AN UNUSUAL CAUSE OF AIRWAY OBSTRUCTION WITH A NOVEL MANAGEMENT MODALITY

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SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Tracheostomy is one of the most common procedures performed in intensive care setting as part of modern airway management. It is one of the oldest surgical procedures known to man and was described in Egyptian artifacts in 3600 BC. Complications can be classified into intra-operative, early and late post-operative complications. Granulation tissue formation is one of the known yet sometimes overlooked complications. We present a case of granulation tissue formation at the distal end of tracheostomy tube (TT) causing almost complete obstruction of airway that was successfully managed using Argon Plasma Coagulation (APC). CASE PRESENTATION: A 52-year-old female with a past medical history of ventilator-dependent chronic respiratory failure secondary to kyphoscoliosis was brought in to our emergency department from the nursing facility where she resides for respiratory distress. Patient has a 7 mm non-fenestrated, Cuffed, single lumen TT placed 2 years prior to her presentation. On admission, Temperature was 36.7, heart rate 100 beats/minute, blood pressure 100/60 mmHg, respiratory rate 24 breaths/minute and pulse oximetry of 94% on pressure-regulated volume control ventilation with 60% FiO2. She was noted to have elevated peak airway pressure of 55 cm H2O with plateau pressure of 15 cm H2O on the ventilator. Patient was awake and able to communicate however appeared to be in moderate respiratory distress with reduced air entry bilaterally on auscultation of her chest. The rest of her physical examination was unremarkable. Urgent flexible fiberoptic bronchoscopy (FFB) showed a soft tissue mass fungating from the trachea and almost completely occluding the distal end of the tracheostomy tube. The bronchoscope was advanced through a small laminal opening in the granulation tissue. Distal airway was patent with no lesions or secretions noted. The granulation tissue was excised using APC and TT was exchanged to a 6-mm extended-length tube to bypass the remaining obstruction. Patient had significant improvement of her symptoms and was transferred back to the nursing facility. DISCUSSION: Granulation tissue formation post tracheostomy can develop from repetitive irritation leading to mucosal metaplasia and as it matures, it becomes fibrous and if large enough, may impose a risk for airway obstruction. Management modalities range from topical medications to surgical interventions. APC uses high frequency electric current for thermal coagulation and devitalization of tissue. It gives a controlled limited penetration of tissue with good control of bleeding. CONCLUSIONS: Given that granulation can recur, patients with this condition should undergo surveillance imaging and bronchoscopy. We report this case so that clinicians would keep a high index of suspicion for post-tracheostomy granulation tissue formation and to emphasize the role of FFB with APC in diagnosing and managing such complications. Reference #1: Bhatia G, Abraham V, Louis L. Tracheal granulation as a cause of unrecognized airway narrowing. J Anaesthesiol Clin Pharmacol. 2012;28(2):235-8. Reference #2: Sato M., Terada Y., Nakagawa T., Li M., Wada H. Successful use of argon plasma coagulation and tranilast to treat granulation tissue obstructing the airway after tracheal anastomosis. (2000) Chest, 118 (6) , pp. 1829-1831. Reference #3: Rasband-Lindquist, Allison; Sale, Keith. A novel approach to excision of distal tracheal granulation tissue in tracheostomy patients with difficult anatomy. ENT: Ear, Nose & Throat Journal . Oct/Nov2016, Vol. 95 Issue 10/11, p454-459. 5p DISCLOSURES: No relevant relationships by Abdullah Al Twal, source=Web Response No relevant relationships by Delyse Garg, source=Web Response No relevant relationships by Marc Lindner, source=Web Response No relevant relationships by Christina Migliore Patel, source=Web Response No relevant relationships by Habib Nazir, source=Web Response No relevant relationships by Pratik Patel, source=Web Response