Postintubation Tracheal Stenosis Research Articles

Post-Traumatic Tracheal Stenosis: Results of Tracheal Reconstruction: A Multicenter Case Series

Objectives: to find out the long-term results of tracheal reconstruction in terms of presentation, operation, complications, and outcomes of tracheal reconstruction. Methods: In this case-series study, the patients who developed post-intubation tracheal stenosis following respiratory failure were followed up for two years for the possible complications. The patients were diagnosed by experienced pulmonologist in two surgical centers, Erbil and Sulaimaniya in Iraqi Kurdistan in 2017. Results: The number of patients who were included in this study was 20; including males (n=13) and females (n=7) ranged between 18-58 years. The causes of the stenosis in patients were post-intubation (n=18) and post-tracheostomy for trauma (n=5). Most patients underwent extubation after 72 hours. The Myer-Cotton Grade of stenosis were grade 1 (n=1), grade 2 (n=13), and grade 3 (n=6). The major complications were dehiscence (n=3) and anastomotic edema (n=5). The minor complications were granulation (n=13) and mild anastomotic edema (n=1). One patient developed a surgical site infection and one patient developed a mild infection. The anastomotic fibrin deposition was developed in five patients. All patients had excellent satisfaction except for two patients (unsatisfactory). One of these patients died at month 1. The patients had normal medical conditions at different times of follow-ups. Conclusions: This study showed that the results of the patients with post-traumatic tracheal stenosis were acceptable at different times for most of them.

COVID-19-related Post-intubation Tracheal Stenosis: Early Experience With Surgical Treatment.

Tapias, Luis F. MD∗; Lanuti, Michael MD∗; Wright, Cameron D. MD∗; Hron, Tiffiny A. MD†; Ly, Amy MD‡; Mathisen, Douglas J. MD∗; Ott, Harald C. MD∗ Author Information

Various Uses of Laryngeal Mask Airway during Tracheal Surgery.

The use of laryngeal mask airway (LMA) ventilation in surgeries to be performed in upper tracheal stenosis has been reported in the case series. However, there is no generally accepted standardized approach for the use of LMA. In this study, LMA usage areas and advantages of trachea surgery were examined. The records of 21 patients who underwent tracheal surgery using LMA ventilation between March 2016 and May 2020 were evaluated retrospectively. The patient data were analyzed according to age, gender, mean follow-up time, surgical indication, mean tracheal resection length, anastomosis duration, mean oxygen saturation, mean end-tidal CO2 levels, and postoperative complications. Four patients were female and 17 were male, their median age was 43 (11-72 range) and the mean follow-up time was 17.6 months. The most common surgical indication was postintubation tracheal stenosis. The mean tracheal resection length was 26.6 mm and the mean anastomosis duration was 11.3 minutes. The mean pulse oximetry and mean end-tidal CO2 during laryngeal mask ventilation was 97.6% ± 2.1 and 38.1 ± 2.8 mm Hg, respectively. Postoperative complications were higher in patients with comorbidities. LMA-assisted tracheal surgery is a method that can be used safely as a standard technique in the surgery of benign and malignant diseases of both the upper and lower airway performed on pediatric patients, patients with tracheostomy, and suitable patients with tracheoesophageal fistula.

Submucosal Injection of Mitomycin-C Due to Development of Tracheal Restenosis After Resection

Tracheal stenosis following laryngotracheal intubation and tracheostomy is still one of the most common clinical problems today. Although surgery is the first option for its treatment, bronchoscopic approaches can be successfully used for treatment of restenosis that may develop after surgery. In this report, we could prevent the recurrence of granulation tissue by submucosal injection of mitomycin-C to the stenosis by using rigid bronchoscopy to the 28-year-old patient who underwent tracheal resection due to postintubation tracheal stenosis and subsequently developed granulation tissue. In this report, the submucosal injection of mitomycin-C, a potent fibroblast inhibitor, was tried for the first time for tracheal restenosis.

Use of an Insulation-Tipped Knife during Rigid Bronchoscopic Treatment of Benign Tracheobronchial Stenosis.

