SEVERE TRACH EAL STENOSIS FOl

PROLONGED MECHANICAl VENTllLAOWING

TION
.Ailian
IVi'
Croitoru, Shiman Ivry, Edward Altma n, Sh elly Kri
Nicola Makhoul, Simona Croitoru' merman,

On Yom Kippur will be sealed how many will poss from the earth and how

... who willlive ond who will die'

who wil! dle at nis predestined time ond w h o b'erore h,s
..' tlme'
who by water ond who by fire, who by sword , who by beost, who by famine .
who by thirst, who by storm, who by Plagu;,
who by suffocotian ...

Prolonged mechanical ventilation of critically ill patients may be corn-

plicatedby formation of postintubation tracheal stenosis with respiratory
disordersof different grades. Critical postintubation tracheal stenosis may
createlife threatening conditions. However, organized team work on the
groundof ICU may give positive results. We are presenting some of our ca-
ses,management and outcome compared to medicalliterature.

CASE NO. 1
A 59 year old patient was adrnitted to our hospital due to hoarsen~ss.A
lS
CT examination confirmed the suspected diagnosis of tracheal stenos . HISn
. . di old nlyocardial infarctlO ,
medIcaI historv included: ischemlc neart . Isease,I f '1 .
dlabetes n1eI1. 1tus,
pumonary edema, mechanical ventilatlo , n rena al ure. . e Sp C -
a tI . I . th ee vessel dlseas , o
r ena hypertension , coronaryatherosclerosls, rh h spital where ne re-
ronaryangiography. The patient was send to anot er I~ f f his syn1ptOn1s.
ut
celveda laser treatment (stenosis debridement) with re le o t lent witho
Ih h laser trea n
ree rnonths later the patient received anot er
~. . I Nnhnryn, Isrnel
nal Zio" Medical Center, Hatfa, Wcstcrn Gnli/ce Hospllo ,

T'
Jnlişoara 2011
 relief of symptoms. The following night he arrived a~ the hospital after CiI",
intubated with a tube no 6, after a difficult intubation-

We performed a low surgical tracheostomy and .sent him to a rehabilita.

tion hospital. Three months later, the patient arrived for th~ secon~ tilIl
e
intubated with a tube no. 6, two weeks after tracheal resection. lhls tilIl
e
we diagnosed a postoperative tracheal stenos!s. and perfor~ed the second
tracheostomy. The patient was sent to a rehabilitation hospital,

CASE NO. 2
A 68 year old patient admitted to the hospital due to respiratory distress_
138
His medical history included: SP Hemicolectomy, SP sepsis-peritonitis Can.
dida sepsis, SP aspiration pneumonia, SP prolonged mechanical ventilation.
On the first day he was treated with conservative treatment: inhalations
steroids, supplemental oxygen, without positive results. On the second da;
deterioration in his general condition, with increased dyspnea and the pati-
ent was expeditiously taken to the operating room, after Cf examination.

In the operating room, under general anesthesia with high frequencyjet

ventilation the patient underwent rigid tracheoscopy, which revealed severe
stenosis in the cervical trachea due to massive granulations. He was treated
by resection of the granulations with the tip of the rigid bronchoscope and
removal by suction, dilatation of trachea to 8 mm, diathermy coagulation
of bleeding points. On the third day weaning from mechanical ventilation
and transfer to another hospital for stent insertion. 30 months after tra-
cheal stent the patient's condition was stable, without major respiratory
complaints.

CASE NO. 3
A 74 year old patient admitted to hospital due to acute respiratory failu-
re and hemoptysis Her medical history included: SP coronary artery bypass
graft, SP Prolonged mechanical ventilation, SP Cervical tracheal stenosis,SP
Tracheal stent insertion, Chronic renal failure

On the ~rst day after admission dyspnea, moderate hemoptysis, treatedby

con.s~rvatlve treatment: Inhalations, steroids, supplemental oxygen, without
posrt.ve results. On ~he second day: deterioration of his general conditian,
mcrea~ed hernoptvsls and dyspnea. The patient was taken urgently to the
operatinq room. In the operating room und b th'lng and
. . , er spontaneous rea
consoousness sedation, attempt of rigid b h At the be'
ronc oscopy was done.

