Estenosis traqueal postintubación después de neumonía grave por coronavirus / Postintubation Tracheal Stenosis after Severe Coronavirus Pneumonia

Introducción: La rápida propagación del SARS­CoV­2 ha provocado una pandemia mundial. Si bien puede salvar vidas, la intubación traqueal presenta el riesgo inherente de inducir daño en la mucosa traqueal con estenosis, con una incidencia estimada de 4,9 casos por millón cada año. Objetivo: Caracterizar la presentación de una estenosis traqueal por intubación prolongada en un paciente que sufrió neumonía grave por coronavirus. Presentación del caso: Se asiste a un paciente de 55 años que sufrió neumonía grave por coronavirus y necesitó intubación orotraqueal prolongada. Una vez recuperado comienza con disnea de empeoramiento progresivo. Se diagnostica una estenosis traqueal y se decide tratamiento quirúrgico donde se realiza resección y anastomosis. El paciente no presentó complicaciones y evolucionó satisfactoriamente. Conclusiones: La estenosis traqueal debe reconocerse como una complicación potencial, aun cuando los pacientes se recuperan de una neumonía grave por COVID-19. El diagnóstico definitivo de estenosis traqueal se realiza mediante fibrobroncoscopia. La resección traqueal con anastomosis entre tráquea y tráquea es el procedimiento más comúnmente realizado(AU)

Introduction: The rapid spread of SARS-CoV-2 has resulted in a global pandemic. Although tracheal intubation can save lives, it presents the inherent risk of inducing tracheal mucosal damage with stenosis, with an estimated annual incidence of 4.9 cases per million. Objective: To characterize a case of tracheal stenosis due to prolonged intubation in a patient with severe coronavirus pneumonia. Case presentation: A 55-year-old patient who suffered severe coronavirus pneumonia and required prolonged orotracheal intubation was attended. Once recovered, the patient began with progressively worsening dyspnea. Tracheal stenosis was diagnosed and surgical treatment was decided, in which resection and anastomosis were performed. The patient did not present any complications and evolved satisfactorily. Conclusions: Tracheal stenosis should be recognized as a potential complication, even when patients recover from severe COVID-19 pneumonia. A definitive diagnosis of tracheal stenosis is made by fibrobronchoscopy. Tracheal resection with anastomosis between trachea is the most commonly performed procedure(AU)

Pedicled latissimus dorsi myocutaneous flap for treatment of acquired tracheo-esophageal fistula combined with tracheocutaneous fistula: A case report / 中国胸心血管外科临床杂志

@#We reported a patient intubated for more than 30 d following brain injury, transferred to our department with tracheocutaneous fistula and a 2 cm fistula between the trachea and the esophagus. We performed tracheal resection and esophageal closure with a latissimus dorsi myocutaneous flap interposed between suture lines. The patient continued mechanical ventilation after surgery and the tracheotomy was achieved 14 d after the beginning of surgical treatment. The patient was started oral feeding and discharged on the 10 d after tracheotomy and referred to a neuromotor recovery clinic for treatment of post-traumatic sequelae.

Cuidados de las fístulas traqueoesofágicas postintubación / Care of the post-intubation tracheoesophageal fistulae

RESUMEN Introducción: Las fístulas traqueoesofágicas posintubación son lesiones graves que presentan alta frecuencia de complicaciones y mortalidad. Objetivo: Actualizar el diagnóstico y tratamiento de pacientes con esta afección. Método: Se revisó la literatura en PUBMED/Medline e Infomed con las palabras clave: fístula, traqueoesofágica, fístula traqueoesofágica, postintubación y las correspondientes en inglés. Se revisaron las referencias bibliográficas de los artículos en busca de publicaciones relevantes. Se escogieron, preferentemente, trabajos prospectivos. Los informes de casos sólo se tomaron en cuenta cuando hacían referencia a alguna técnica novedosa. Desarrollo: Se encontraron 4260 artículos en Medline/Pubmed y 17 en Infomed. No se encontraron ensayos clínicos, metanálisis, ni revisiones sistemáticas. La mayoría de los artículos revisados hacen referencia a presentación de casos y algunos fueron estudios retrospectivos. Las presentaciones de casos se usaron solo si describían una técnica novedosa. Conclusiones: La intubación endotraqueal prolongada es la causa principal de FTEs. La patogenia se asocia con isquemia secundaria a compresión de las paredes traqueal posterior yesofágica anterior, entre el manguito insuflado del tubo endotraqueal y la sonda nasogástrica. El tratamiento conservador, generalmente, no cura la fístula, pero puede limitar la contaminación del árbol traqueobronquial y garantiza la nutrición. La derivación esofágica raramente está indicada, excepto cuando persiste entrada a la VR del contenido gastrointestinal. Actualmente, el tratamiento definitivo es la sutura esofágica y, en la mayoría de los casos, la resección y anastomosis traqueal(AU)