Background and Objectives: Tracheal or bronchial tears are potential complications of rigid bronchoscopy. This study aimed to investigate the acute complications and outcomes of using an insulation-tipped (IT) knife in combination with rigid bronchoscopic dilatation for treating benign tracheobronchial stenosis. Materials and Methods: We conducted a chart review of patients with benign tracheobronchial stenosis who were treated with rigid bronchoscopy and an IT knife at two referral centers. Treatment success was defined as a clinically stable state without worsening symptoms after 3 months of treatment. Results: Of the 23 patients with benign tracheobronchial stenosis, 15 had tracheal stenosis and 6 had main bronchial stenosis. Among them, three cases were of simple stenosis (13%), while the others were of complex stenosis (87%). The overall treatment success rate was 87.0%. Pneumomediastinum and subcutaneous emphysema occurred due to bronchial laceration in two cases of distal left main bronchial stenosis (8.7%), and no other significant acute complications developed. Silicone stents were inserted in 20 patients, and successful stent removal was possible in 11 patients (55.0%). Six of the seven stents inserted in patients with post-intubation tracheal stenosis were removed successfully (85.7%). However, most of the patients with post-tracheostomy tracheal stenosis required persistent stenting (80%). Pulmonary function was significantly increased after treatment, and the mean increase in the forced expiratory volume in 1 s was 391 ± 171 mL (160–700 mL). Conclusion: The use of an IT knife can be suggested as an effective and safe modality for rigid bronchoscopic treatment of benign tracheobronchial stenosis.

A Case of Post-intubation Tracheal Stenosis That Required Tracheal Resection and Reconstruction for Repeated Stenosis After Endoscopic Dilatation

A Case of Post-intubation Tracheal Stenosis That Required Tracheal Resection and Reconstruction for Repeated Stenosis After Endoscopic Dilatation

Trakeal Stenoz Cerrahisinde Nöromuskuler Blok Yönetimi; Retrospektif Değerlendirme

Objective: In the surgical treatment of tracheal stenosis, whether in long procedures such as tracheal resection-anastomosis or in short procedures such as rigid bronchoscopy and dilatation, performing a deep neuromuscular block to provide patient comfort and facilitate the surgery. In this study, neuromuscular block antagonism using sugammadex during the surgical treatment of tracheal stenosis was investigated. The aim of our study was to evaluate the antagonism of the neuromuscular block with sugammadex in cases of postintubation tracheal stenosis and posttracheostomy tracheal stenosis in terms of postoperative residual block, complications and its effect on postoperative respiratory pattern. Method: In order to evaluate the effectiveness of the anesthesia methods and neuromuscular block management procedures applied during the surgical treatment of tracheal stenosis, patient files, anesthesia record forms, early postoperative follow-up and discharge process were retrospectively reviewed. Since most of the 34 patients diagnosed with tracheal stenosis underwent more than one surgical procedure at different times, a total of 140 interventional procedures and anesthesia applications were examined. Patients who underwent tracheal stenosis surgery and used sugammadex for neuromuscular block antagonism were included in the study. Results: 34 patients were evaluated as postintubation- posttracheostomy tracheal stenosis. While rigid bronchoscopy (n = 78), balloon dilatation (n = 35) and stent (n = 5) were applied to the patients as short surgical procedures, 22 patients underwent tracheal resection-anastomosis surgery. After the use of sugammadex in short and long surgical procedures, the time to start spontaneous breathing was found to be similar. No complications related to sugammadex were identified. Conclusion: We argue that the use of sugammadex under the monitoring of anesthesia depth and muscle strength in tracheal stenosis surgery is an effective and reliable choice for neuromuscular block antagonism.

Ultrasound as a bedside tool for diagnosis of post-intubation tracheal stenosis

BackgroundScreening of post-intubation stenosis can allow early diagnosis, early management of stenosis, and possible prevention of progress. Fiberoptic bronchoscope is the gold standard for diagnosis of tracheal stenosis. Other imaging modalities as computed tomography can be considered but are not available in intensive care unit.Purpose of the studyTo evaluate the validity of ultrasound (US) as a bedside test for early diagnosis of post-intubation stenosis compared to multidetector computed tomography (MDCT) and fiberoptic bronchoscope (FOB).ResultsOut of the 50 included patients, 12 patients were found to have definite stenosis by FOB. Compared to CT, significant positive correlation was found between all ultrasound parameters (laryngeal width, tracheal diameter) and corresponding CT parameters (r = 0.798, p < 0.001; r = 0.714, p < 0.001 respectively). Compared to FOB results, the yield of MDCT chest for diagnosis of stenosis had 91.6% sensitivity and 100% specificity, while the yield of US detected by mucosal irregularity as a diagnostic tool for tracheal stenosis had comparable sensitivity (91.6%) but lower specificity (88.9%).ConclusionDue to its high sensitivity, US could help in detection of possible post-intubation laryngotracheal stenosis in critically ill MV patients.