Actualităţi in Anestezie şi Terapie I1Itt~

 . of the cervical trachea fresh blood ela
9,",'1"9 enoue to the unstable condition ~f th ts and maSSlvt
9 n
weresest~mythrough the stent was dane BI ed.patientemerg ;a U1atlons
racheo TI . ee Ing fr t
n SurglcI
t d by diathermy. le next day weanin f om granulaf a
stOPPt~nsfer to the hospital where the stcnt ~ r~m mechanical ve~Ot~IS ~as
and r as Inserted. I atlon

CASE NO. 4, .
68yearold patient, adruitted to the hospital f
A b ' I ' ar acute res '
th suspected ac t ena pneumonia. His medical hi ,plratoryfailure
y
1'11 rt disease,chronic atrial fibrillation diabete Istlor Included: ischemi~
hea, I 's rne litus SP
raccident, SP trac ieostomv. an the first day ft ' cerebral vas-
CU,Ia a er admi '
onRxleft pneumonia, treated by antibioties, fluids inha ,ssion dyspnea,
I-
amination: rracheal stenosis. an the 10lh day afte' d ,la~lons.On the CT
l ex . r a rmssion su ' I
heos1omywas performed In the operating room b ENI rqica tra-
s, r . Y . The pati t
transferredto ICU. an arrival at the ICU, the staff c Id ,en was
y , O fi b ' ou not ventllate th
,,~t,enteffectlvely. n I eroptic bronehoscopy: traeheal tenosl e
r- The oati s enoslSwasnoted
be!owthe cannula. . . e patient was reintubated
. with a sm II d'
a lameter rn
:J~rne next day, riqid bronchoscopy. with boogies was unsuccessu f IIy per-.
f2r01ed.Employment of balloon dilation had good results and reintubation
1', th m no. 6.5 was performed. A day later the same procedure with reintu-
batlOnwith a m no 8. 3 days later the patient was transferred to a special
renterfor tracheal stent insertion.

CASE NO. 5
A 54year patient, mechanically ventilated after acute myocardial infarc-
!lOn, was admitted 2 months later to the hospital for stridor. On CI exami-
~atlon:tracheal stenosis. The patient was transferred for laser treatment to
a'lOtrer hospital. with clinical improvement after the treatment. One week
Dasttre laser treatment, he arrived once again to aur hospital due to acute
'e~plratorl failure. Under ventilation with a laryngeal mask an emergent
tracheostomywas done.

CASENO. 6
A 76vear old patient admitted to Dur hospital for dyspnea, shock hypo~o-
lemltacute renal failure and suspected urinary tract infection. His med~cal
hist . . iutus hypertenSlon,
ory Included' congestive heart failure, dlabetes me 1, 't 'IS
SP, . . . th a SP translen -
h mechanlcal ventilation restrictive lung dlsease, as ma, . due to gra-
~ ~rnlcattack, SP tracheaÎ stent insertion, SP tracheal stenos~~atoryfailure
thu/tlo~Slaser treated in stent. Due to progressive acute rce:I~~ventilated.
patlent was intubated through the stent and mechan

