Virginia Research Day 2022

Medical Resident Research Case Reports

10 Post Mechanical Intubation Tracheal Stenosis

Sidrah Ghaffar, DO; James Rixey, DO Corresponding author: Sidrah.ghaffar@lpnt.net

SOVAH Health Internal Medicine Residency Program

Context: Complications associated with endotracheal tubes occur during or immediately following initial placement including tracheal and laryngeal stenosis, inflammation, edema, vocal cord ulceration, granuloma, and paralysis. Case Report: 52-year-old African American female presented to the ER for altered mental status. She was intubated for airway protection. Medical History: ESRD due to diabetic nephropathy currently on hemodialysis, hypertension, hyperlipidemia, insulin- dependent diabetes mellitus, depression, chronic normocytic anemia, gastroparesis. Surgical History: Cervical spine diskectomy in 2006, Right arm arteriovenous fistula in 2018, left retinal detachment repair surgery in 2014. Family History (Hx): Father, deceased, had lung cancer at age 69. Mother has hypertension and diabetes. Sister has hypertension and diabetes. Social Hx: Lives at home with mother. Smokes less than ½ pack per day. No history of alcohol, or illicit drug use. Pertinent Review of Systems: 13-point review of system was unable to be obtained due to patient's unresponsive condition.

Pertinent Admission Physical Exam: Blood pressure 217/100, pulse 72, respiratory rate 16, temperature 96.6° F, oxygen saturation 98% on mechanical ventilation. Acutely ill- appearing African American female, intubated and sedated. Regular rhythm but tachycardic. Mechanical breath sounds bilaterally. No wheezes, rales or rhonchi. Neck supple. No masses. Trachea midline. No thyromegaly. No thyroid mass noted. Physical Exam Day #3 Post Extubation: Audible stridor, wheezing, and respiratory distress. Pertinent Lab: WBC 11,880, Hgb 11.9, platelets 171,000, TSH 1.42, Troponin <0.015, BNP 59, D-dimer 0.08, Potassium 4.5, Anion gap 10, BUN 47, Creatinine 7.50, Blood glucose 323, Ammonia 13 ECG: Sinus rhythm at 82 beats per minute, no ST changes. Imaging Studies: CT chest without contrast post extubation shows significant narrowing of trachea at vocal cords. Diagnosis: Tracheal stenosis with stridor secondary to recent intubation. Treatment: Patient was assessed by ENT who performed bedside nasopharyngoscopy

2 0 2 2 R e s e a r c h R e c o g n i t i o n D a y includes corticosteroids for edema, vocal cord injection for paralysis and speech training for dysphonia. Extensive tracheal stenosis may require endoscopic stenting, balloon dilation or laser resection. Tracheostomy is the final option. with no obstructive lesions noted at the level of the glottis. Recommendation was to repeat nasopharyngoscopy outpatient in 2-3 weeks. Patient was treated with systemic steroids and was provided steroid taper at discharge. Patient Outcome: Patient achieved significant recovery with treatment and was sent home with supplemental oxygen Comments: Tracheal stenosis is usually caused by high ETT cuff pressure exceeding the mean capillary pressure in the tracheal mucosa causing obstruction of capillary blood flow leading to ischemia, inflammation, and erosion of the mucosa followed by necrosis, destruction of the tracheal architecture, and scarring. Risk factors: Prolonged intubation, traumatic intubation, large endotracheal tube. Definitive diagnosis requires bronchoscopy or laryngoscopy. Management: Most conditions associated with laryngeal injury heal spontaneously and symptomatic therapy may be administered while recovery is pending. Management

23