ABSTRACT Introduction: Post-intubation tracheoesophageal fistulae are severe lesions with high frequency of complication and high rate of mortality. Objective: To update the knowledge about the diagnosis and treatment of patients with this disease. Method: Literature review made in PUBMEDF/Medline and Infomed using the keywords: fistula, traqueoesophageal, tracheoesophageal fistula, and post-intubation in Spanish and English. References of articles were also reviewed to find out relevant publications. Prospective papers were particularly chosen. The case reports were only taken into account when they made reference to some novel technique. Results: In this search, 4260 articles were found in Medline/Pubmed and 17 in Infomed databases. No clinical assays, meta-analysis or systematic reviews were found. Most of the articles made reference to case reports and some to retrospective studies. The case reports were only used if they described a novel technique. Conclusions: Prolonged endotracheal intubation is the main cause of traqueoesophageal fistula. The pathogeny is associated to ischemia secondary to compression of posterior tracheal wall and anterior esophageal wall between the inflated cuff of the endotracheal tube and the nasogastric probe. In general, the conservative treatment does not cure the fistula but may restrict contamination of the tracheobronchial tree and guarantee nutrition. The esophageal shunt is rarely indicated, except when the gastrointestinal content continues entering into the VR. At present, the definitive treatment is the esophageal suturing and in most of cases, the resection and tracheal anastomosis(AU)

Cytokines and Defensins in Tissue Biopsies Obtained by Bronchoscopy from Patients with Post-Intubation Tracheal Stenosis.

Aims: The objective of our study was to perform the routine analysis of bronchoscopically obtained tracheal samples to determine the appearance and relative distribution of cytokines and antimicrobial proteins in patients with post-intubation tracheal stenosis (PITS). Study Design: Retrospective. Place and Duration of Study: Rīga Stradiņš University, Institute of Anatomy and Anthropology, Pauls Stradiņš Clinical University Hospital, between May 2014 and May 2015. Methodology: Five patients with PITS were involved in this study. Tissue samples were obtained by bronchoscopy from the upper part of trachea, then proceeded for routine histological staining with hematoxylin and eosin. Interleukine-1 (IL-1), interleukine-10 (IL-10) and tumor necrosis factor alpha (TNFα), as well as beta defensin-2 (β def-2) were detected by use of immunohistochemistry (IMH) method. The number of immunoreactive (positive) structures was graded semi-quantitatively. Results: Squamous metaplasia, inflammatory cell infiltration and formation of granulation tissue were observed in all cases. Significant expression of IL-10 and β def-2 was seen as various number of immunoreactive structures in tracheal tissue. Only few scattered IL-1 and TNFα positive macrophages were found in part of cases. Conclusions: The leading role in pathogenesis of post-intubation tracheal stenosis is assumed to be the chronic inflammation, fibrous scarring, as well as the remodeling of tracheal wall due to the ischemia. Compensatory expression of antimicrobial peptide β def-2 and anti-inflammatory cytokine IL-10 indicates the intense local tissue defense reactions. TNFα and IL-1 are not among the most significant factors in pathogenesis of PITS.

Prognostic Factors for Endotracheal Silicone Stenting in the Management of Inoperable Post-Intubation Tracheal Stenosis

PURPOSE: Stenting has been developed to deal with airway stenosis and is applicable in patients with post-intubation tracheal stenosis (PITS) in whom surgery would not be indicated. The purpose of this study was to investigate the prognostic factors in inoperable patients in whom a silicone stent was inserted due to PITS. MATERIALS AND METHODS: We retrospectively evaluated 55 PITS patients undergoing silicone stenting between January 2001 and December 2009. RESULTS: Silicone stent was inserted to narrowed trachea after the combination of pre-dilatation including laser cauterization, mechanical bougienation and ballooning. Following airway stabilization, the stent could be removed successfully in 40% (22/55) of the patients after median 12 months of stenting. However, in 60% (33/55) of patients, the stent could not be removed successfully and surgical management was needed after initial stabilization. Multivariate analysis revealed that the stent could be successfully removed more frequently in those who do not have cardiovascular disease [odds ratio (OR)=12.195; p=0.036] and the intervention was performed within 6 months after intubation (OR=13.029; p=0.031). CONCLUSION: Among those patients undergoing silicone stenting due to PITS, the stent could be successfully removed when patients do not have cardiovascular disease and stented within 6 months after intubation.

