Postintubation Tracheal Stenosis Research Articles

Virtues of routine suprahyoid release during tracheal resection and anastomosis in patients with post intubation stenosis.

Postintubation tracheal stenosis is the most common cause of benign tracheal stenosis. Surgical treatment is more challenging in long-segment stenosis. Suprahyoid release can increase tracheal length resected without anastomotic tension in patients with post-intubation tracheal stenosis. Its effect on swallowing has not been objectively studied and this article aims to explore its virtues and potential complications in a tertiary center for airway surgery. A prospective cohort study was conducted on forty consecutive patients from June 2020 till December 2023. Patients of both genders had tracheal resection anastomosis surgery with routine suprahyoid muscle release for resected tracheal segment of more than 2.5 cm in length aiming to decrease the anastomotic tension. Within two weeks postoperatively, a video naso-laryngoscope was done on all the patients to detect any vocal cord disorders, then they were examined by video fluoroscopy swallowing study VFSS to detect swallowing problems. Follow up was done for 6 months postoperatively. 40 patients were studied. Twenty-five patients (62.5%) were males. 21 patients (52.5%) had a cricotracheal resection. VFSS was performed on 38 patients (two patients excluded for serious morbidity). Six (15.7%) and four (10.5%) patients had residual semisolid and solid food in the vallecula and pyriform fossa respectively during swallowing. Five patients (13%) out of eight patients with abnormal VFSS had aspiration and dysphagia. Video nasolaryngoscopy was done pre- and post-operatively and showed that 7 patients (17.5%) had unilateral vocal cord paralysis, two of them had the same lesion preoperatively. Two patients developed postoperative anastomotic complications. All symptoms of dysphagia improved within 3 weeks of the procedure and improvement persisted for 6 months. Suprahyoid muscle release had a considerable reversible drawback on the process of swallowing. Its routine use in high-risk patients requiring long segment tracheal resections could be considered.

Tracheal resection and anastomosis in postintubation tracheal stenosis: a systematic review.

Surgical resection of the stenotic segment with end-to-end anastomosis is considered the gold standard in postintubation tracheal stenosis. However, outcomes of this concrete aetiology are not well described. With the aim to examine the extent, range and characteristics of the existing evidence, a scoping review was performed. Data sources included MEDLINE, Scopus, Ovid and the Cochrane databases. Inclusion criteria consisted of studies in adult patients with postintubation tracheal stenosis that reported characteristics, surgical management and outcomes. A total of 125 articles were identified, of which 10 were included in the final analysis. All studies were case reports or case series (level 4 evidence) grouping 110 patients, 75 males and 35 females. The age ranged from 15 to 71 years. Cotton-Myer stenosis grade was 1 [1 (0.9%)], 2 [25 (22.7%)], 3 [70 (63.6%)] and 4 [14 (12.7%)]. Stenosis location was in the tracheal upper-third in 108 (98.2%), in the middle-third in 1 (0.9%) and in the lower-third in 1 (0.9%). Stenosis length ranged from 1 to 5.6 cm. Follow-up ranged from 1 to 60 months (2 years for the most). Most frequent complications were transitory dysphagia in 13 (11.3%), granuloma formation in 8 (7.3%), dehiscence or air leak in 5 (4.5%) and wound infection in 4 (3.6%). Restenosis rate ranged from 2% to 25%. There was no perioperative mortality. Tracheal resection and primary anastomosis in postintubation tracheal stenosis appear to be safe and effective in the short and mid-terms; however, the very low level of evidence found prevents definitive conclusions.

Type and morphology affect the success rate of bronchoscopy for postintubation tracheal stenosis.