Postintubation Multisegmental Tracheal Stenosis: A 24-Year Experience

Management of multisegmental tracheal stenosis is challenging. In this 24-year longitudinal single-center study, we present an algorithmic treatment approach. A retrospective analysis of 2167 patients with postintubation tracheal stenosis indicated 83 (3.83%) patients with multisegmental tracheal stenosis. Patients were assigned to 4 management groups according to the length, location, and severity of stenoses; tracheal infection/mucositis; laryngeal function; symptoms; general condition; and comorbid diseases. Type 1 (n= 13): 1-stage resection of both strictures, Type 2 (n= 6): 2-stage resection of both strictures, Type 3 (n= 40): resection of 1 stricture and nonresectional management of the other, Type 4 (n= 24): nonresectional management of both strictures. Outcomes were categorized as Good, Acceptable, or Poor. Univariate analyses for factors predictive of recurrence and outcome were performed. Follow-ups were completed in 70 (84.34%) patients (median, 22.5 months). Outcome was assessed as Good in 56 (82.35%), Acceptable in 10 (14.71%), Poor in 2 (2.94%), and mortality in 2 (2.94%) patients. The median length of airway resection was 46, 67.5, and 40 mm in Types 1-3, respectively. Only 11 (13.25%) patients had no history of tracheostomy or tracheal surgery. By univariate analysis, a shorter intubation period was associated with Good outcome (P= .017). No factors predictive of recurrence or outcome were ascertained. Multisegmental tracheal stenosis, generally caused by performing an inappropriate tracheostomy, is an iatrogenic disease that can be prevented. Although resection of both strictures may be feasible and is associated with Good results, in the majority of cases, a combination of surgical resection and non-resectional methods are sufficient to achieve Good results.

