Post-intubation tracheal stenosis typically correlates with the duration of intubation and rarely develops when intubation is less than a week. Our patient remained intubated for only 48 h. Only a handful of cases have been reported on tracheal stenosis developing in patients intubated for less than 48 h.7–9
Different proposed mechanisms of this complication include mucosal destruction caused by erosion of the endotracheal tube tip, excessive movement of a sedated patient after intubation and endotracheal tube cuff pressures of more than 20 mmHg.10
These findings have encouraged the use of high-volume, low-pressure ET tube cuffs to avoid tracheal injury. This has reduced the number of cases of post-intubation tracheal stenosis.
The risk factors for post-intubation tracheal stenosis in our patient were female gender, advanced age and respiratory failure as a consequence of cardiogenic shock.
Onset of symptoms usually occurs weeks to months later,11
as in our case most patients have progressively increasing exertional dyspnoea associated with variable degrees of wheezing. Rarely, patients present in emergency room with respiratory failure as in our case. The differential diagnosis of a patient presenting in the emergency room with new onset wheezing include new onset severe asthma, bilateral vocal cord paralysis, foreign body aspiration, tracheal tumours, postintubation/tracheostomy tracheal stricture, Wegener's granulomatosis, obstruction of trachea or mainstem bronchi due to external compression from mediastinal tumours or adenopathy.11
In the past, tracheal stenosis was managed with dilatation alone, and success was measured by the ability to wean patients from tracheostomy tubes. Until recently, surgical resection and end-to-end anastomosis was considered the only definitive treatment for tracheal stenosis. Single-stage resection and reconstruction by a competent tracheal surgeon give good results in 93.7% of patients, with a failure rate of 3.9% and a mortality rate of 2.4%.11
Grillo and Mathisen have reported mortality rates as low as 1.8% associated with surgical intervention but others have reported mortality rates up to 5%. Interventional bronchoscopy procedures can serve as a bridge to surgical treatment but most importantly, can constitute definitive therapy for many patients, including those who are not surgical candidates or those who refuse surgery. Studies have reported variable success rates of interventional bronchoscopic procedures like rigid bronchoscopy with neodymium-yttrium aluminium garnet laser resection or stent implantation ranging from 32 to 66%.12
This case report highlights the importance of early recognition and management of an uncommon and potentially lethal complication of intubation, which is often mistaken for bronchial asthma.13
Careful physical examination, supported by characteristic flow volume loops on spirometry and early evaluation by fibreoptic laryngobronchoscopy, enables identification of this condition. Attempted endotracheal intubation in the presence of tracheal stenosis might worsen mucosal oedema precipitating a near-total obstruction.
- This case report highlights the importance of early recognition and management of an uncommon and potentially lethal complication of intubation, which is often mistaken for bronchial asthma.12
- Careful physical examination, supported by characteristic flow-volume loops on spirometry and early evaluation by fiberoptic laryngobronchoscopy, enables identification of this condition.
- Attempted endotracheal intubation in the presence of tracheal stenosis might worsen mucosal oedema precipitating a near-total obstruction.