7th January 2011

Friday Presentation

Discuss management of a 19 year old patient

with history of emergency intubation following

acute organophosphate poisoning 2 months

ago presenting with recurrent noisy breathing,

dyspnoea and reduced effort tolerance.

Question

Establishing diagnosis Laryngotracheal stenosis

Noisy breathing Stridor

Phases: inspiratory, expiratory, biphasic Wheezing

Recurrent : precepitating factors and aggravating factors Infection, exercise

History of emergency intubation Suggest higher possibility of intubation trauma due to repetition, stylet

use and higher friction Duration of mechanical ventilation (2-5/7: 0-2%, 5-10/7: 5-10%, >10/7:

12-14%)2,3, cuff pressure (laryngeal microcirculation critical P 30mmHg) 1

Tracheostomy (site, type of incision, tube biomechanics)4

Acute organophosphate poisoning: primary reason of intubation contributes to laryngotracheal stenosis

Dysphagia, change in quality of voice

History

1. Nordin U, Lindholm CE. The trachea and cuff induced tracheal injury. Acta Otolaryngol 96 (Suppl345)1-71, 19772. Whited RE. A study of endotracheal tube injury to the subglottis. Laryngoscope 95: 1216-9,1985. 3. Bryce DP. The surgical management of laryngotracheal injury. J Laryngol Otol 86:547-87, 1972.

4. Lulenski JC,Batsakis JG. Tracheal incision as a contributing factor to tracheal stenosis. An experimental study. Ann Otol 84: 781-6, 1975.

Infective (Tuberculosis of the larynx)Prolonged history of fever, unintentional weight

loss, cough, hemoptysis, change in quality of voice, neck swelling.

Contact with tuberculosis patientsImmune mediated (Sarcoidosis, Rheumatoid

arthritis, Pemphigus)Onset and progression is usually gradualRelated symptoms: joint pain and deformity, skin

lesions, Vocal fold immobility

Change in quality of voiceAspiration symptoms

History

Establishing severity Dyspnoea and reduced effort tolerance

At rest?Walking?Climbing stairs?Acute emergency visits to the hospital or clinic

ProgressionAcute deterioration in airway symptomsGradual worsening

History

Other related historyPatient’s general medical condition

Optimization for definitive surgical airway management

Oxygen demandPrior surgical intervention to the larynx or

tracheaPatient dermographics

Distance to hospitalEducation

History

General examinationConcious levelStridor: inspiratory, expiratory, biphasicCyanosisTachypnoeaSubcostal, intercostal recessionPulse OxymetryVital signs

Focused examinationQuality of voiceSingle breath counting5

1-10 in a single breath; correlates well with PEFR and FEV1Neck scar +/- tracheostomyExamination of the larynx

Physical examination

5. Joel MB. Bruce SU, Jonathan MR, Dylong K. Single breath counting in the Assessment of Pulmonary function. Annals of Emergency Medicine 24: 256-9, 1994.

Adhesion, granulation tissueVocal cord

Mobility7

Only significant risk factor for failure of decannulation following definitive airway reconstruction

Vocal fold immobility: neuromuscular or joint fixation? Laryngeal electromyography

Phonatory gapLaryngeal sensationEvidence of reflux6

Prophylactic antireflux medication following laryngeal injury

Recalcitrant stenosis

Examination of the larynx

6. Gaynor EB. Gastroesophageal reflux as an etiologic factor in laryngeal complication of intubation. Laryngoscope 98: 972-9, 1988

7. White DR, Cotton RT, Bean JA et al. Pediatric cricotracheal resection. Arch Otolaryngol Head Neck Surg 131: 896-9, 2005

Respiratory systemRhonchiExclude secondary lung infection

Physical examination

Arterial Blood GasesUsually shows Type 1 respiratory failureCO2 retention in decompensated cases hence

require immediate establishment of airway

Investigation

Direct Laryngo bronchoscopy Cotton Myer grading (1994)