IMPROVISED T-TUBE FOR MANAGEMENT OF COTTON-MYER GRADE IV SUBGLOTTIC STENOSIS

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Post-intubation and post-tracheostomy injury are among the most common etiologies of subglottic stenosis. Bronchoscopic interventions for the treatment of subglottic stenosis include laser therapy, balloon dilation, and/or stent placement. The Montgomery T-tube (MTT) is a silicone tube with a vertical limb that works as a stent within the trachea and a horizontal limb which functions as a tracheostomy tube (TT). It has unique indications, such as proximal stenosis that result in loss of voice who do not respond to common intervention or are not surgical candidates. Utmost care is required in the maintenance of a MTT, and patients with poor access to medical care or poor compliance may not be appropriate candidates. CASE PRESENTATION: A 56-year-old-male with history of motor vehicle collision complicated by post-intubation tracheal stenosis requiring tracheostomy presented in interventional pulmonology clinic for loss of voice. Patient had a Shiley 6.0 cuffless fenestrated TT at this visit. Patient underwent flexible bronchoscopy and electrocautery radial incisions and balloon dilation for a Cotton-Myer Grade III subglottic stenosis 2 cm below the vocal cords (VC). Due to recurrence of symptoms, repeat FB was performed 4 weeks later and was remarkable for a Cotton Meyer grade IV subglottic stenosis 1 cm below the VC. Patient had multiple clinic visits before his repeat FB where he was found to have >50% occlusion of his TT inner cannula with mucus and lacked compliance with suctioning despite repeated education. He underwent rigid bronchoscopy and had sequential dilations using a balloon over a guide-wire that was inserted through the center of the stenosis. A 14x40mm silicone stent was placed inside the airway with the proximal end of the stent 0.5 cm below the VC. The TTs’ obturator was inserted through the tracheostomy stoma and gently pushed to visualize an indentation on the stent. The stent was removed and jet ventilation was continued. A side-hole was punched at the marked location of the stent and the fenestrated TT fit was tested. The stent was placed back in the trachea with the customized hole placed anteriorly and the TT was inserted through the stent. The fenestrations aligned with the tracheal lumen and VC. Patient was able to speak with capping or finger occlusion and on 18-month follow up maintains his speech and TT maintenance. DISCUSSION: Montgomery t-tube is a rarely used stent with unique indications. Its placement and long-term management requires subspecialized training in IP or ENT. Because the tube does not have an inner cannula, regular daily suctioning and care is required for its maintenance. When troubleshooting is required, most doctors are not familiar with the t-tube, hence proximity to a center with specialized teams may be necessary. CONCLUSIONS: The use of the modified t-tube may decrease the risk of complications in the aforementioned patient population. Reference #1: D'Andrilli, A., Venuta, F., & Rendina, E. A. (2016). Subglottic tracheal stenosis. Journal of thoracic disease, 8(Suppl 2), S140–S147. Reference #2: Hu, H., Zhang, J., Wu, F., & Chen, E. (2018). Application of the Montgomery T-tube in subglottic tracheal benign stenosis. Journal of Thoracic Disease, 10(5), 3070–3077. Reference #3: Fiorelli, A., Natale, G., Freda, C., Cascone, R., Carlucci, A., Costanzo, Santini, M. (2019). Montgomery T-tube for management of tracheomalacia: Impact on voice-related quality of life. The Clinical Respiratory Journal, 14(1), 40–46. DISCLOSURES: No relevant relationships by Kevin Davidson, source=Web Response no disclosure on file for Ray Shepherd; no disclosure on file for Samira Shojaee; No relevant relationships by Zulma Swank, source=Web Response

Postintubation Tracheal Stenosis Evaluated by Endobronchial Optical Coherence Tomography: A Canine Model Study

Background: The predictors and airway morphological changes during the development of postintubation tracheal stenosis (PITS) have not been well elucidated. Objectives: To elucidate the validation of endobronchial optical coherence tomography (EB-OCT) in assessing the airway morphological changes in PITS. Methods: We performed oral endotracheal intubation in 12 beagles to establish the PITS model. EB-OCT was performed respectively before modeling and on the 1st, 7th, and 12th day after extubation in 9 canines, and was conducted consecutively in 3 canines during the development of PITS. Histological findings and the thickness and gray-scale value of the tracheal wall assessed by EB-OCT measurements were analyzed and compared. Results: The tracheal wall edema, granulation tissue proliferation, cartilage destruction in PITS, and airway wall thickening detected by EB-OCT were in concordance with the histopathological measurements. The consecutive EB-OCT observation of the airway structure demonstrated the tracheal wall thickness significantly increased from 344.41 ± 44.19 μm before modeling to 796.67 ± 49.75 μm on the 9th day after modeling (p < 0.05). The airway wall gray-scale values assessed by EB-OCT decreased from 111.19 ± 14.71 before modeling to 74.96 ± 4.08 on the 9th day after modeling (p < 0.05). The gray-scale value was negatively correlated with the airway wall thickness (r = –0.945, p = 0.001). Conclusion: The EB-OCT imaging, in concordance with the histopathological finding, was validated for assessing the airway morphological changes during the development of PITS. The EB-OCT evaluation of cartilage damage and gray-scale value measurement might help predict the development and prognosis of PITS.

TRANS-CATHETER CLOSURE OF TRAUMATIC VENTRICULAR SEPTAL DEFECT AND BRONCHOSCOPY DILATION OF POST-INTUBATION TRACHEAL STENOSIS RESULTING FROM A STAB WOUND

Cardiac penetrating injury accounts for few of ventricular septal defect (VSD) and percutaneous repair has been widely used recently. Post-intubation tracheal stenosis is a known complication and is fit for endoscopic therapy. A 16 years old boy was stabbed in the chest 3 months ago. Left ventricle

Surgical treatment of acquired tracheal stenosis in pediatrics

Acquired tracheal stenosis is a very infrequent lesion in the pediatric age group and may be due to diverse causes, being post-intubation stenosis and stenosis secondary to tracheostomy the most common ones. The management of acquired tracheal stenosis remains controversial. Endoscopic treatment provides immediate relief of symptoms but it is associated with a high recurrence rate, and the use of endoluminal prostheses can increase the length of the stricture complicating future surgery. Conversely, good long-term results have been documented with tracheal resection and primary anastomosis. We describe our experience with tracheal resection followed by end-to-end anastomosis for the treatment of post-intubation tracheal stenosis in 8 patients.