With advancements in respiratory interventional techniques, bronchoscopic intervention technology has emerged as a viable approach for managing postintubation tracheal stenosis (PITS). However, there was a paucity of research investigating the potential impact of stenosis characteristics and morphology (such as stenosis degree, length, type, and morphology) on bronchoscopic intervention treatment prognosis for PITS patients. This study was to assess the impact of various preoperative stenosis characteristic factors on the bronchoscopic cure rate among patients. This is a retrospective study analyzing the medical records of patients with PITS who received bronchoscopic intervention at the tertiary interventional pulmonology center. Among the cases, 115 individuals achieved a in a success rate of 79.86% for bronchoscopic intervention therapy and were assigned to Group S. On the other hand, 29 cases required surgical intervention, accounting for a surgical treatment rate of 20.14% and were assigned to Group F. The stenosis in the Group F predominantly exhibited irregular shapes with scar granulation accompanied by tracheal chondromalacia collapse. Patients in group S experienced fewer total procedures, rigid bronchoscopy treatment, intraoperative hypoxemia, needed emergency re-bronchoscopy in 24 h and transferred to ICU postoperatively. Patients with pure scar and granuloma, the rate of bronchoscopic success cure was higher than patients with scar granulation accompanied by tracheal chondromalacia (odds ratio: 8.208; 95% confidence interval: 2.755-24.459), and regular stenosis morphology was associated with a higher bronchoscopic success cure rate (odds ratio: 9.463; 95% confidence interval: 3.128-28.623). Irregular airway stenosis, chondromalacia or airway collapse are key factors affecting the success rate of bronchoscopic treatment for post-intubation tracheal stenosis. Level of evidence: 4 (historically controlled studies).

The Wound Healing of Autologous Regenerative Factor on Recurrent Benign Airway Stenosis: A Canine Experimental and Pilot Study

Introduction: Benign airway stenosis (BAS) is a severe pathologic condition. Complex stenosis has a high recurrence rate and requires repeated bronchoscopic interventions for achieving optimal control, leading to recurrent BAS (RBAS) due to intraluminal granulation. Methods: This study explored the potential of autologous regenerative factor (ARF) for treating RBAS using a post-intubation tracheal stenosis canine model. Bronchoscopic follow-ups were conducted, and RNA-seq analysis of airway tissue was performed. A clinical study was also initiated involving 17 patients with recurrent airway stenosis. Results: In the animal model, ARF demonstrated significant effectiveness in preventing further collapse of the injured airway, maintaining airway patency and promoting tissue regeneration. RNA-seq results showed differential gene expression, signifying alterations in cellular components and signaling pathways. The clinical study found that ARF treatment was well-tolerated by patients with no severe adverse events requiring hospitalization. ARF treatment yielded a high response rate, especially for post-intubation tracheal stenosis and idiopathic tracheal stenosis patients. Conclusion: The study concludes that ARF presents a promising, effective, and less-invasive method for treating RBAS. ARF has shown potential in prolonging the intermittent period and reducing treatment failure in patients with recurrent tracheal stenosis by facilitating tracheal mucosal wound repair and ameliorating tracheal fibrosis. This novel approach could significantly impact future clinical applications.

A multicenter observational study assessing the safety, feasibility, and complications of Bonastent in central airway obstruction.

Self-expandable metallic stents (SEMS) are increasingly used in the management of both malignant and nonmalignant airway stenosis. There are multiple stents available in the market; however, the current literature on the efficacy and safety of newly available 3rd generation SEMS (Bonastent) is extremely limited and only has data from single center studies. To report the efficacy and early (<7 days) and late (⩾7 days) complications in patients with central airway obstruction (CAO) treated with Bonastent placement at two institutions. We performed a retrospective analysis of data of consecutive patients who underwent therapeutic bronchoscopy and Bonastent placement at two tertiary care university hospitals between January 2019 and November 2023. Bonastent deployment was performed in the operating room. Stents were deployed using rigid or flexible bronchoscopy under direct visualization with a flexible bronchoscope and in conjunction with fluoroscopic guidance. We then analyzed the effectiveness, short-term, and long-term complications of Bonastent placement. A total of 107 Bonastents® were placed in 96 patients. The most common etiology of CAO was malignancy, 92.7% (n = 89), followed by excessive dynamic airway collapse (EDAC) and post-intubation tracheal stenosis. Seventy-three patients (76%) had improvement in symptoms or imaging within 7 days of stent placement, including successful liberation from mechanical ventilation in a patient with CAO. Early complications occurred in seven patients (two-airway bleeding, two-mucus plugging that improved with airway clearance, two-stent migrations, and one-cough).Late complications occurred in 23 patients (1-stent migration requiring revision bronchoscopy and replacement of airway stent, 11-mucus plugging, 6-granulation tissue, 2-pneumonia, 1-cough, 1-tumor ingrowth/stent fracture, 1-airway emergency due to excessive granulation tissue obstructing the distal end of the stent and had a failed cricothyroidotomy leading to death). Overall, the early complication rate was 7.3% (7/96) and late complication rate was 23.9% (23/96). Our study is the first multicenter study that found a good safety profile with a low complication rate after tracheobronchial Bonastent placement with improvement in symptoms soon after stent placement.

