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Airway management in acute respiratory distress secondary to tracheal stenosis following one time intubation

Brooklyn, New York

To the Editor:

In this correspondence we detail our perioperative management of a 16-yr-old male asthmatic, who developed tracheal stenosis, following one time brief intubation (36 hr) a month previously, presenting with acute respiratory distress requiring emergency intubation in the pediatric intensive care unit. Direct laryngoscopy revealed normal looking vocal cords but firm resistance was encountered subglottically even to a size 5 cuffed endotracheal tube (ETT). The patient was transferred to the operating room (OR) with the ETT in situ. Airway resistance was high (45 to 50 cm of H₂O), EtCO₂ > 99 mmHg with SaO₂ of 92 to 95% on 100% O₂.

Emergency tracheostomy was done under iv ketamine and inhalational anesthesia supplemented with 1.5% lidocaine local anesthesia. Postoperative computed tomography failed to reveal convincing evidence of tracheal stenosis. However fibreoptic laryngoscopy revealed a funnel shaped subglottic narrowing with a very small distal opening. Mucosal biopsy demonstrated chronic inflammation and fibrosis.

Nineteen percent of patients intubated translaryngeally develop significant stenosis.^1,2 While prolonged intubation has been associated with a higher incidence of laryngotracheal injury,³ there are case reports of tracheal stenosis following brief intubation of 24 hr duration.⁴

In critically ill and hypo-perfused patients, endotracheal balloon pressure can exceed perfusion pressure and cause mucosal injury. Periodic deflation of the ETT cuff during prolonged intubation, or switching from volume control to pressure control mode, may minimize ischemic injury. Trauma at the time of intubation and excessive crowbar effect of heavy ventilator related equipment prying the tube against the laryngotracheal mucosa, are preventable causes of tracheal stenosis.¹ Excessive movement during the initial intubation period causes the balloon to act like a fulcrum with a long handle exerting a large amount of torque force at the cuff.⁴ Controlling agitation and excessive body movement during mechanical ventilation could prevent ischemic injury.⁴

Patients with airway stenosis often present with progressively worsening dyspnea, going on to stridor and later to episodes of obstruction. Too often these cases are mistaken for bronchial asthma.⁴ Careful physical examination, supported by characteristic flow volume loops should prompt early evaluation by fibreoptic laryngobronchoscopy, enabling treatment options ranging from corticosteroids and antibiotics⁵ to tracheal dilatation.¹

In the presence of acute respiratory distress, definitive management should always take place in the OR under inhalation anesthesia without muscle relaxant, a surgeon skilled in emergency airway access standing by.¹ While bridging supraglottic airways would be ineffective, attempted endotracheal intubation might worsen mucosal edema precipitating a near total obstruction.

References

1 Grillo HC, Donahue DM. Postintubation tracheal stenosis. Chest Surg Clin N Am 1996; 6: 725–31.[Medline]

2 Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981; 70: 65–76.[Medline]

3 Whited RE. Laryngeal dysfunction following prolonged intubation. Ann Otol Rhinol Laryngol 1979; 88: 474–8.[Medline]

4 Yang KL. Tracheal stenosis after a brief intubation. Anesth Analg 1995; 80: 625–7.[Medline]

5 Weymuller EA Jr, Bishop MJ, Fink BR, Hibbard AW, Spelman FA. Quantification of intralaryngeal pressure exerted by endotracheal tubes. Ann Otol Rhinol Laryngol 1983; 92: 444–7.[Medline]

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