree of tracheomalacia to be pretty impressive. Granted, I don't do flex bronchs. IF you know how to post it on the thread, I am OK with that. There is no patient identifying information, no HIPAA concerns. I also have to wonder, with his OSA, just how much the posterior lesion might relate to continual negative intrathoracic pressure and almost certain reflux. I did start PPIs and H2 blockers, Mediterranean diet, alkaline water, all the usual stuff people don't adhere to.

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Should have told me you were ENT. I was educating you on subglottic stenosis - LOL. BTW there are case reports of tracheomalacia due to prolonged intubation. Another consideration relapsing polychondritis. I've seen it very commonly in the elderly - "presbytrachea" similar to presbyesophagus. Certainly not this younger obese guy with DM, HTN, OSA -'murca.

All kidding aside - one needs to know the amount of dynamic exhalation collapse and symptoms to decide on stenting. First I'd fix the subglottic stenosis.

I just emailed you.