Site of Tracheostomy and Its Influence on The Surgical Outcome and Quality of Life After Tracheal Resection and Anastomosis in Patients with Tracheal Stenosis.

Introduction With the advances in critical care, the incidence of post intubation tracheal stenosis is increasing. Tracheal resection and anastomosis have been the gold standard for the management of grades III and IV stenosis. Scientific evidence from the literature on the determining factors and outcomes of surgery is not well described. Objective This study was aimed at determining the influence of tracheostoma site on the surgical outcomes and postoperative quality of life of patients undergoing tracheal resection anastomosis. Methods Thirteen patients who underwent tracheal resection and anastomosis during a period of 3 years were followed up prospectively for 3 months to determine the degree of improvement in their quality of life postsurgery by comparing the pre and postoperative validated Tamil/vernacular version of RAND SF-36 scores and Medical Research Council (MRC) dyspnea score. Results As per preoperative computed tomography (CT), the mean length of stenosis was found to be 1.5 cm while the mean length of trachea resected was 4.75 cm. We achieved a decannulation rate of 61.53%. There was an estimated loss of 3.20 +/- 1.90 cm of normal trachea from the lower border of the stenosis until the lower border of the stoma that was lost during resection. Analysis of SF-36 and MRC dyspnea scores revealed significant improvement in the domains of physical function postoperatively in comparison with the preoperative scores ( p < 0.05). Conclusion Diligent placement of tracheostomy in an emergency setting with respect to the stenotic segment plays a pivotal role in minimizing the length of the resected segment of normal trachea.

The role of thoracic surgery in the management of complicated acute and post-acute COVID-19 pneumonia (PASC).

COVID-19 is considered a respiratory virosis in its classic form, although it may present with heterogeneous symptoms. Thoracic complications occur in a small percentage of patients. Our objective was to evaluate existing experience with this disease and its thoracic manifestations and to determine the real-world status of care of these patients. This study is a retrospective, single-institution analysis of a group of patients hospitalized with acute and post-acute COVID-19 pneumonia at Thomayer Hospital in Prague in the period from December 2020 to March 2022 and indicated for a thoracic surgical procedure. During the peak of COVID-19 pandemic, a thoracic intervention was performed in 46 admitted patients. Thoracic drainage (due to pneumothorax in 18 cases, fluidothorax in 3 cases, CT-guided lung abscess drainage in 2 cases, and CT-guided pneumatocele drainage in 2 cases) were the most common thoracic surgical procedures. Pleurectomy/decortication surgery was done in 10 cases. Additionally, 12 lung parenchyma-sparing resections were performed, while lobectomy was required in 2 cases. Resection of postintubation tracheal stenosis due to a severe course of COVID-19 pneumonia was indicated in 2 patients. Even mild COVID-19 may cause a considerable morphological a functional alteration of the respiratory system. The most common complications of COVID-19 pneumonia that require a thoracic surgical intervention include pathologies associated with an air leak and accumulation of air (pneumothorax, pneumomediastinum and subcutaneous emphysema). The development of pulmonary necrosis, symptomatic bronchiectasis, pneumatocele, and bullous-fibrotic formations may result in pneumothorax, hemothorax or thoracic empyema in sporadic cases. An early thoracic surgical intervention to treat thoracic complications of COVID-19 pneumonia can improve the survival of COVID-19 patients.

Swiss Cheese Trachea: An Unwarranted, Unique Form of Post-intubation Tracheal Stenosis.

How to cite this article: Bajad P, Pahuja S, Agarwal S, Khanna A. Swiss Cheese Trachea: An Unwarranted, Unique Form of Post-intubation Tracheal Stenosis. Indian J Crit Care Med 2024;28(1):84-85.

Our Clinical Experience With Patients Requiring Intensive Care for Tracheal Stenosis: A Retrospective Case-Control Study.

