Tracheal stenosis due to endotracheal tube cuff hyperinflation: a preventable complication

Endotracheal intubation injuries are rare, but may be devastating­mostly among the pediatric patients or when these occur in the distal trachea. Such complications typify a therapeutic challenge, which, besides requiring intellectual and technical resources, takes a long time to reach a resolution. The authors present the case of a 15-year-old girl admitted with an abnormal state of consciousness due to diabetic ketoacidosis. She was submitted to endotracheal intubation with hyperinflation of the tube cuff, which rendered tracheal necrosis and detachment of the tracheal mucosa, and consequent obstruction. Later, she developed scarring retraction and stenosis. The patient was successfully treated with an endotracheal prosthesis insertion. The aim of this report is to illustrate a preventable complication.

Avaliação da resposta inflamatória traqueal ao curativo de celulose bacteriana após escarificação cirúrgica em coelhos / Tracheal inflammatory response to bacterial cellulose dressing after surgical scarification in rabbits

Dentre as causas de insucesso nas cirurgias para a estenose traqueal está a formação de tecidos de cicatrização exuberantes. O uso de curativos para evitar esta reação pode ser de grande valia nestes casos. A celulose bacteriana produzida por acetobacter xylinun pode ser útil nestes casos. Não há estudos na região laringotraqueal. OBJETIVO: Avaliar a resposta tecidual subglótica de coelhos após escarificação e colocação de curativo de celulose, comparando com grupo controle. FORMA DE ESTUDO: Experimental MATERIAL E MÉTODOS: Foram estudados 26 coelhos, submetidos a escarificação da região laringotraqueal e tratados com curativo e comparados com controle. Foram estabelecidos 4 tempos de seguimento. Os seguimentos laringotraqueais foram examinados histologicamente e os resultados foram avaliados estaticamente. RESULTADOS: O grupo de estudo evoluiu com o passar do tempo com resultados estatisticamente semelhantes ao do grupo controle, nos parâmetros Congestão vascular, Exsudato purulento, Inflamação aguda, Integridade do epitélio, Proliferação fibrosa e Reação granulomatosa. CONCLUSÃO: Não foram observadas diferenças entre os grupos controle e de estudo quanto aos parâmetros inflamatórios ou cicatriciais. Não houve sinais inflamatórios relacionados ao uso da membrana de celulose que não tivessem ocorrido devido ao traumatismo cirúrgico.

Exuberant scarring tissue formation is among the failure causes of tracheal stenosis surgery. Dressings that could avoid such reaction could be very helpful in these cases. Bacterial cellulose, produced by acetobacter xylinun can be useful in these cases. There are no studies in the laryngotracheal region. AIM: to assess subglottic tissue response in rabbits after scarification and placement of cellulose dressing, and comparing it to a control group. STUDY DESIGN: experimental. MATERIALS AND METHODS: 26 rabbits underwent laryngotracheal scarification, received the dressing and were compared to the control group. We established four follow up periods. Laryngotracheal specimens underwent histological exam and the results were statistically assessed. RESULTS: the study group had statistically similar results when compared to the control group in the following parameters: vascular congestion, purulent oozing, acute inflammation, epithelial integrity, fibrous proliferation and granulous proliferation. CONCLUSION: we did not observe differences between the study and control groups as far as inflammation and scarring are concerned. There were no inflammatory signs associated with the use of the cellulose membrane that did no occur because of surgery.

[How postintubation tracheal stenosis could be prevented?]