Distance from vocal cord Measure using endoscope, take average of three readings

Length of stenotic segment Consistency of stenosis (granulation tis or fibrous) Shape of stenosis (circumferential or not) Presence of tracheomalacia Mobility of vocal cord

Investigation

Grade 1 0-50%

Grade 2 51-70%

Grade 3 71-99%

Grade 4 >99%

Role of imaging To determine extent of stenosis especially in

higher grade stenosis where length of stenosis cannot be ascertained endoscopically

For planning of surgery especially when stenosis involve the lower trachea and requires combined approach through a median sternotomy or right thoracotomy or release procedures

CT better ascertain the integrity of cartilaginous framework

Investigation

OxygenEstablish airway

Intubation Preoperative intubation in patients with thin

segment stenosis amendable to endolaryngeal procedures

Or intraoperative mask ventilation followed by quick dilatation to allow safe intubation

TracheostomyPreferably trachea incised at the level of

stenosis to spare normal trachea from another injury

Acute management

EndolaryngealDilatationLASER: ShapshayCold instrumentation

OpenLaryngotracheal reconstructionCricotracheal resection and anastomosisTracheal resection and anastomosisShian LeeLaryngofissureSlide tracheoplasty

Adjunct Stents, Corticosteroids, Mitomycin C, Antibiotics

Definitive management

24/Indian ladyAccidental organophosphate poisoning July 10

Presented with dysphagia to JBGH Intubated in the ED and then managed in ICUTracheostomy D4Assisted ventilation 11/7Successful weaning off ventilation and decannulated after

3/52Discharged home

4/7 later presented with dyspnoea and reduced effort toleranceEmergency intubation and mechanical ventilationSuccessful weaning off ventilation and discharged home

Another similar presentation 1/12 after, managed similarly

Case presentation

In September 2010, acute onset noisy breathing, dyspnoea and reduced effort tolerance Tracheostomy and Dlscopy in KPJ JB Tracheal stenosis

Subsequently managed in PPUKMUnderwent emergency endolaryngeal dilatation 22nd Sept 2010

and was later decannulated in late NovemberPresented with acute deterioration of symptoms two weeks

later ,Cotton grade 3 tracheal stenosis of 2cm length 6cm from the vocal cord, Shapshay, dilatation was performed

Just 10/7 after presented similarly , Shapshay, dilatation and application of mitomycin C performed

1/52 later presented again with upper airway obstruction hence tracheostomy was performed as patient opted for long term tracheostomy

No significant medical history No known allergiesCompleted studies in Diploma in Healthcare

Management however is unemployed due to recurrent admissions

Single and living with her parents in JB

Biphasic stridorSaturation 97% under RATachypnoeic RR=26bpmIntercostal and subcostal recessionAfebrile, hemodynamically stableHealed anterior neck scar

Physical Examination

Jet ventilation

Emergency Endolaryngeal Surgery

CT thoraxTracheal stenosis measuring 2.35 cm in length,

ends 2 cm above the carina, about 7 cm from the vocal cords

Other investigations

EndolaryngealDilatationLASER: Shapshay

OpenTracheal resection and

anastomosisSlide tracheoplasty

Adjunct Stents, Corticosteroids,

Mitomycin C, Antibiotics

8. Chen Y, Wang WJ, Wang HF. Therapeutic effect of tracheal anastomosis versus interventional bronchoscopy in the treatment of airway stenosis. NaFang Yi Ke Da Xue Xue Bao. 2010 Jun;30(6):1359-62.

9. Baugnee PE, Marquette CH, Ramon P, Darras J, Wurtz A. Endoscopic treatment of postintubation tracheal stenosis. Review of 58 cases. Rev Mal Respir. 1995;12 (6): 585-92.

