Iatrogenic Tracheal Stenosis Research Articles

Identifying Molecular Pathophysiology and Potential Therapeutic Options in Iatrogenic Tracheal Stenosis.

While most patients with iatrogenic tracheal stenosis (ITS) respond to endoscopic ablative procedures, approximately 15% experience a recalcitrant, recurring disease course that is resistant to conventional management. We aimed to explore genetic profiles of patients with recalcitrant ITS to understand underlying pathophysiology and identify novel therapeutic options. We collected 11 samples of granulation tissue from patients with ITS and performed RNA sequencing. We identified the top 10 most highly up- and down-regulated genes and cellular processes that these genes corresponded to. For the most highly dysregulated genes, we identified potential therapeutic options that favorably regulate their expression. The dysregulations in gene expression corresponded to hyperkeratinization (upregulation of genes involved in keratin production and keratinocyte differentiation) and cellular proliferation (downregulation of cell cycle regulating and pro-apoptotic genes). Genes involved in retinoic acid (RA) metabolism and signaling were dysregulated in a pattern suggesting local cellular RA deficiency. Consequently, RA also emerged as the most promising potential therapeutic option for ITS, as it favorably regulated seven of the ten most highly dysregulated genes. This is the first study to characterize the role of hyperkeratinization and dysregulations in RA metabolism and signaling in the disease pathophysiology. Given the ability of RA to favorably regulate key genes involved in ITS, future studies must explore its efficacy as a potential therapeutic option for patients with recalcitrant ITS.

Tracheal microbiome and metabolome profiling in iatrogenic subglottic tracheal stenosis

BackgroundTo study the role of microecology and metabolism in iatrogenic tracheal injury and cicatricial stenosis, we investigated the tracheal microbiome and metabolome in patients with tracheal stenosis after endotracheal intubation.MethodsWe collected 16 protected specimen brush (PSB) and 8 broncho-alveolar lavage (BAL) samples from 8 iatrogenic subglottic tracheal stenosis patients, including 8 PSB samples from tracheal scar sites, 8 PSB samples from scar-free sites and 8 BAL samples, by lavaging the subsegmental bronchi of the right-middle lobe. Metagenomic sequencing was performed to characterize the microbiome profiling of 16 PSB and 8 BAL samples. Untargeted metabolomics was performed in 6 PSB samples (3 from tracheal scar PSB and 3 from tracheal scar-free PSB) using high-performance liquid chromatography‒mass spectrometry (LC‒MS).ResultsAt the species level, the top four bacterial species were Neisseria subflava, Streptococcus oralis, Capnocytophaga gingivals, and Haemophilus aegyptius. The alpha and beta diversity among tracheal scar PSB, scar-free PSB and BAL samples were compared, and no significant differences were found. Untargeted metabolomics was performed in 6 PSB samples using LC‒MS, and only one statistically significant metabolite, carnitine, was identified. Pathway enrichment analysis of carnitine revealed significant enrichment in fatty acid oxidation.ConclusionOur study found that carnitine levels in tracheal scar tissue were significantly lower than those in scar-free tissue, which might be a new target for the prevention and treatment of iatrogenic tracheal stenosis in the future.

Factors affecting occurrence of post intubation and post tracheostomy tracheal stenosis in intensive care units

Objective: Iatrogenic tracheal stenosis is a life threatening iatrogenic complication of prolonged endotracheal intubation and tracheostomy in intensive care units (ICUs). It is one of the toughest morbidities in otolaryngology.Aim of the Study: This prospective observational study was conducted to detect the factors affecting occurrence of tracheal stenosis in patients subjected to tracheostomy after endotracheal intubation in ICUs.Patients and Methods: Sixty eight patients were included in this prospective study. They were admitted to (ICUs) and were subjected to endotracheal intubation, mechanical ventilation and tracheostomy due to prolonged intubation during their stay in (ICUs). The patients were followed up after being discharged for six months to detect incidence and factors affecting occurrence of tracheal stenosis. They were followed up using flexible fiber optic tracheobronchoscopy under local anesthesia, just after weaning from mechanical ventilation three and six months later.Results: Of the studied patients, 50 patients had no tracheal stenosis until the end of follow up period (without tracheal stenosis (WTS) group) while, 18 patients had tracheal stenosis (TS group). The mean duration of mechanical ventilation in WTS group (12.1 ± 7.6 days) was statistically shorter than that of TS groups (16.6 ± 10.4 days) (P = 0.048). Tracheostomy stoma wound sepsis was recorded in 4 patients in TS group and in 2 patients in WTS group.Conclusion: The main predisposing factors for post intubation and post tracheostomy tracheal stenosis are tracheostomy stomal wound sepsis and prolonged duration of mechanical ventilation. In contrary, tracheal cartilage injury during tracheostomy, age, sex and reason for mechanical ventilation was found to have no role in occurrence of tracheal stenosis.

