Effect of corticosteroids on post-intubation tracheal stenosis

Factors associated with the occurrence of stomal stenosis after tracheostomy in adults

OBJECTIVE

Although tracheal stomal stenosis can be life-threatening, factors associated with the occurrence of stomal stenosis remain unknown. This study was performed to evaluate these factors in adult patients.

METHODS

We retrospectively identified adult patients who underwent tracheostomy from 2010 to 2016 using a Japanese national inpatient and outpatient database. We performed Cox proportional hazard regression analyses to evaluate factors associated with the occurrence of tracheal stomal stenosis.

RESULTS

We obtained data on 25,436 eligible patients. The proportion of tracheal stomal stenosis was 0.9%. Tracheal stomal stenosis was significantly less likely to occur in patients with regular use of oral steroids [hazard ratio (HR), 0.28; 95% confidence interval (CI), 0.09-0.88; P = 0.03] and in male patients (HR, 0.75; 95% CI, 0.57-0.97; P = 0.03). The occurrence of tracheal stomal stenosis was significantly associated with use of a mechanical ventilator at home (HR, 2.54; 95% CI, 1.55-4.15; P < 0.001) and a body mass index of <18.5 kg/m² (HR, 1.45; 95% CI, 1.06-1.99; P = 0.02).

CONCLUSION

Our study revealed several factors that are associated with tracheal stomal stenosis. These findings may help physicians to manage tracheal stomas.

Effect of inhaled fluticasone propionate on laryngotracheal stenosis after balloon dilation: a randomized controlled trial

PURPOSE

Laryngotracheal stenosis describes various airflow compromising conditions leading to laryngeal and tracheal narrowing, including subglottic and tracheal stenosis. Direct laryngobronchoscopy is the diagnostic gold standard for laryngotracheal stenosis. This study aimed to explore the effect of inhaled fluticasone propionate as adjuvant medical therapy in patients with laryngotracheal stenosis after balloon dilation.

METHODS

This prospective randomized controlled trial was conducted from April 2019 to April 2020. Fourteen adults (≥ 18 years) with laryngotracheal stenosis consented to participate. All patients underwent endoscopic balloon dilation. Seven patients were treated with inhaled fluticasone propionate, and seven acted as controls. Detailed documentation of operative findings and pre- and post-balloon dilation spirometry measurements were recorded. Basic demographic data and operative details, including information about the percentage of laryngotracheal stenosis, distance of laryngotracheal stenosis from the vocal cords, the stenotic segment vertical length, and the largest endotracheal tube used before and after dilation were noted.

RESULTS

Spirometry measurements were obtained on 34 occasions (17 before and 17 after balloon dilation). The two groups were similar in spirometry values after treatment. Both groups had significantly improved on most spirometry values after balloon dilation.

CONCLUSION

We found that using inhaled steroids after balloon dilatation in patients with laryngotracheal stenosis had no benefit over non-user patients in spirometry parameters during the short postoperative follow-up. To confirm this outcome, we recommend a large-scale double-blind study with a longer follow-up period.

Intratracheal Dilation-injection Technique in the Treatment of Granulomatosis with Polyangiitis Patients with Subglottic Stenosis

OBJECTIVE

An analysis of subglottic stenosis (SGS) occurrence frequency in patients with granulomatosis with polyangiitis (GPA) based on the time of appearance of clinical symptoms, and an assessment of treatment effectiveness, in particular with the intratracheal dilation-injection technique (IDIT).

METHODS

Review and treatment with IDIT of 34 patients with SGS associated with GPA.

RESULTS

SGS developed in 34 of 250 patients with GPA (13.6%) and was not reflective of disease activity in the organs in 15 of 34 patients (44%): 11 cases after and 4 cases during immunosuppressive therapy (IST) when patients did not have organ symptoms. All patients underwent IDIT and in total, the treatment resulted in immediate improvement. In addition, in 21 cases, IST was applied because of other organ involvement or of the lack of longterm efficacy of IDIT. The median time of response was 37 months and the median interval between sessions was 5 months. None of the patients required tracheostomy after beginning IDIT in our hospital.

CONCLUSION

SGS often occurs independently of other features of active GPA. IDIT is a safe and effective technique in the treatment of GPA-related SGS. It should be performed in all patients with GPA who develop significant SGS and in those with multiorgan disease concomitantly with IST. In patients with isolated SGS, IDIT also makes IST and tracheostomy unnecessary.

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Recurred Post-intubation Tracheal Stenosis Treated with Bronchoscopic Cryotherapy

Post-intubation tracheal stenosis accounts for the greatest proportion of whole-cause tracheal stenosis. Treatment of post-intubation tracheal stenosis requires a multidisciplinary approach. Surgery or an endoscopic procedure can be used, depending on the type of stenosis. However, the efficacy of cryotherapy in post-intubation tracheal stenosis has not been validated. Here, we report a case of recurring post-intubation tracheal stenosis successfully treated with bronchoscopic cryotherapy that had previously been treated with surgery. In this case, cryotherapy was effective in treating web-like fibrous stenosis, without requiring more surgery. Cryotherapy can be considered as an alternative or primary treatment for post-intubation tracheal stenosis.

Diagnosis and conservative management of late tracheotomy complications in chronic ventilator-dependent patients

BACKGROUND

Complications associated with long-term tracheotomy are obstruction of the distal end of the tube by granulation tissue and tracheomalacia. These complications have traditionally been surgically treated.

METHODS

Prospective study in a chronic ventilator-dependent division, including 234 consecutive patients with tracheotomy and mechanical ventilation. Endoscopic evaluation was performed in patients in whom there was respiratory distress with difficulty in passing a suction catheter through the tube, and/or increased inspiratory resistance and increased peak inspiratory pressure.