Definitive management of lower tracheal stenosis

1 Tracheal resection and anastomosis is associated with lowest restenosis rate in tracheal stenosis8

2 Some authors advocate stenosis of <1cm , some 3 cm length cut off point for repeated endolaryngeal dilatation and intervention8,9

Associated with recurrence rate of almost ¾ if used as a primary therapy10,11

Factors that improve success rate12:Thin segment of stenosisSoft or immature scarsUsed as adjunct to other endolaryngeal

technique (ie. LASER Shapshay)Acquired stenosis resists dilatation due to

hyalinization and collagen cross linking, hence incompressible.

Endolaryngeal dilatation

10. Clement P, Hans S, de Mones E, et al. Dilatation for assisted ventilation induced laryngotracheal stenosis. Laryngoscope 115: 1595-8, 2005

11. Herrington HC, Weber SM, Anderson PE. /modern management of laryngotracheal stenosis. Laryngoscope 116: 1553-7, 2006

12. Simpson GT, Strong MS, Healy GB, et al. Predictive factors for failure or success in the endoscopic management of laryngeal and tracheal stenosis. Ann Otol Rhinol Laryngol 91: 384-8, 1982

CO2 laser advantages:Precision and visual field not obscured by

instruments, hence better preservation of normal tissue

HemostasisEarly reepithelization and slow fibroblast proliferation

and collagen formation13

DisadvantagesRisk of fire or combustionCorneal burnsCost and availability

The shapshay (radial incision and dilatation) technique popularized in 198714

Light Amplification by Stimulated Emission of Radiation

13. Toohill RJ, Duncavage JA, Grossman TW: Wound healing in the larynx. Otolaryngol Clin North Am 17: 429-36, 1984.

14. Shapshay SM, Hybels RL, Bohigian RK et al. Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation. Ann Otol Rhinol Laryngol 1987: 661-4.

Largest series in Italy; 209 patients with acquired tracheal stenosis over 10 yrs with 2 yrs follow up

Endoscopic laser and mechanical dilatation gives success rate of 96% in simple stenosis (mean of 2.3 procedures per patient)15

Other smaller series show promising results with endoscopic treatment for length <3cm (success rate of 60-80%) 16,17

15. Galluccio G, Lucantoni G, Battistoni P et al. Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up. Eur J Cardiothorac Surg. 2009 Mar;35(3):429-

3316. Cavaliere S, Bezzi M, Toninelli C, Foccoli P. Management of post-intubation tracheal stenoses using the

endoscopic approach. Monaldi archives for chest disease 2007 67 (2) 71-2.17. Reza SA, Khalid G, Anil P et al. Outcome of Endoscopic Treatment of Adult Postintubation Tracheal

Stenosis. Laryngoscope 117 (6): 1073-9

Results

In experienced hands, remains mainstay of treatment in symptomatic lower tracheal stenosis

However, instances where it is not advisablePresence of severe inflammationLength of stenosis too long for resection and

anastomosis

Preceded with rigid bronchoscopy and serial dilatation through the stenosis to alleviate hypercarbia

Remeasurement of length and site of stenosis, presence of inflammation

Tracheal resection and anastomosis

Supine, neck extended with expandable sandbag

Collar incision +/- median upper sternotomy or right thoracotomy

Subplatysmal flap sup (cricoid) and inf (sternum)

Trachea dissected close to its wall to expose area of stenosis and not more than 1 cm normal trachea superiorly and inferiorly

Not to injure vascular supply from inferior thyroid,bronchial, subclavian, right internal thoracic, and innominate arteries. Note that vascular supply comes from lateral then transverse intercartilaginous arterioles

Tracheal resection and anastomosis

Flexible scope thru ETT, tube pulled back till above the stenosis if area of stenosis can’t be ascertained externally

Circumferential resection of stenotic airway with preservation of normal trachea as much as possible

Use sterile anode tube cannulated to distal end

Place traction sutures at lateral aspect 1cm from edge

Place posterolateral sutures

Advance the proximal airway and place anterior sutures

Oppose anastomosis and tighten traction sutures then anterior followed by posterior sutures with neck flexed