Background and objective The clinical course in patients with tracheal stenosis (TS) ranges from being asymptomatic to respiratory failure requiring follow-up in the ICU. In this study, we aimed to assess the clinical characteristics, management,and outcome of TS patients who were admitted to the ICU. Materials and methods The data of patients hospitalized in the ICU due to TS between January 01, 2015, and January 01, 2016, were analyzed. The patients were classified into two groups: the post-intubation tracheal stenosis (PITS) group and the post-tracheostomy tracheal stenosis (PTTS) group. Demographic characteristics, body mass index (BMI), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment (SOFA)score of patients, factors that caused TS, management of TS, and ICU data of patients were compared. The outcome measures of our study were the ICU management of patients diagnosed with PITS or PTTS,their clinical characteristics, and differences in the treatment between patients diagnosed with PITS and those with PTTS in the ICU. Results Fifteen (75%) patients had PITS and five (25%)had PTTS. While BMI was significantly lower in patients in the PTTS group, the APACHE IIand SOFAscores were significantly higherin PTTS patients (p<0.05). In most of the patients in the PITS group, the location of the stenosis was subglottic and at the 1/3 upper part of the trachea, while in the PTTS group, it was located only at the upper 1/3 of the trachea (p>0.05).Mechanical dilatation was performed in all patients in both groups. Mechanical dilatation and cryotherapy were performed in 10 (66.7%) patients in the PITS group (p>0.05), and a stent was applied in addition to this treatment in three (20%) patients in the PITS group and four (80%) patients in the PTTS group (p<0.05). Mechanical ventilation was not needed in 10 (66.7%) PITS patients and three (60.0%) PTTS patients after the interventional procedure.All patients were eventually discharged from the ICU after treatment. Conclusion While higher BMI was common in PITS patients, the PTTS patients were generally in worse condition. In this patient group, interventional pulmonology procedures in the ICU can be life-saving.

Restenosis Following Bronchoscopic Airway Stenting for Complex Tracheal Stenosis.

Nonsurgical patients with complex postintubation tracheal stenosis (PITS) and tracheostomy-associated tracheal stenosis (PTTS) often require airway stenting. However, the optimal approach is unknown. Identifying patients at higher risk for restenosis after stent removal may allow the treating physician to individualize the vigilance and duration of airway stenting, and help optimize outcomes. This was a single-center retrospective analysis of prospectively collected data on all patients with complex PITS and/or PTTS treated with protocolized bronchoscopic airway stenting over a consecutive 16-year period. The primary outcome analyzed was restenosis rate at 1 year after stent removal. Predictors for restenosis and factors influencing risk for death during stent therapy were also assessed. Of the 181 subjects treated with silicone airway stenting, 128 were available for analysis of the primary outcome. Restenosis by 1 year after stent removal occurred in 58%. Independent predictors for restenosis were coexisting diabetes [odd ratio (OR)=3.10, 95% confidence interval (CI)=1.04-9.24; P=0.04], morbid obesity (OR=3.13, 95% CI=1.20-8.17; P=0.02), and occurrence of stent-associated complications requiring bronchoscopic management (OR=2.13, 95% CI=1.12-4.03; P=0.02). The overall mortality during the initial stenting period was 14%, and a silicone Y-stent was associated with a higher risk of death (OR=3.58, 95% CI=1.40-9.14; P=0.008). Tracheal restenosis after silicone stent therapy for complex PITS and PTTS is common and more likely to occur in patients with diabetes, morbid obesity, and frequent stent-associated complications. Mortality risk during stent therapy is not negligible, and a Y-stent should be utilized only after careful consideration. These findings may be incorporated into the approach to bronchoscopic airway stenting in these patients.

Cryotherapy for the Treatment of Tracheal Stenosis: A Systematic Review.