RESULTS

Nineteen patients were diagnosed with granulation or tracheomalacia. Two patients were treated by surgical removal of the obstructing tissue. Nonsurgical patients were conservatively managed with symptoms' resolution by bypassing the pathology with a longer tube than the previous one or by an adjustable flange tube under endoscopic visualization, with a median symptom-free period of 433 days (range, 55-1230 days).

CONCLUSION

In nonsurgical candidates, insertion of a longer tube is a conservative and feasible long-term treatment.

Successful treatment of bronchial obstruction by flexible bronchoscopy and isoniazid: A case report

Interventional bronchology techniques have been employed as an effective first-line treatment in patients with tracheobronchial obstruction. However, recurrent stenosis produced by granulation tissue requires repeated procedures. Previous studies have indicated that isoniazid regulates collagen deposition and decreases collagen content. Thus, isoniazid has been successfully administered to patients with lesions who exhibited a delay in the healing process. A case of a left mainstem obstruction managed by interventional bronchology is described in the present study. Repeated bronchial stenosis was observed even following numerous treatment procedures, however, administration of isoniazid resulted in the inhibition of hypertrophic scar formation and prevention of repeated stenosis. The suppressive effect of isoniazid on granulation formation and further observations are reported. Few studies have been conducted with regard to the function of isoniazid in suppressing scar hyperplasia, therefore, the mechanism requires further investigation.

Successful treatment of tracheal stenosis by rigid bronchoscopy and topical mitomycin C: a case report

Tracheal stenosis is a known complication of prolonged intubation. It is difficult to treat and traditional surgical approach is associated with significant risk and complications. Recurrent stenosis due to granulation tissue necessitates repeated procedures. We describe a case of short web-like tracheal stenosis (concentric membranous stenosis less than 1 cm in length without associated cartilage damage) managed by a minimally invasive thoracic endoscopic approach. Topical application of Mitomycin C, a potent fibroblast inhibitor reduces granulation tissue formation and prevents recurrence.

Management of Benign Stenoses of the Large Airways in the University Hospital in Prague, Czech Republic, in 1998–2003

BACKGROUND

Clinically significant benign stenoses of the large airways develop in about 1% of patients after intubation. The management of benign stenoses is not unified around the world, nor are there any accepted methods for their screening.

OBJECTIVES

The purpose of this study is to describe and compare results of interventional bronchoscopy and surgical therapy of benign stenoses as well as to propose an algorithm for the management of this airways disorder.

METHODS

Prospective study on 80 consecutive patients with benign stenoses of the large airways admitted to the Pulmonary Department of the University Hospital of Prague-Motol.

RESULTS

Sixty-two patients developed stenoses after endotracheal intubation or tracheostomy, in 18 patients the stenosis was caused by other diseases or pathological situations. Thirty-eight patients were sent for surgical resection of the stenotic part of the airways. 2 surgically treated patients developed recurrence of the stenosis and had to be reoperated on. Narrowing of the trachea at the site of end-to-end anastomosis developed in 6 other patients and was cured by interventional bronchoscopy. The remaining 42 patients were treated by interventional bronchoscopy (Nd-YAG laser, electrocautery, stent) which was curative in 35 patients. Sixty-five patients were alive at the time of evaluation, 15 patients died. Five of them died between 3 and 14 (median 4) months after surgery from a disease other than airway stenosis. Ten nonresected patients also died, with 1 exception, due to a disease other than airway stenosis; the median survival was 9 months.

CONCLUSIONS

We recommend to assess the patient for surgery after the initial diagnosis and therapeutic bronchoscopy with dilatation of the stenosis. If the patient is not a suitable candidate for resection, interventional bronchoscopy is an appropriate alternative for the management of benign stenoses of the large airways.

Tracheostomy management in the chronically ventilated patient

Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.

Post-intubation tracheal stenosis

A42-year-old insulin-dependent diabetic woman was admitted in the intensive care unit with aspiration pneumonia following an episode of hypoglycaemia. She was managed by mechanical ventilation with endotracheal intubation. During her stay she had a pulmonary embolism for which she was heparinized. Myocardial infarction further delayed her weaning from the ventilator. She remained intubated for 11 days. She was discharged after 3 weeks hospital stay, in a satisfactory condition.

After 3 weeks, she presented as an ear, nose and throat emergency with breathing difficulty. She was found to have biphasic stridor and arterial oxygen saturation concentration ranged from 70 to 80%. Flexible naso-laryngoscopy showed normal vocal cords. A plain X-ray lateral view of the neck showed narrowing of the air column in the upper trachea. Her flow–volume curve showed features of severe tracheal obstruction with a reduction in peak expiratory and inspiratory flow. All routine blood tests and chest X-ray were normal. She was managed by humidified oxygen, intravenous hydrocortisone (100 mg three times a day) and co-amoxiclav (1.2 g three times a day). She responded to this treatment very well.

A tomogram of larynx and trachea performed the next day showed a narrowing of theupper tracheal lumen (Figure 1). Flexible bronchoscopy showed a ring of granulations, resulting in a circumferential narrowing of the upper trachea of 2–2.5 cm in length.

She settled with conservative treatment. Serial flow–volume curve measurements also showed a significant improvement. She was discharged after a week and maintained on a reducing dose of oral steroids for 2 weeks. She is still under close follow-up.

CO2 laser posterior transverse cordotomy for isolated type IV posterior glottic stenosis

One case of isolated type IV posterior glottic stenosis successfully treated with CO2 laser posterior transverse cordotomy is presented. This report emphasized the value of the CO2 laser posterior transverse cordotomy in this situation. A review of the various therapeutic options advocated in the medical literature to treat isolated posterior glottic stenosis is also presented.