Successful weaning and decannulation after interventional bronchoscopic recanalization of tracheal stenosis

Surgical treatment of severe benign tracheal stenosis

OBJECTIVE

To present clinical experiences regarding surgical treatment of patients with severe cicatricial tracheal stenosis.

PATIENTS AND METHODS

From January 2008 to March 2020, 14 patients underwent tracheal resection and reconstruction under general anesthesia. Nine cases had cervical tracheal stenosis and five cases had thoracic tracheal stenosis. The mean diameter and length of strictured trachea was 0 - 8 mm with a mean of 4.5 ± 2.4 mm and 1 - 3 cm with a mean of 1.67 ± 0.63 cm, respectively. General anesthesia and mechanical ventilation were performed in ten cases and four patients underwent femoral arteriovenous bypass surgery due to severe stenosis. End-to-end anastomosis of trachea was performed in 13 cases and the anastomosis between trachea and cricothyroid membrane was performed in one case. Absorbable and unabsorbable sutures were used for the anterior and posterior anastomoses, respectively. Postoperative neck anteflexion was maintained by a suture between the chin and superior chest wall. The relevant data of the 14 patients were retrospectively reviewed, and the operation time, blood loss, postoperative hospital stay, postoperative complications and follow-up were retrieved.

RESULTS

There was no intraoperative death. The length of resected trachea ranged from 1.5 to 4.5 cm with a mean of 1.67 ± 0.63 cm. Operation time ranged from 50 - 450 min with a mean of 142.8 ± 96.6 min and intraoperative hemorrhage ranged from 10 - 300 ml with a mean of 87.8 ± 83.6 ml. Follow-up period ranged from 5 to 43 months with a mean of 17.9 ± 10.6 months. None of the patients had recurrent laryngeal nerve paralysis during postoperative follow-up. Ten cases were discharged uneventfully. Anastomosis stenosis occurred in three cases who received interventional therapies. Bronchopleurocutaneous fistula occurred in one patient after 6 days postoperatively and further treatment was declined.

CONCLUSION

The strategies of anesthesia, mechanical ventilation, identification of stenosis lesion, the "hybrid" sutures and postoperative anteflexion are critical to be optimized for successful postoperative recovery.

Incidence, causes, and predictors of unsuccessful decannulation following prolonged weaning

Background

Liberation from prolonged tracheostomy ventilation involves ventilator weaning and removal of the tracheal cannula (referred to as decannulation). This study evaluated the incidence, causes, and predictors of unsuccessful decannulation following prolonged weaning.

Methods

Observational retrospective cohort study of 532 prolonged mechanically ventilated, tracheotomized patients treated at a specialized weaning center between June 2013 and January 2021. We summarized the causes for unsuccessful decannulations and used a binary logistic regression analysis to derive and validate associated predictors.

Results

Failure to decannulate occurred in 216 patients (41%). The main causes were severe intensive care unit (ICU)-acquired dysphagia (64%), long-term ventilator dependence following weaning failure (41%), excessive respiratory secretions (12%), unconsciousness (4%), and airway obstruction (3%). Predictors of unsuccessful decannulation from any cause were age [odds ratio (OR) = 1.04 year^-1; 95% confidence interval (CI), 1.02-1.06; p < 0.01], body mass index [0.96 kg/m² (0.93-1.00); p = 0.027], Acute Physiology and Chronic Health Evaluation II (APACHE-II) score [1.05 (1.00-1.10); p = 0.036], pre-existing non-invasive home ventilation [3.57 (1.51-8.45); p < 0.01], percutaneous tracheostomies [0.49 (0.30-0.80); p < 0.01], neuromuscular diseases [4.28 (1.21-15.1); p = 0.024], and total mechanical ventilation duration [1.02 day^-1 (1.01-1.02); p < 0.01]. Regression models examined in subsets of patients with severe dysphagia and long-term ventilator dependence as the main reason for failure revealed little overlapping among predictors, which even showed opposite effects on the outcome. The application of non-invasive ventilation as a weaning technique contributed to successful decannulation in 96 of 221 (43%) long-term ventilator-dependent patients following weaning failure.

Conclusion

Failure to decannulate after prolonged weaning occurred in 41%, mainly resulting from persistent ICU-acquired dysphagia and long-term ventilator dependence following weaning failure, each associated with its own set of predictors.

Tracheobronchial Surgery in Emerging Countries

Tracheobronchial surgery is widely performed in emerging countries mainly as a consequence of the high number of airway-related complications and poor management in intensive care units. This has led to great expertise in the surgical management of postintubation tracheal stenosis, and opportunity for advancing scientific knowledge. Nonetheless, tracheal stenosis has a severe impact on a patient's quality of life, is a major burden to the health system, and should be prevented. Incorporation of innovative techniques, technologies, and prospective databases should prompt earlier diagnosis and lead to fewer complications.