Tracheal stenosis (TS) is an iatrogenic sequela after intubation or tracheostomy that is increasing despite technological improvement and skilled respiratory care in the ICU. According to the studies, the rate of TS varies from 10 to 22%, but only 1-2% of these stenoses are severe and present with inspiratory dyspnea that does not respond to medical management. Bronchoscopy is considered the most appropriate diagnostic test, and laser surgery and tracheobronchial stenting are the most commonly performed procedures for tracheal stenosis. However, alternative treatment options, including cryotherapy for inoperable patients, have yet to be studied widely. As the number of patients requiring ICU admission with mechanical intubation is increasing, it is crucial to acknowledge this complication and consider alternative management options. Here we present a review of the use of cryotherapy for post-intubation tracheal stenosis. Pubmed, Cochrane, and EMBASE databases were inquired for studies performed using the keywords'airway stricture' OR 'airway obstruction' AND 'post-intubation' OR 'post-extubation' OR 'tracheostomy'AND 'cryotherapy'. After the primary and secondary screening, five studies were included in the analysis. We included 67 patients were included in the analysis, with a mean age of 50.2 (range: 42-55) years. Tracheal stenosis and subglottic stricture were the most common sites of stenosis. Twenty-nine patients were treated with cryotherapy only, while the rest 38 patients had cryotherapy followed by balloon dilation. After the intervention, 48 patients experienced improvement, five experienced no change in the symptoms, 13 patients were asymptomatic before the treatment, and one died. No complication was reported in 65 patients, with only minor complications reported in rest. Although, there is no clear treatment protocol for patients with inoperable tracheal stenosis. Our review demonstrates that cryotherapy for inoperable tracheal stenosis can be an acceptable alternative treatment with significant clinical improvement. Additionally, cryotherapy has fewer adverse effects compared to other treatment options.

IgG4-infiltrate in post-intubation tracheal stenosis: a call to interventional pulmonologist and thoracic surgeons.

Since December 2019, Sars-CoV2 infection has become a pandemic health emergency. The most severe manifestation of COVID-19 is acute respiratory distress syndrome requiring intensive care unit admission and mechanical ventilation. The most serious, although rare, complication of prolonged MV is post-intubation tracheal stenosis. We hypothesized that, in addition to recognized risk factors in COVID-19 patients, additional factors may promote airways injury. We analyzed data from 13 patients with PITS referred to our Thoracic Surgery Department from 2020 to 2022 divided in two groups: 8 ex-COVID-19 patients (in MV for ARDS during Sars-Cov2 positivity) and 5 non-COVID-19 patients (in MV for other reasons). Computer-tomography and bronchoscopy were performed to confirm diagnosis of PITS. Surgical treatment including tracheal resection and end-to-end anastomosis was performed in all patients. Tracheal samples were histologically analyzed to define the existence of any difference between the two groups. The presence of total immunoglobulin G (IgG) and immunoglobulin G4 (IgG4) were tested. IgG infiltrate was present in both groups. IgG4-infiltrate was significantly represented in the tracheal sample of ex-COVID-19 patients and absent in the non-COVID-19 cohort of patients. It is suggested that COVID-19 patients have almost double the risk of developing tracheal injuries. This work supports the idea of a major predisposition for such injuries in COVID-19 patients due to a possible immune-mediated mechanism leading to aberrant and fibrotic wound healing following a trigger insult (in this case MV with oro-tracheal tube). In the near future an increasing incidence of PITS is expected. Interventional pulmonologist and thoracic surgeons might be called to deal with this possibility. Clarification of the physiopathology of PITS is needed to prevent excessive tracheal scarring following prolonged endotracheal intubation and recurrence after endoscopic and/or surgical treatment. Careful prevention, early detection and effective management of this life-threatening condition are warranted.

Post-Intubation Tracheal Stenosis: Multicenter Study from 2010 to 2022

Objective: To study the epidemiological, clinical, paraclinical, therapeutic and evolutionary aspects of post-intubation tracheal stenosis occurring in patients admitted to intensive care units. Patients and methods: This is a multicenter, retrospective and descriptive study conducted from November 1, 2010 to June 1, 2022 in 7 intensive care units and 3 ENT departments. From medical records, we collected epidemiological data (frequency, age, sex), medical history, data relating to tracheal intubation (indication, duration, inflation pressure of the intubation tube balloon), data on post-intubation (PI) tracheal stenosis (symptoms and time to onset), paraclinical data, treatment and evolution modalities. The data collected were expressed as averages with their standard deviation. Results: During the study period, 19 patients presented with PI tracheal stenosis. The frequency ranged from 0.03% to 0.1%. The average age of the patients was 25.7 years 11.07 14-38 years. Patients had been intubated in a traumatic context in 47.37% of cases. The average duration of ventilatory support was 10.37 days  03.03 4-15 days No intubation tube cuff pressure monitoring was done for any patient. Dyspnea was the main telltale sign. Its average time to onset was 33.21  days 12.07 1h-3months. Endoscopically, the average degree of tracheal stenosis was 72.63% 50-99% . Therapeutically, in intensive care, 5 patients (26.31%) who presented with acute respiratory failure underwent a life-saving surgical tracheostomy. Curative surgery resulted in a tracheal resection-anastomosis (73.68%) and enlargement tracheoplasty (26.32%). The outcome was favorable for 9 patients (47.37%). The recurrence of the stenosis after curative surgery was observed in 31.58% of cases. Death occured in 3 patients (15.79%). Conclusion: Over-inflation of the intubation tube cuff is the leading cause of PI tracheal stenosis. Prevention is based on the systematic monitoring of its inflation pressure.