Risk factors for decannulation failure after single-stage reconstruction of adult post-intubation tracheal stenosis: 10-year experience at a tertiary center

Background: Although the risk factors for decannulation failure have been discussed in the literature, there are many unclear points on this issue.Aims and objectives: To identify risk factors for developing decannulation failure after single-stage surgical reconstruction of post-intubation tracheal stenosis (TS).Material and methods: A total of 45 adult patients with post-intubation TS admitted to our institution and underwent single-stage surgical reconstruction between April 2008 and May 2018. Nine patients developed decannulation failure by postoperative 6 months (Failed Decannulation Group), and 36 patients were decannulated successfully (Successful Decannulation Group). Causal factors of intubation were noted. Patient-related risk factors of decannulation failure were compared between two groups.Results: Failed Decannulation Group had a significantly higher body mass index (p = .034) and were more likely to have diabetes (p = .025). Patients who were previously intubated for more than 48 h (p = .043) were significantly more likely to have decannulation failure. The presence of comorbid diseases did not place a patient under statistically significant risk of decannulation failure.Conclusion: Patients with high body mass index, the ones with diabetes, and patients who were previously intubated for more than 48 h were more likely to develop decannulation failure.

Different results of tracheoplasty for various tracheal diseases

Background: Tracheoplasty is a challenging surgical procedure for treating tracheal diseases. Preserving the voice and achieving normal breaths are considered favorable results. This article reports the mid-term results of tracheoplasty. Materials and Methods: From July 1988 to June 2018, a total of 91 adults with various tracheal diseases who underwent tracheoplasty were enrolled in this study. Tracheal diseases were divided into two categories. Category 1 was not related to neoplasm and included posttracheostomy or postintubation tracheal stenosis, caustic tracheal stricture, tuberculous tracheal stenosis, and congenital tracheal stenosis. Category 2 was related to neoplasm and included tracheal neoplasm and tracheal invasion by thyroid cancer or esophageal cancer. The surgical procedures mainly involved segmental resection of the trachea, telescopic anastomosis following a middle split of thyroid-cricoid cartilage, spiral tracheoplasty, and slide tracheoplasty. Results: One hospital death (1.1%) occurred. Favorable results of tracheoplasty were 81.3% (74/91). The failure rate of tracheoplasty was higher in Category 1 (24.2%, 15/62) than Category 2 (3.6%, 1/28). The subglottic involvement also induced a higher failure rate of tracheoplasty (35.3%, 6/17 vs. 13.7%, 10/73). However, the multivariate logistic regression model demonstrated that the category of tracheal disease and subglottis involvement did not statistically significant induce surgical failure of tracheoplasty. Sixteen (17.6%) patients had surgical failure resulted from anastomotic leaks, regrowth of granulation, or subglottic involvement. Conclusions: Carefully evaluating the tracheal lesions and selecting the appropriate surgical procedure can yield favorable results of tracheoplasty.

Therapeutic bronchoscopic interventions for nonmalignant central airway obstruction provide rapid and sustained improvement in symptoms and functional status