Iatrogenic subglottic tracheal stenosis after tracheostomy and endotracheal intubation: A cohort observational study of more severity in keloid phenotype.

BackgroundTracheostomy and endotracheal intubation can result in subglottic tracheal stenosis, and predisposition to keloid scar formation can increase stenosis risk after tracheal injury. This study aims to compare the incidence and severity of subglottic tracheal stenosis in keloid and non‐keloid patients following iatrogenic tracheal injury, in particular tracheostomy.MethodsFrom 2012 to 2017, 218 573 patients were intubated for surgery; 2276 patients received tracheostomy in People’s Hospital of Zhengzhou University, China. Among these patients, 133 patients, who developed tracheal stenosis after intubation and/or tracheostomy, were divided into keloid or non‐keloid groups; their Myer and Cotton grading of tracheal stenosis, time‐to‐onset of airway stenosis, and treatment outcome were assessed and compared.ResultsThe percentages of high grade (Myer and Cotton grading III/IV) tracheal stenosis were higher among keloid patients than non‐keloid patients (intubation: 83.3% vs 25.7%; tracheostomy: 77.7% vs 33.3%). Time‐to‐onset of airway stenosis following intubation (tracheostomy) was 27 ± 5 (38 ± 13) and 41 ± 7 (82 ± 14) days for keloid and non‐keloid patients, respectively (P < 0.01). The incidence of tracheal stenosis is higher in keloid than non‐keloid subjects (19.4% vs 1.82%, P < 0.001). Keloid patients also required more frequent treatment (P < 0.01) of longer duration, yet cure rate was significantly lower (P < 0.01).ConclusionsOur study suggests that tracheostomized patients with keloid phenotype are more susceptibility to develop iatrogenic tracheal stenosis of greater severity and with poorer treatment outcome. Greater cautions may be required when performing tracheostomy in keloid subjects. More substantive analysis is warranted to establish keloid phenotype as a risk factor for tracheal stenosis.

Iatrogenic Tracheal Stenosis After Yasui Operation in a Neonate With Aortic Atresia and Type B Aortic Interruption

Iatrogenic Tracheal Stenosis After Yasui Operation in a Neonate With Aortic Atresia and Type B Aortic Interruption

Tracheal stenosis after intubation and/or tracheostomy

IntroductionThe tracheal iatrogenic stenosis remains a frequent, sometimes severe tracheal resection, anastomosis is the treatment of choice. However, the endoscopic treatment is used as an alternative therapy. Materials and methodsWe report a retrospective study for a period of 8years. Results174 patients had an iatrogenic tracheal stenosis of intubation (55.17%) and/or tracheotomy (44.82%).The appearance and extent of stenosis were assessed by bronchoscopy, we noted a tracheal malacia (15%), a circumferential stenosis (58%), a little tight stenosis (12%) and diaphragm (5%).Some patients have benefited from several therapeutic procedures, 90 patients were operated on early interventions with 53 and 37 after surgery, an improvement of the patient’s clinical status have been postponed earlier, after failure of endoscopic methods. 293 interventional bronchoscopies were performed, 192 stenting, 45 Nd-YAG laser, 55 patients required a recalibration in the tube of the bronchoscope and one patient received cryotherapy, knowing that there are the patients who received combination therapy. We lamented death in the immediate postoperative sepsis, a recurrence of stenosis in 117 patients, and among the 192 implants placed we identified 37 migrations, 52 congestion, development of granulomatous lesions, an overhaul of the prosthesis is noted in 7.29%, three implants were embedded in the tracheal mucosa and there was only one spontaneous rejection. The long-term evolution was satisfactory in 92 patients. ConclusionNevertheless, the management of post intubation tracheal stenosis and/or post tracheostomy cannot be that requiring a multidisciplinary collaboration.

Iatrogenic Tracheal Stenosis Presenting as Persistent Asthma

Although the incidence of post-intubation tracheal stenosis has markedly decreased with the advent of large volume, low pressure endotracheal tube cuffs, it still occurs, commonly in patients after prolonged intubation. We report a case of tracheal stenosis that developed after a brief period of endotracheal intubation, and that was misdiagnosed and treated as asthma and panic attacks.

Accuracy of finger-tip palpated tracheostomy tube cuff pressure readings among otolaryngologists

The tracheal mucosa is very a delicate structure, and pressure-ischaemia problems following the use of cuffed tracheostomy tubes are well documented. Iatrogenic tracheal stenosis is one of the consequences of mucosal ischaemia and is very difficult to treat. In this study the accuracy of finger-tip tested tracheostomy tube cuff inflation pressure, as judged by consultants and non-consultants, was assessed by comparison with manometric pressure readings. The estimated pressure readings from the consultant group were more accurate than those from the non-consultant group, but a high standard deviation and very big difference between low and high readings in both these groups showed the real extent of the problem. Participants who performed 10 or more tracheostomies a year obtained more accurate results. No definite correlation was observed between the readings and the experience of the participants in otolaryngology or the size of the tube used. The authors recommend that instrumental monitoring of cuff pressure be considered good practice among junior otolaryngologists.

