AN UNUSUAL PRESENTATION OF TRACHEAL STENOSIS FOLLOWING 22 HOURS OF ENDOTRACHEAL INTUBATION IN A COCAINE ABUSER

Abstract

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Tracheal stenosis following intubation is a relatively rare but a serious problem. Thermal airway injury from cocaine inhalation resulting in tracheal stenosis has been rarely reported. We present an unusual case of tracheal stenosis in a cocaine abuser which developed following twenty two hours of endotracheal intubation. CASE PRESENTATION: An 18 year old female with history of depression was brought to the hospital due to acute encephalopathy secondary to suspected Benzodiazepine (BDZ) overdose. She was found unresponsive and was intubated for airway protection. This was her first intubation. She was also getting treatment for aspiration pneumonia. Urine toxicology tested positive for BDZ and cocaine. She was extubated the next day after her mentation improved. After 4 days, she went into respiratory distress associated with significant stridor. The possibility of bronchial asthma or allergic reaction to medication was sought. Emergency intubation was done to secure the airway but there was no apparent tongue swelling, vocal cord edema or paralysis. Because of persistent stridor despite of aggressive bronchodilator treatment, flexible bronchoscopy was done. It showed endotracheal circumferential growth (4-5 cm above carina) which narrowed 50% of the lumen. Biopsy from the growth was negative for viral, fungal and bacterial etiology. Tissue pathology showed fragments of fibrin, acute inflammatory changes suggestive of tracheal stenosis. Patient was transferred to higher level of care. She underwent cryotherapy and dilation of stenosis and was successfully extubated. DISCUSSION: Recent endotracheal intubation and history of cocaine inhalation are important risk factors for tracheal stenosis in our patient. It seems unlikely that trauma at the time of intubation induced tracheal stenosis. Another important risk factor is cocaine inhalation, which can cause thermal injury, mucosal damage to trachea and consequent tracheal stenosis. Thermal airway injury secondary to cocaine smoking may result from either (a) inhalation injury from chemical byproducts transported in the smoke, or (b) intratracheal combustion of highly inflammable solvents used in the production process. We think that cocaine inhalation initiated injury to mucosa and recent intubation aggravated development of tracheal stenosis. CONCLUSIONS: Tracheal stenosis should be kept in a differential diagnosis in patient with post extubation stridor who has history of cocaine abuse despite of short duration of intubation. Treatment options include cryotherapy, balloon tracheoplasty, laser therapy and surgery. Reference #1: Carlos S. Restrepo, MD, Jorge A. Carrillo, MD, Santiago Martínez, MD, Paulina Ojeda, MD, Aura L. Rivera, MD, and Ami Hatta, MD Pulmonary Complications from Cocaine and Cocaine-based Substances: Imaging Manifestations Reference #2: Post intubation tracheal stenosis, Sajal De and Sarmishtha De Reference #3: Taylor, RF and Bernard, GR. Airway complications from freebasing cocaine. Chest. 1989; 95: 476–477 DISCLOSURES: No relevant relationships by Muhammad Habib, source=Web Response No relevant relationships by Mohammad Islam, source=Web Response No relevant relationships by Manish Patel, source=Web Response No relevant relationships by Thien Vo, source=Web Response