Background:Central airway obstruction (CAO) is a potentially lethal condition that requires urgent endobronchial intervention and may occur due to several nonmalignant causes. The effect of these interventions on clinically relevant outcomes such as symptomatic and functional status over a period of time is, however, sparsely studied.Materials and Methods:Consecutive patients with CAO due to nonmalignant causes and undergoing various therapeutic bronchoscopy procedures were evaluated. Symptoms were assessed using the Visual Analog Scale (VAS) and Speiser score, and functional status was assessed using the 6-min walk test, spirometry, and St. George Respiratory Questionnaire (SGRQ) score at baseline and after 48 h, 4 weeks, and 12 weeks postprocedure.Results:Over 2 years, 31 patients with CAO due to nonmalignant etiology underwent 41 therapeutic bronchoscopic procedures. Majority of procedures (96.8%) were done using the rigid bronchoscope under general anesthesia. Postintubation tracheal stenosis was the most common indication (32.2%). The various procedures included, controlled radial expansion balloon dilatation of the stenotic airway (53.6%), deployment of silicone stents (19.5%), and mechanical debulking of airway tumors (16.1%). Significant improvement occurred in dyspnea and cough scores and in the Speiser score from baseline to 48 h postprocedure, and further improved at 4 weeks and 12 weeks. Similarly, the 6 min walk distance, forced expiratory volume in 1 s, and SGRQ scores progressively improved from baseline to 12 weeks. Complications occurred in 26.8% of total procedures, with no procedure-related mortality.Conclusion:Therapeutic bronchoscopy interventions provide rapid and sustained benefits in symptoms and functional status of participants with CAO of nonmalignant etiology, with an acceptable safety profile.

Prognostic factors associated with morbidity and mortality after surgery for postintubation tracheal stenosis

Prognostic factors associated with morbidity and mortality after surgery for postintubation tracheal stenosis

The role of interventional bronchoscopy in the management of post-intubation tracheal stenosis: A 20-year experience

PurposeBenign tracheal stenosis management is still controversial, and there is no international consensus on the best treatment option. Thus, we aimed to look into the history of PITS and the different strategies used in its treatment. The importance of bronchoscopic treatment was also defined, and its effectiveness and safety were assessed. MethodsRetrospective study of patients diagnosed with PITS, who were referred to the Bronchology Department between January 1996 and December 2016. ResultsOf 115 patients enrolled (mean age 48.5±17.6 years, 53% males), 66.1% had complex stenosis. The most common causes of intubation were respiratory (29.9%), neurological (26.8%) and surgical (19.6%). Complex stenosis was caused by longer intubation, and was more frequent among previously tracheostomized patients. The most common location was the upper third of trachea (60.9%). Most cases were initially treated by interventional bronchoscopy, and although serial dilations were effective in some complex PITS, a higher proportion of simple stenosis was successfully managed with this treatment option. Long-term recurrence after serial dilation was observed in 25.0% of cases. Stent placement was required (19.1%) only for complex PITS. Stent-related complications were frequent (61.9%) and linked to the stenting time (p<0.001). Overall, there were no procedure-related complications. Surgical intervention was also performed (30.0%), always with complex PITS. Post-surgical recurrences were observed in 24.2% of cases. ConclusionsInterventional bronchoscopy is an efficient and safe modality in PITS management. Further studies are needed for better classification and improved knowledge of PITS pathogenesis, and to achieve international consensus of definition to guide clinicians in their practice.

Dr. Douglas Mathisen: management complications after tracheal surgery—the earlier the intervention, the better the outcome

At the 6th Oriental Congress of Thoracic Surgery (OCTS 2019) in Shanghai, Dr. Douglas Mathisen ( Figure 1 ), from Massachusetts General Hospital, gave impressive presentations on the two topics—“Management complications after tracheal surgery” and “Postintubation tracheal stenosis—the MGH experience”, sharing his experience on tracheal surgery. During the congress, with the great honor, we took this opportunity to interview Dr. Douglas Mathisen.

Spontaneous breathing anesthesia for cervical tracheal resection and reconstruction.

Spontaneous breathing anesthesia (SBA) may have advantages over general anesthesia for cervical tracheal resection and reconstruction (TRR), avoiding the difficulties and complication caused by endotracheal intubation and surgical cross-field intubation. This prospective study evaluates SBA for cervical TRR. Date was obtained from 35 patients who had cervical TRR under SBA from May 2015 to March 2019. Intravenous sedation and ultrasound-guided bilateral superficial cervical plexus block (CPB) were applied to maintain effective analgesia and sedation. Thirty-two patients with tracheal tumors and 3 patients with post-intubation tracheal stenosis underwent TRR. After the airway was opened, 29 patients resumed stable spontaneous breathing, 1 patient needed high-frequency jet ventilation, and 1 patient needed anesthesia conversion for surgical reasons. Spontaneous breathing anesthesia is feasible for the cervical TRR. It can be an alternative anesthetic technique for certain patients.