Postintubation Tracheal Web

Abstract

To the Editor: A 20-year-old man was admitted to our department for evaluation of chronic cough. He also reported dyspnea and stridor on exertion. His history included endotracheal intubation, tracheostomy, and a prolonged intensive care unit stay after a motor vehicle accident. After his initial discharge from the hospital, he continued to experience dyspnea and once required reintubation. Total duration of need for the tracheostomy was 3 months. On admission, a scar was visible at the site of the tracheostomy. The rest of the physical examination was unremarkable. His spirometric values were: forced vital capacity (FVC) 109%, forced expiratory volume in 1 second (FEV1) 83%, and FEV1/FVC 65%. His flow-volume loop is presented in Figure 1.FIGURE 1: A flow-volume loop of the patient compatible with a fixed upper airway obstruction. A color version of this figure can be accessed using the Article Plus feature on the Journal's Web site: www.bronchology.com.Bronchoscopy revealed a thin cord extending between the anterior and posterior wall of the trachea just below the vocal cords (Fig. 2). Below the cords at the anterior tracheal wall a pseudotract, corresponding to the site of the prior tracheostomy, was present, which ended blindly just under the skin. Granulomatous tissue was present surrounding this pseudotract. The cord was cut by the biopsy forceps. After the removal of the cord, the patient's symptoms gradually improved. A surgical reconstruction at the tracheotomy site was performed by a plastic surgeon, offering a good cosmetic result.FIGURE 2: A thin cord crosses vertically the tracheal lumen just below the vocal cords. Under the cord at the anterior tracheal wall, granulomatous tissue is visible that surrounds the orifice of the tract of a prior tracheostomy. A color version of this figure can be accessed using the Article Plus feature on the Journal's Web site: www.bronchology.com.During the last 4 decades, a large number of patients have been nursed in intensive care units and have been subjected to either endotracheal intubation or tracheostomy. The stenosis of the trachea is a well-described, although rare, complication of these procedures. The high pressure of the cuffs of the originally used endotracheal tubes was a main cause of mucosal necrosis. Other factors such as infections, positive pressure ventilation, mechanical irritation, and steroid administration may also contribute to this condition leading to scarring and stenosis of the tracheal lumen.1 The use of large-volume low-pressure cuffs and efficient management of the endotracheal tubes has lowered the incidence of this complication.2 Typically, tracheal stenosis occurs at the subglottic area after endotracheal intubation or at the site of the stoma when the patient has been subjected to tracheostomy. Almost all patients are symptomatic. Prominent symptoms are dyspnea and/or stridor. Sometimes the patients feel asphyxiated and an emergency therapeutic decision has to be made.1,3 Currently, early treatment by rigid bronchoscopy with dilation, stenting, or Nd:YAG laser has been used successfully as an alternative to surgery.4-6 Surgical intervention may be preferred if the stenosis is lengthy or complex.7,8 In our case, the repeatable use of endotracheal devices and for a long period of time could be the main cause for the creation of the cord. The upper outer wall of the horizontal part of the tracheostomy tube probably served as a matrix, on which inflammatory cells from the neighboring injured tracheal wall eventually formed fibrotic tissue in the form of a web/cord a few months later. This web, after the removal of the tracheostomy tube, held the tracheal walls in a fixed position, which might explain the shape of the flow-volume loop. The turbulent airflow through the upper part of the trachea and/or the chronic inflammatory changes of the tracheal wall might explain, at least in part, the chronic cough of the patient. Patients with chronic cough, dyspnea on exertion, and impaired spirometric values might mimic other airway diseases such as asthma. This case stresses the need of obtaining a flow-volume loop, especially when there is a history of intubation. Bronchoscopy will provide the diagnosis and treatment options. Ioannis Kokkonouzis, MD Charalampos Mermigkis, MD Kostas Psathakis, MD Kostas Tsintiris, MD Department of Pneumonology Army General Hospital of Athens Athens, Greece