YOU HAD STRIDOR FOR HOW LONG? IT'S TIME WE DO SOMETHING ABOUT IT

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SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Post-extubation stridor is defined as inspiratory stridor occurring within 24 hours of extubation. It is associated with significant morbidity and mortality related to re-intubation, prolonged duration of mechanical ventilation, and longer length of ICU stay (3). The same complications are increased in those undergoing unplanned extubation (1). The rapid onset of stridor following extubation is usually caused by vocal cord edema and presents within hours of extubation (2). There are few published reports describing stridor secondary to tracheal stenosis. The objective of this report is to describe the unique etiology of post-extubation stridor related to tracheal stenosis. CASE PRESENTATION: In this case report, we describe a 70-year-old male with a past medical history of asthma, liver cirrhosis, CKD, COPD, obstructive sleep apnea, peripheral vascular disease, dyslipidemia, DM, HTN and GERD presenting with increasing shortness of breath and orthopnea for the past week. 3 months prior he was intubated for a severe COPD exacerbation. He then had to undergo unplanned extubation and re-intubation due to a mucous plug causing respiratory arrest and atrial fibrillation with a rapid ventricular response. During his current emergency department visit the patient was found to have significant respiratory distress and stridor on examination. The audible stridor was notably worse on inspiration but present on both phases of the respiratory cycle indicating a fixed intrathoracic obstruction. Objective data included: tachypnea (27 breaths/min) and hypotension (69/33) which resolved after placing patient on a nasal cannula at 2L/min and giving a fluid challenge. Labs revealed a leukocytosis (12.0 x10(3)/mcL Chest x-ray was unremarkable except for some hyperinflation of the lungs. Narrowing of the subglottic trachea to 5 mm along an 8 mm segment was visualized on CT of soft tissues of the neck. A balloon dilation via fiberoptic bronchoscopy was attempted but results were deemed unsuccessful. As a result, the patient was transferred to an accepting facility where he underwent an uncomplicated tracheal resection. DISCUSSION: Traumatic extubation is associated with significant mortality and morbidity in critically ill patients. Post-extubation stridor is also associated with poor outcomes. The patient, in this report, experienced a traumatic extubation and had an unusual presentation of stridor and respiratory distress that became critical 3 months following extubation. This presentation was unique in that the patient attributed his “mild symptoms” post-extubation to COPD. CONCLUSIONS: It is critical to establish proper follow-up with patient’s PCP following extubation to monitor for complications. Reference #1: Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000; 161:1912. Reference #2: Hartley M, Vaughan RS. Problems associated with tracheal extubation. Br J Anaesth. 1993;71:561–568. doi: 10.1093/bja/71.4.561 Reference #3: Schnell D, Planquette B, Berger A, et al. Cuff Leak Test for the Diagnosis of Post-Extubation Stridor. J Intensive Care Med 2017; :885066617700095. DISCLOSURES: No relevant relationships by Rafael Otero, source=Web Response No relevant relationships by Abaigeal Thompson, source=Web Response