Skin closureChin stay sutures (submental to

presternal) to keep neck in flexed position

Extubate patient in the OTBronchoscopy before discharge and

4/52 after

Indicated in tracheal resections of more than 3 cm. Allow resection of up to 6.4 cm without affecting anastomotic tension

Involves:right hilar dissection and division of the right

pulmonary ligamentdivision of the left main bronchusfreeing pulmonary vessels from the

pericardium

Release procedures

ComplicationsAnastomotic Complications (9%)• Separation of suture line (50%)• Recurrent stenosis (50%)

• Obstructing granulation tissue from mucosa (10%)

• Managed by permanent T tube, permanent tracheostomy, (4.2%) reoperation, and repeated dilatationOther Complications

• Laryngeal dysfunction (5%); 50% temporary• Hemorrhage: bleeding from innominate artery

(2%)• Infection (6.8%)• Death (1.2%)

901 patients over 28 yr period (2004)165 pts with lower tracheal stenosis req partial

median sternotomy , only 15 patients (18%) develop anastomotic complications

Anastomotic complications lower in pts requiring release procedure via right thoracotomy (2.5%)

Tracheal length resected 1-6.5cm11 deaths, 6 from anastomotic dehiscenceAnastomotic complications are uncommon, and

important risk factors are reoperation, diabetes, lengthy resections (>4cm), young age (pediatric patients), and the need for tracheostomy before operation.

18. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complication after tracheal resection: prognostic factors and management. Jthorac.Cardiovasc.Surg 2004 128:731

Results

Collar incisionSite of stenosis exposed in the same manner

Theoretical value in acquired stenosis, mostly used in congenital stenosis in the pediatric age group19. Peter BM, Michael JR, Asher L, Resmi G, Bradley SM. One slide fits all: The versatility of slide

tracheoplasty with cardiopulmonary bypass support for airway reconstruction in children J. Thorac. Cardiovasc. Surg., January 2011; 141: 155 - 161.

Slide Tracheoplasty

Horizontal incision

midway of stenotic segment

Vertical incision

anteriorly and posteriorly

Slide the edges of

trachea to double its

circumference

Anastomosed side by side

• Oral and topical steroids in early tracheal stenosis: reports show clinical improvement

• Intralesional in anastomotic granulomas

Steroids

• Complex laryngeal and tracheal stenosis of more than 1 cm length successfully treated with combined laser incision, dilatation and application of mitomycin C

Mitomycin C

• Used peri and postoperatively as exposed cartilage runs risk of perichondritis

Antibiotics

20. Braidy J, Breton G, Clement L. Effects of corticosteroids on post intubation tracheal stenosis. Thorax. 1989 44 (9) 753-55.

21. Shapshay SM, Reza R, Healy GB. Mitomycin: Effects on Laryngeal and Tracheal Stenosis, benefits and complications. Ann Otol Rhinol Laryngol 2001

Adjunct treatment

22. Brendan P.M, Steven AS,Piers Mitchell M. Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation.Ann Thorac Surg 2000;70:1191-1193

323. Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents.ERJ 2006 6 1258-1271

Stents

Evolved since 1965

Montgomery: Dumon silicone

tracheal stent

Gianturco stainless steel

stent

Ultraflex covered

expandable metallic stent

Stent complicationsFailure of deploymentStent dislodged/ malpositionStent fracture

Sputum retentionGranulation tissue formationRecurrent respiratory infectionErosion

Complications

Post intubation stenosis is the

commonest indication for

tracheal resection and reconstruction

Prevention is possible in these

cases: high volume low pressure cuff,

cuff pressure monitoring

Endolaryngeal surgery can be the

first line management in

carefully selected patients

Segmental tracheal resection and reconstruction

is preferable in lower, complex

stenosis

Conclusion

Thank you and Have a nice weekend