Although it is assumed that appropriate care of endotracheal tubes and airway might prevent postintubation airway stenosis [PIAS], but this concept has not been investigated adequately. The purpose of the study was to investigate practical ways for prevention of PIAS in intubated patients. The study was implemented in 3 phases. First we collected information about methods of caring for airways and tubes in intensive care units in Tehran and other cities [control group] and data collection based on filling 10-20 questionnaires in each intensive care unit. Then we assessed patients who had PIAS and had been treated by us during a 6 year period [1994-2000] [study group]. In the final phase, collected data were analyzed and we looked for important pitfalls in caring for airways in intensive care units in our country and also looked for the practical measures to prevent PIAS. In phase I, 341 questionnaires were filled out in 18 intensive care units [12 in Tehran, 6 in other cities]. There were 133 females and 208 males aged 3 month to 98 years [mean 46.1]. Head injury was the commonest cause of intubations in 24%. of patients. Out of 356 tracheal tubes which had been used in these patients, 318 were high volume low pressure types [new tubes], and 32 were high pressure low volume types [old tubes]. In 179 patients [52.4%], there was not any type of care for tubes and airways by attending physicians, in 140 patients [41%] there was some kind of care although not organized or sufficient and in only 21 patients [6.1%] the care was organized and sufficient. Mean time of intubation was 8 days [1-45 days]. Tracheotomy had been undertaken without any established criteria and mostly by junior staff with low experience [usually junior residents]. In phase II, 120 patients were treated for PIAS [36 females, 84 males aging 1-83 years, mean 25.9 years]. Head injury was the cause of intubation in 78 [65%] patients, the site of stenosis was tracheal in 88 and laryngotracheal in 32 patients. More than half of the patients were intubated by inappropriate old tubes. Direct cause of stenosis was the cuff in 92, tip of the tubes in 15 and stoma in 10 patients. In 3 patients more than one factor were the causes. Mean time of intubation was 14.9 days [1-90] and mean length of stenosis was 3.2 cm [1-7]. Caring of tubes and airways was inappropriate and inorganized in all patients. Factors which were statistically different in study and control group were: time of intubation [14.9 day vs 8 days, P=0.000], suicide attempts [12 vs 5, P=0.000], head injuries [65% vs 24% P=0.000], Age [25.9y Vs 46y, P=0.05], using old tubes [50% vs 9% P=0.000], organized caring of tubes and airways [0.0%vs6.1%P=0.000]. The following measures are effective in decreasing the PIAS: decreasing time of intubation, using appropriate tubes, [including PVC tubes], continuous care of airway and tube, cuff monitoring and daily recording of information about tubes and cuff pressure, and special care for intubated young patients who had sustained head injury or had attempted suicide

Estenosis laringotraqueal / Laryngotracheal stenosis

Se realiza una evaluación retrospectiva de los pacientes con estenosis laringotraqueal vistos por el autor en el departamento de otorrinolaringología, en los últimos 12 años. La muestra consta de 64 pacientes en los cuales se analiza la distribución por sexo, edad y causas de la estenosis laringotraqueal en la que destaca la intubación endotraqueal prolongada en un 62 por ciento de los casos, seguida por el traumatismo laringotraqueal en un 18 por ciento. Se analizan algunos aspectos del manejo de estos pacientes, agrupados en dos categorías: manejo quirúrgico y observación. Se evalúa el éxito de la terapia en base al porcentaje de pacientes que logran decanularse posterior al tratamiento y al tiempo en que dicha decanulación puede realizarse. Finalmente se realiza una revisión de la literatura acerca del tema, haciendo hincapié en la prevención de la estenosis laringotraqueal, atacando directamente las causas que mayormente inciden en su producción, como es la intubación endotraqueal prolongada

Las estenosis laríngeas en el niño / Laryngeal stenosis in children

La estenosis laríngea congénita es rara. La adquirida es provocada, principalmente por traumatismos y/o intubación endotraqueal, siendo esta última la causa más importante. El manejo de la estenosis laríngea secundaria e intubación endotraqueal aún es motivo de controversia. La mortalidad es alta con la política de realizar traqueostomía y esperar el crecimiento de la laringe, lo que indica que se debería tener una conducta más activa. El desarrollo de la microcirugía laríngea ha permitido, recientemente, realizar promisorias técnicas quirúrgicas para tratar esta afección. Sin embargo, lo más importante es la prevención. En este sentido, es vital el buen manejo de la técnica de intubación endotraqueal y la no prolongación de ella más allá de siete días. De ser necesario prolongarla debería practicarse una traqueostomía. El diagnóstico de estenosis laríngea debe ser precoz y para tal efecto, es indispensable el examen endoscópico. El tratamiento incluye corticoides locales y sistémicos, antibioterapia específica y eventualmente, dilataciones o cirugía