A CASE OF SEVERE POST INTUBATION TRACHEAL STENOSIS: BREATHING THROUGH A STRAW

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Post intubation tracheal stenosis (PITS) is a relatively rare but serious complication of intubation. We present a case of severe PITS requiring urgent bronchoscopic intervention. CASE PRESENTATION: A 56 year-old woman former smoker with morbid obesity, obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS), initially admitted for respiratory failure requiring endotracheal intubation and mechanical ventilation for a week. Three weeks after discharge, she returned with increased work of breathing, inability to lie flat and loud stridor. Patient admitted in ICU, in severe respiratory distress, unable to speak more than a few words with fear of suffocation. Imaging of the neck showed severe tracheal stenosis in multiple levels with a minimum diameter of 4.3 mm. Due to severe tracheal stricture, she was not a candidate for endotracheal intubation and her multiple comorbidities made her a poor candidate for surgical treatment. In a team effort by interventional pulmonologist and ENT specialist a bronchoscopy was done which revealed a severe complex tracheal stenosis, 2.5 cm below the vocal cords and 3 cm in length. Balloon dilation was attempted with 50% improvement in lumen size. The intervention provided significant but short-term relief. In the next bronchoscopy sessions, patient underwent laser treatment and gradual tracheal dilation followed by a Dumon silicone hourglass stent placement (16-14-16 mm x 15-20-15 cm). Patient remained stable with significant improvement in functional status for 2 years. She continued to need home oxygen and occasional noninvasive mechanical ventilation partly due to other underlying diseases. Surveillance bronchoscopies ensured a patent airway and no stent complications. The stent was removed upon patient’s agreement after 2years. After a month, dyspnea recurred and bronchoscopy showed narrowing of the trachea but less severe than first time. A silicone stent was placed again after balloon dilation of the trachea. DISCUSSION: Studies of the patients with PITS show they are more likely to be obese females1. Obesity is also associated with EDAC (excessive dynamic airway collapse) and OHS that can lead to respiratory failure and intubation 2,3. Poor functional status and comorbidities associated with morbid obesity often make these patients poor candidates for surgical interventions. Our patient is still at high-risk for tracheal resection. CONCLUSIONS: Bronchoscopic interventions for airway dilation and stents placement can be an effective treatment in patients with tracheal stenosis as a bridge to surgery. More studies are needed to assess the safety of long term placement of silicone stent in patients who are not surgical candidate. Reference #1: Nikolaos Zias, et al. Post tracheostomy and post intubation tracheal stenosis: Report of 31 cases and review of the literature. BMC Pulm Med. 2008; 8:18. Reference #2: Boiselle PM, et al. Dynamic expiratory tracheal collapse in morbidly obese COPD patients. COPD 2013;10:604–610 Reference #3: Lyaker MR, et al. Excessive dynamic airway collapse: An unexpected contributor to respiratory failure in a surgical patient. Case Rep Anesthesiol 2015. 2015:596857 DISCLOSURES: Consultant relationship with Olympus Please note: $1-$1000 Added 03/14/2019 by Ali Sadoughi, source=Web Response, value=Consulting fee Consultant relationship with Olympus Please note: $1-$1000 Added 03/14/2019 by Ali Sadoughi, source=Web Response, value=not yet Consultant relationship with Olympus Please note: $1001 - $5000 Added 03/15/2019 by Ali Sadoughi, source=Web Response, value=not yet No relevant relationships by bradley schiff, source=Web Response No relevant relationships by Neda Valizadeh, source=Web Response