Tracheal resection in post COVID-19 patients is associated with high reintervention rate and early restenosis.

A remarkable increase in the number of patients presenting with tracheal complications after prolonged endotracheal intubation and mechanical ventilation for the management of the severe COVID-19 - associated respiratory failure has been observed. In this study, we assessed the postoperative outcomes of tracheal resection in COVID-19 patients. We conducted a retrospective study in which all patients with a history of prolonged invasive mechanical ventilation due to COVID-19 infection, who were treated with tracheal resection and reconstruction, were included. The primary objective was in-hospital mortality and postoperative reintervention rate. The secondary objective was the time to tracheal restenosis. During the 16-month study period, 11 COVID-19 patients with tracheal complications underwent tracheal resection with end-to-end anastomosis. Mean patient age was 51.5 ± 9 years, and the majority were male (9 patients). Eight patients were referred for management of post-intubation tracheal stenosis and 3 for tracheoesophageal fistula. Eight patients had a history of tracheostomy during the COVID-19 infection hospitalization. There was one in-hospital death (9.1%) due to septicemia in the Intensive Care Unit, approximately two months after the operation. Postoperatively, 32 reinterventions were required for tracheal restenosis due to granulation tissue formation. The risk for reintervention was higher during the first 3 months after the index operation. Four patients developed tracheal restenosis (36.4%) and two of them required endotracheal stent placement during the follow up period. Tracheal resection and reconstruction after COVID-19 infection is associated with a high reintervention rate postoperatively. Such patients require close follow up in expert interventional pulmonology units and physicians should be on high alert for the early diagnosis and optimal management of tracheal restenosis.

Management of COVID-19-related post-intubation tracheal stenosis.

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has affected Italy since the beginning of 2020. Endotracheal intubation, prolonged mechanical ventilation, and tracheostomy are frequently required in patients with severe COVID-19. Tracheal stenosis is a potentially severe condition that can occur as a complication after intubation. The aim of this study was to evaluate the utility and safety of endoscopic and surgical techniques in the treatment of tracheal stenosis related to COVID-19. Between June 2020 and May 2022, consecutive patients with tracheal stenosis who were admitted to our surgical department were considered eligible for participation in the study. A total of 13 patients were included in the study. They consisted of nine women (69%) and four men (31%) with a median age of 57.2 years. We included seven patients with post-tracheostomy tracheal stenosis. Bronchoscopy was performed to identify the type, location, and severity of the stenosis. All patients underwent bronchoscopic dilation and surveillance bronchoscopy at 7 and 30 days after the procedure. We repeated endoscopic treatment in eight patients. Three patients underwent tracheal resection anastomosis. Final follow-up bronchoscopy demonstrated no residual stenosis. The incidence of and risk factors associated with tracheal stenosis in critically ill patients with COVID-19 are currently unknown. Our experience confirms the efficacy and safety of endoscopic management followed by surgical procedures in cases of relapsed tracheal stenosis.

Achieving Successful Extubation and Cost-Effective Recovery Following Anesthetic Airway Management in Supracarinal Tracheal Reconstruction Surgeries: A Retrospective Analysis.