Successful Bronchoscopic Balloon Dilation of Nonmalignant Tracheobronchial Obstruction Without Fluoroscopy

To evaluate the safety and efficacy of bronchoscopic balloon dilation (BBD) without fluoroscopy for relief of tracheobronchial obstruction. We performed a retrospective study of all adult patients who underwent BBD without fluoroscopy at the Tulane University Hospital and Clinic between July 1, 1997, and June 30, 2002. Twenty-four patients (mean [+/- SD] age, 58 +/- 14 years; 80% men) underwent 59 BBD procedures without fluoroscopy for the following conditions: iatrogenic tracheal stenosis (80%); saber-sheath trachea (4%); bronchial stenosis resulting from lung transplantation (4%); sarcoidosis (4%); Wegener granulomatosis (4%); and idiopathic stenosis (4%). All BBD procedures were performed via a rigid bronchoscope (61%) or a flexible bronchoscope (39%) without fluoroscopy. BBD was often combined with mechanical debridement (64%), stent placement (47%), or laser photoresection (19%), although in 26% of cases BBD was the only intervention. During the 59 procedures, 71 different balloon catheters were deployed a total of 112 times (deployment was defined as any use of balloon dilation in a different location, for a different purpose, or to a different inflation diameter). These 112 deployments were performed for primary dilation (49%), dilation prior to stent placement (28%), and stent seating (22%). Improvement in stenosis was achieved immediately postprocedure in all 59 procedures (100%). One balloon ruptured during inflation without clinically significant effect, and no other complications occurred. BBD without fluoroscopy for the relief of nonmalignant tracheobronchial obstruction can be safely performed through a rigid or flexible bronchoscope. It can be used alone or as an adjunct to other therapeutic modalities. In this series, 100% of airway obstructions were improved, and there were no clinically significant complications. BBD of a tracheobronchial obstruction without fluoroscopy is safe, efficacious, and cost-effective.

의인성 기관협착증에 관한 임상적 고찰

의인성 기관협착증에 관한 임상적 고찰

Evolution des techniques d'anesthésie pour résection-anastomose de trachée

A series is reported of 109 patients, 45 ± 18 yr old, undergoing tracheal sleeve resection. 101 patients had iatrogenic tracheal stenosis, 5 tracheal cylindroma, 2 tracheal cancer and 1 tracheal trauma. 84 patients underwent preoperative laser coagulation to increase the airway internal diameter. Anaesthesia for the sleeve resection was induced by thiopentone, and maintained by an opiate, nitrous oxide and, if necessary, a volatile anesthetic. Patients were intubated, after having been given a muscle relaxant, with either a normal length and diameter tube with a low pressure cuff, or a narrow (internal diameter < 6 mm) 50 cm long tube with or without a low pressure cuff. Patients with long tubes were ventilated with intermittent positive pressure, and the others with high frequency jet ventilation (HFJV) via a urethral catheter within the endotracheal tube. 20 % of the long tubes had to be replaced during surgery because of perforation of the cuff by a tracheal stitch. In all, six patients died, one as a result of a pneumothorax and air embolus due to HFJV. Preoperative photocoagulation reduced the risk of induction and intubation ; the choice of endotracheal tube no longer depended on the tracheal diameter, but on the method of ventilation chosen. However, HFJV has tended to be phased out, except for the surgery of lesions close to the carena ; it has been replaced by intermittent positive pressure ventilation via long tubes. Because laser photocoagulation can completely cure small stenoses, these patients requiring surgery were those with long stenoses which were difficult to treat. Laser photocoagulation and long narrow endotracheal tubes have made easier the anaesthetic management of these patients.

Tracheal resection with primary anastomosis in children

We observed nine tracheal stenoses following intensive respiratory care in 524 neonates and infants. For all but four of them, we used medical and endoscopic treatment only, with satisfactory immediate and late results. In four children between 6 and 16 yr, we were obliged to perform a tracheal resection with primary anastomosis. All four children had primary tracheostomies as emergency procedures. Subsequent respiratory distress was the result of a dense fibrotic stenosis resistant to medical and endoscopic management. The technique of resection is described, especially, in dealing with the innominate artery. Three to five rings were resected. Cardiopulmonary bypass, was found to be unnecessary. One patient died 1 mo after operation, from an endoscopic accident. The remaining three had excellent results assessed clinically and by endoscopy and radiocinematography. Iatrogenic tracheal stenosis in children is a serious lesion, which can be prevented by correct intensive respiratory care.