Airway obstruction due to post intubation circumferential tracheal web formation: A case report

Tracheal stenosis is well known complication of endotracheal intubation. However, severe post intubation tracheal stenosis that requires interventional bronchoscopy or tracheal surgery is un-common. Necrosis induced by cuff pressure-related loss of regional blood flow is the central injury leading to postinubation tracheal stenosis. The large volume, low pressure cuff of endo-tracheal tubes have markedly reduced the occurrence cuff-induced injury. However, in any patient who develops symptoms of airway obstruction, who has been intubated and ventilated in the recent past, possibility of tracheal stenosis should be considered. We report a case of severe tracheal stenosis by tracheal web formation a 52-year-old following ventilator therapy for ARDS.

Cambios hemodinámicos con el uso de la máscara laríngea versus tubo endotraqueal / Hemodynamic changes with the use of the laryngeal mask versus endotracheal tube

En nuestro medio se conoce poco acerca de las ventajas del uso de la máscara laríngea sobre el tubo endotraqueal en el manejo de la vía aérea. El presente estudio es comparativo y descriptivo; se realizó en 40 pacientes operados bajo anestesia general balanceada, usando máscara laríngea en un primer grupo de 20 pacientes y tubo endotraqueal en un segundo grupo de 20 pacientes restantes como manejo de la vía aérea. El objetivo principal fue el de determinar los cambios hemodinámicos que produce el uso de la mascarilla laríngea y tubo endotraqueal, después de la intubación. En el grupo 1 , en la mayoría de los pacientes, los cambios de presión arterial, frecuencia cardiaca y saturación de oxígeno se mantienen invariables después de colocar la máscara laríngea. En el grupo 2, se presenta un aumento de la presión arterial y frecuencia cardiaca después de realizar la intubación; la saturación de oxígeno se mantiene sin cambios tras la intubación en la mayor parte de los casos. Por tanto la máscara laríngea proporciona estabilidad hemodinámica. El tiempo quirúrgico haciendo uso de la mascarilla laríngea fue de 15 min. a 2hrs y 40 min. Se realizaron varios tipos de cirugía. No se presentaron complicaciones transoperatorias en ninguno de los 2 grupos, pero se identificó que con el uso de tubo endotraqueal en el posoperatorio los pacientes presentaron dolor de garganta, disfonía, náuseas y vómitos. En cambio usando la máscara laríngea sólo presentaron náuseas.

We know very little about the advantages of the use of the laryngeal mask over the endotracheal tube, in the aerial route handling. This is a comparative and descriptive study, and it was carried out on 40 operated patients under balanced general anesthesia. We used laryngeal mask in one first group of 20 patients and endotracheal tube in a second group of 20 remaining patients as a handling of the aerial route. The aim of this work is to compare the haemodynamic changes that produce the use of the laryngeal mask and endotracheal tube after intubation. In the first group, in most of the patients, the values of arterial pressure, cardiac frequeney and oxygen saturation remain the same after placing the laryngeal mask. In the second group it seems to increase the blood pressure and cardiac frequency after do the intubation. Oxygen saturation remains without changes. Therefore we conclude that the laryngeal mask provides more haemodynaic stability. The surgical time with laryngeal mask was 15 minutes to 2 hours and 40 minutes. There were not transoperatory complications in any of both groups, but we observed that with endotracheal tube in the postoperatory the patients presented, sore throat, dysphony, nausea and vomits. However, with laryngeal mask only nausea was present.

A Case of Postintubation Tracheal Stenosis Treated by Endoscopic Nd-YAG Laser and Balloon Catheter / 결핵

The complications of endotracheal intubation are inevitable, of which postintubation tracheal stenosis may be required for surgical resection with primary reconstruction. Before surgery, several less invasive therapeutic modalites including bougie dilatation, stenting, and Nd-YAG laser incision are still available in use. Especially, good results were noted in selected patients with lengthy scars of less than 1cm and without tracheomalacia using endoscopic laser incision and dilatation. We report a case of a 54 yr-old woman with postintubation tracheal stenosis who was successfully treated by endoscopic Nd-YAG laser incision and esophageal balloon catheter.