Introduction From an anesthesiologist's perspective, perioperative concerns related to supracarinal tracheal reconstruction surgery include having uninterrupted smooth ventilation without any laryngeal edema, glottic dysfunction, and airway leak. Surgical concerns comprise various kinds of anastomotic dissections, fistulas to innominate arteries, and the esophagus. The most serious complication following tracheal surgery is anastomotic separation, which might manifest modestly as stridor, respiratory distress, and extremis. To avoid dire repercussions, prompt management and securing the airway are necessary.Against this background,we wanted tohighlight the importance of early extubation and discharge of supracarinal tracheal reconstruction patients from hospitals without any postoperative complications and with the least expenses possible, since mostof these patients have already undergone postintubation tracheal stenosis and prolonged intensive care unit stay, and have experienced significant financialburden incurring from preceding events. Methodology Medical records of allpatients admitted for tracheal reconstruction during the period from March 2019 toApril 2022(four years)were reviewed to collect patient demographic details, surgical descriptions, anesthesia data, records of pre-anesthetic evaluations, and postoperative details up until the hospital discharge. Results The most common reason for tracheal stenosis among our patients was post-intubation tracheal stenosis (PITS), which was seen in 8/13 patients (61.53%);4/13patients (30.76%)had stridorat rest and underwent emergency tracheostomy preoperatively immediately following admission to the hospital.The stenosis was situated at a median distance of 3 cm [interquartilerange (IQR): 0.5-7] from the true vocal cords or 7 cm (IQR: 3-9) from the carina. The median length of tracheal resection was 2 cm(IQR: 1-4).Weobserved that the mode ofinductionfor airway management was tracheostomytubein four patients (with 90% tracheal stenosis), placement of laryngeal mask airway (LMA) with spontaneous ventilationin four patients (with 75% tracheal stenosis), andsmall-size (#5-7.5sizes) endotracheal tube (ETT) placement in five patients (with less than 75% tracheal stenosis).The postoperative complicationnoted was bleeding from the operative site in 1/13 patients (7.6%); a 0% mortality rate was noted during the hospital stay and up until six months post-discharge. We noted that the median duration of postoperative hospitalizationwas five days (IQR: 2-15), and the total cost incurred by each patientwas less thanINR 85,000 (USD 1,000). Conclusion Our analysis revealed that all our patients were extubated in the operative room andshifted to the ward. In the "open airway phase",standard distal tracheal intubation and cross-field ventilation techniques, and tracheal suturing were facilitated by the apnoea-ventilation-apnoea technique. Both the techniques along with the emergency tracheostomies done in severe tracheal obstruction preoperatively and intraoperative anesthesia management with the insertion of LMA Supreme,maintained with spontaneous breathing techniques, offered potential advantages in the management ofsupracarinal tracheal reconstruction surgeries. The multidisciplinary teamwork along with close communication and good rapport with the surgical team was found to be the key factor in the fast-track extubation and recovery of these patients.

Surgical Management of Post-Intubation Tracheal Injuries: A Single-Center Experience from Nepal

Introduction: Despite various improvements in technology and patient care, tracheal intubation and tracheostomy still result in significant tracheal injuries like stenosis and airway fistula. Pressure necrosis by the inflated balloon is the commonest culprit. Post-intubation tracheal stenosis is a major indication for tracheal resection and anastomosis. This study was done to find out the indications and results of surgery for post-intubation tracheal lesions. Methods: It was a descriptive observational study of patients with post- intubation tracheal lesions managed in Manmohan Cardiothoracic Vascular and Transplant Center over a period of 20 years (2001 to 2021). Results: Twenty-five patients were treated for post-intubation tracheal lesions. Four had isolated tracheo-esophageal fistula (TEF); eighteen had an isolated tracheal stenosis and three had both. Most had a tracheal resection and end-end anastomosis (REEA) via a cervical approach, resecting an average of 2.7 cm of tracheal length. The average size of stenotic lumen was 4.32 mm. There were no operative deaths. Two patients expired within a month of surgery: one due to fatal restenosis and the other due to sepsis. There were a few immediate and a few long-term complications. The average follow-up period was 5 years. Conclusion: Among the various post-intubation lesions, tracheal stenosis is the commonest indications for surgery. The management is challenging but safe and feasible, with a multidisciplinary team approach.

Severe and non-severe Covid-19 patients with postintubation tracheal stenosis

Severe and non-severe Covid-19 patients with postintubation tracheal stenosis

Severe and non-severe Covid-19 patients with postintubation tracheal stenosis

Severe and non-severe Covid-19 patients with postintubation tracheal stenosis

Postintubation Tracheal Stenosis: Report of Two Cases and Literature Review

Tracheal stenosis (TS) is a well-recognized yet underdiagnosed complication of prolonged intubation. Mechanisms include tracheal injury during intubation and ischemia of tracheal mucosa at the site of the endotracheal tube cuff and resultant fibrotic stenosis. TS usually develops 3–6 weeks following extubation and is often misdiagnosed as bronchial asthma. We report two such cases who developed TS following prolonged intubation.