Tin!'
lŞ oara 2011
 Dtscussfons I t hro I . fi
Tltere are dlfferent causes of trache~1 stenos s: rauma, c n C In .""
matory disease, benign neoplasm, maltgnant neoplasm, collagen vaSCUI't
disease. It is incontestable that the most common cause of lary~go-tracheal
stenosis continues to be internal or external trauma. From the Internal tra.
umatic causes prolonged endotracheal intubation is the leading cau5e Of
laryngo-tracheal stenosis.
Pathophysiology. Mucosal ischemia is the first sign and it is due to low
capillary perfusion pressure produced by direct contact with EIT segment o,
by an increase in the pressure in the tube cuff. The events that lead to steno.
140 sis involve: ulceration of the mucosa and cartilage, inflammatory reactions
with associated granulation tissue, fibrous tissue formation and contractio"
of fibrous scar tissue.
Tracheal stenosis causing acute on chronic respiratory failure or failu_
re to wean in patients requiring prolonged mechanical ventilation is not a
new problem, it is only a forgotten complication of prolonged mechanical
ventilation (1) Nowadays it is not due only to prolonged mechanical Venti-
lation but also due to tracheostomy, surgical or percutaneous(2). In spite of
.ts advantages percutaneous tracheostomy is associated with an increased
risk of severe suprastomal tracheal stenosis compared to the surgical tech-
nlque.(3) Not aII the authors agree with this conclusion. Ledl believe that
there is no influence of tracheostomy technique on hypergrannulations.lts
development depends on the duration of cannulation (4) He recommends
to keep the duration of cannulation as short as possible with respect to the
underlying impairment.
Tracheal stenosis IS sometimes critica! and may pose difficult problems 10
save lives. There are different techniques to solve this problem.
According to Chao (5) rigid bronchoscopy could provide good results for
controlltng arrwav In patients with critical stenosis. For Schmidt (6) the solu-
tron is endotracheal balloon dilation and stent implantation but sometimes
we must remove (7) the tracheal stent. Amoros propose tracheal and crico-
tracheal resection for laryngotracheal stenosis. (8)
In our opinion prevention is better than cure. Precise control of the pre-
ssure in the cuff dunng prolonged mechanical ventilatlOn is the main pro-
phylactic measure.

What is tracheal stenosis??? What is critical tracheal stenosis??? When

and how to evaluate it?

There are differ.ent technlques to evaluate tracheal stenosis. For Noura-

el (9) the svstem IS ba sed on the classi fication f f rway
dyspnea, voice and swallowing or (10) flow I o our parameters:
. al f the'
vo ume testmg. Because o

ActUl/lităfi ill Allcslezir şi Terapir Inlrnsifd

 relationship between airway rad'
di IUSand
'IIrvngotrac h ea I rmensrons can teac t ' ,resistanc
ce and this may continuously chan o sI9Micant cha~' slIUIlI
ge
resiSt~rn"ental study (11) the simulated pre the flow VOlun}es In a1rway
~ , ' ~~d ~~~I
eXP to dramatlcally mcrease only when ove 7 rop over the . ~ an
n
see rated and it increases critically oniy w; 0% of the traChe:ltelnosis is
obllte en the sten " umen is
cneallumen, OSISISover 900'
a
Ir our oplnlOn"th e b est ti'ee rruque to appr ' 'o of
In "1 1 eClate trach
developmentIS ~lttLla aryn~o tracheoscopy (12), T' eal stenosis and its
dedicatedtearn In every hospital, his must be dane bya

Conclusions
Fewintensive care services carrv out long term f II
, "1 o ow up of p t'
trachealstenOslS or critica tracheal stenosis Reh bili , a lents with
, ' ' a I Itatlon spe ' l'
beresponslble for them, which may account for th lati eia ist may
" I li e re ative paucit f
po rtsin the critica care iterature
. dealing with long t erm ollow up yo
f of re-.
entswith tracheal stenosis. When they arrive in a crinrea 1 condltlon ' , w patl-
the only doctors that can solve the problem and save their lives ,e are
Forthis reason we must know the problem arid prepare ton o meet ,It pro-
perly,

References

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Journal 2005, 32(2) 154-158
J. KOttschevA, Simon C, Blumendtoek G, Mach H, Graumuller S, Suprastomal tracheal stenosis after dilatio-
nal and surgieal traeheostomy m critically ill patients. Anesthesia 2006; 9 (61): 832-837,
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men
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lai'o'loru M,rOltoru
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in p,gs,
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ron o simulated granulation and slenoS'S o

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