Tracheal stenosis in prolonged mechanically ventilated patients: prevalence, risk factors, and bronchoscopic management

Background

Various complications may arise from prolonged mechanical ventilation, but the risk of tracheal stenosis occurring late after translaryngeal intubation or tracheostomy is less common. This study aimed to determine the prevalence, type, risk factors, and management of tracheal stenoses in mechanically ventilated tracheotomized patients deemed ready for decannulation following prolonged weaning.

Methods

A retrospective observational study on 357 prolonged mechanically ventilated, tracheotomized patients admitted to a specialized weaning center over seven years. Flexible bronchoscopy was used to discern the type, level, and severity of tracheal stenosis in each case. We described the management of these stenoses and used a binary logistic regression analysis to determine independent risk factors for stenosis development.

Results

On admission, 272 patients (76%) had percutaneous tracheostomies, and 114 patients (32%) presented mild to moderate tracheal stenosis following weaning completion, with a median tracheal cross-section reduction of 40% (IQR 25–50). The majority of stenoses (88%) were located in the upper tracheal region, most commonly resulting from localized granulation tissue formation at the site of the internal stoma (96%). The logistic regression analysis determined that obesity (OR 2.16 [95%CI 1.29–3.63], P < 0.01), presence of a percutaneous tracheostomy (2.02 [1.12–3.66], P = 0.020), and cricothyrotomy status (5.35 [1.96–14.6], P < 0.01) were independently related to stenoses. Interventional bronchoscopy with Nd:YAG photocoagulation was a highly effective first-line treatment, with only three patients (2.6%) ultimately referred to tracheal surgery.

Conclusions

Tracheal stenosis is commonly observed among prolonged ventilated patients with tracheostomies, characterized by localized hypergranulation and mild to moderate airway obstruction, with interventional bronchoscopy providing satisfactory results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01821-6.

Health-related quality of life evaluation in patients with non-surgical benign tracheal stenosis

Background

The primary objective of the study was to evaluate the health-related quality of life (HRQL) of patients with benign post-intubation tracheal stenosis considered as unfit for surgical treatment. Secondary objectives were: (I) to determine if clinical variables (gender, age, total treatment time, and type of tracheal device) could influence HRQL and (II) to compare the results with a normal standardized population.

Methods

Prospective study between August-2014 and December-2016 including patients with tracheal stenosis treated with silicone stents, T-Tubes or tracheostomy. Candidates to airway resection and reconstruction were excluded from the analysis. HRQL was assessed with the SF-36 Health Questionnaire. Backward stepwise regression model analyzed the influence of clinical variables on the SF-36 domains and component summaries. Norm-based results were compared with normative data. Alpha error was 5%.

Results

Ninety-three patients (62M/31F; mean age 38±14 years) were included. Mean overall HRQL in all 8 SF-36 domains was poor. Lowest scores were in the role physical (mean 31.7±38), bodily pain (mean 39.2±35), and role emotional domain (mean 48.7±40). The physical component summary (PCS) was more affected than the mental (P<0.001). Norm-based results indicated that most domains and both physical and mental summaries were below the mean for the USA normative population. Total stenting time significantly influenced the physical (P=0.001) and mental component summaries (P=0.001).

Conclusions

Quality of life of patients with benign tracheal stenosis is severely impaired, and norm-based results indicate that the HRQL is below normative data. Physical and mental discomfort seems to be attenuated by total treatment time.

The differential diagnosis for failure to wean from mechanical ventilation

PURPOSE OF REVIEW

In this review, we discuss the causes for a failed weaning trial and specific diagnostic tests that could be conducted to identify the cause for weaning failure. We briefly highlight treatment strategies that may enhance the chance of weaning success.

RECENT FINDINGS

Impaired respiratory mechanics, respiratory muscle dysfunction, cardiac dysfunction, cognitive dysfunction, and metabolic disorders are recognized causes for weaning failure. In addition, iatrogenic factors may be at play. Most studies have focused on respiratory muscle dysfunction and cardiac dysfunction. Recent studies demonstrate that both ultrasound and electromyography are valuable tools to evaluate respiratory muscle function in ventilated patients. Sophisticated ultrasound techniques and biomarkers such as B-type natriuretic peptide, are valuable tools to identify cardiac dysfunction as a cause for weaning failure. Once a cause for weaning failure has been identified specific treatment should be instituted. Concerning treatment, both strength training and endurance training should be considered for patients with respiratory muscle weakness. Inotropes and vasodilators should be considered in case of heart failure.

SUMMARY

Understanding the complex pathophysiology of weaning failure in combination with a systematic diagnostic approach allows identification of the primary cause of weaning failure. This will help the clinician to choose a specific treatment strategy and therefore may fasten liberation from mechanical ventilation.