Laryngotracheal stenosis in critically ill patients

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.

Laryngotracheal stenosis in burn patients requiring mechanical ventilation

Objective

To identify the incidence of laryngotracheal stenosis (LTS) in burn patients requiring mechanical ventilation at a regional academic burn center.

Methods

A retrospective review of all burn patients requiring endotracheal intubation or tracheostomy for airway management between 2003 and 2009 was performed. A group of trauma patients requiring similar airway instrumentation during the same period of time was used as a control.

Results

None of the trauma patients and 2 of the burn patients developed LTS. Both presented with stridor and were diagnosed within 2–5 weeks after extubation. One patient underwent successful carbon dioxide laser radial incision and dilation and continues to do well. The other patient failed endoscopic treatment and required T-tube placement. The incidence of LTS in burn patients requiring mechanical ventilation was 2.98% overall and 4.76% among those with inhalational injury.

Conclusions

Patients become symptomatic within weeks of the initial injury. Treatment is challenging and multiple surgical procedures are often required. A larger study is necessary to determine if the incidence is higher among burn patients.

Analysis of Age-Related Differences of Risk Factors and Comorbidities in Laryngotracheal Stenosis Patients

Laryngotracheal stenosis (LTS) is a life threatening airway problem that is mainly caused by prolonged intubation. The authors intend to assess whether there was variability in the risk factors depending on age, and to determine which risk factors and comorbidities were more important in the development of LTS at older or younger ages. Fifty-two LTS patients were evaluated for comorbidities and risk factors retrospectively. The LTS etiologies, demographics, and medical and surgical histories of the patients were determined by the medical records. The patients under 40 years old were defined as group 1, and the patients 40 years of age or older were defined as group 2. Our study revealed that with regard to GERD, hypertension, DM2, and pulmonary infection, there was a statistically significant difference between group 1 and group 2 (p = 0.025, p = 0.0005, p = 0.002, and p = 0.000, respectively). Those patients ≥ 40 years old exhibited higher rates of GERD, hypertension, DM2, and pulmonary infection. However, there were no statistically significant differences between the groups with regard to smoking, alcohol consumption, COPD/asthma, immunological disease, and obesity (BMI > 30). There was a statistically significant difference between the groups for all the risk factors except a previous tracheotomy (p = 0.115). The risk factors and comorbidities thought to be involved in the development of LTS could show age-related variability. Therefore, in patients over 40 years of age with comorbidities (GERD, hypertension, DM2, and pulmonary infection), it is necessary to take precautions before the development of LTS. Prolonged intubation and tracheotomy history are the main risk factors for all patients, regardless of age.