Tracheal Stenosis Following Cuffed Tube Tracheostomy

Transcription

1 Tracheal Stenosis Following Cuffed Tube Tracheostomy Anatomical Variation and Selected Treatment Armand A. Lefemine, M.D., Kenneth MacDonnell, M.D., and Hyung S. Moon, M.D. ABSTRACT Tracheal stenosis resulting from tracheostomy and the use of cuffed tracheal tubes has been treated by either endobronchial or cervical sleeve resection in 6 patients. Three patients had an obstructing thin, transverse membrane or a granuloma with only mild cartilaginous distortion that permitted resection through a bronchoscope. The remaining 3 patients required segmental resection up to 4 cm. in length. The only recurrence was in a patient with a subglottic deformity involving the cricoid cartilage that limited the completeness of resection. The bronchoscopic approach is effective for patients carefully selected by laminagraphy and endoscopic evaluation. T he treatment of tracheal stenosis must of necessity be varied to meet the clinical problem. The judgment involved is always delicate, since the condition is chronic, debilitating, and often progressive. Obstruction and respiratory arrest are ever-present possibilities. Grillo [3] and Pearson and Andrews [5] have detailed the experimental and clinical problems of posttracheostomy stenosis and the surgical techniques of segmental resection of the trachea. Segmental resection for the isolated lesion of the upper trachea offers an excellent chance for complete rehabilitation with relatively low mortality and morbidity and is particularly suited to the posttracheostomy stenosis, which usually presents as a circumferential, fibrous scar that does not yield to dilation. However, variants occasionally present themselves and offer possibilities for endotracheal resection or for dilation through a bronchoscope without tracheostomy or resection. Admittedly, this approach is selective and offers less chance of success. This report includes experience with 6 patients with tracheal stenosis, 3 of whom were treated by transbronchoscopic means. Clinical Experience Six patients with tracheal strictures following prolonged cuffed tube intubation varied in age from 16 to 65 years. The youngest was the only one whose stricture resulted from a transoral endotracheal tube, which had been From the Department of Surgery, Tufts University School of Medicine, and St. Elizabeth s Hospital, Boston, Mass. Accepted for publication Jan. 15, Addrcss reprint requests to Dr. Lefemine, St. Elizabeth s Hospital of Boston, 736 Cambridge St., Brighton, Mass THE ANNALS OF THORACIC SURGERY

2 Treatment of Tracheal Stenosis used to treat drug ingestion. The remainder of the patients experienced stricture following tracheostomy for pulmonary insufficiency due to a variety of causes. One patient developed tracheal stenosis during the original hospitalization. The remainder were discharged and returned from 2 to 6 months later with stridor, dyspnea, and ineffective cough. The Table is a resume of the location of the stricture and its treatment and results. The patients have been divided according to location of their stricture to emphasize the difficulty in handling the subglottic lesion involving the cricoid cartilage and to stress the strong possibility that a lesion at the tracheostomy site can be resected or dilated at bronchoscopy. The location and extent of the lesions are safely determined by anteroposterior and lateral tomograms of the trachea and by oblique films of the cervical trachea. Evaluation by bronchoscopy was not hazardous in this group and allowed confirmation of the location though not the extent of the lesion. The appearance of the lesion by tomography and bronchoscopy helps to decide whether an attempt at resection or dilation during bronchoscopy should be made. TRANSBRONCHOSCOPIC RESECTION One patient, an 18-year-old girl with severe stenosis following intubation with an endotracheal tube, had a thin, membranous obstruction with a mild circumferential stricture. At bronchoscopy she had an extremely small opening, 3 mm., with a flexible membrane that could be grasped easily with a biopsy forceps and removed in small pieces (Fig. 1A). A tracheogram (Fig. 1B) and bronchoscopy following the resection revealed that a mild stricture remained. The symptomatic result was good; however, the follow-up is short (9 months), and there is a good possibility of recurrence. A second patient, a 58-year-old woman with a 3 mm. narrowing at the tracheostomy site, responded well to passing the bronchoscope through the stenosis and resecting granulation tissue from the anterior wall of the trachea. This tissue undoubtedly represented a thin membrane obstruction similar to that in the first patient. A repeat bronchoscopy confirmed a 1.5 cm. lumen. A 2-year follow-up reveals no recurrence. A third patient returned 2 months after tracheostomy because of pneumonia and stridor at rest. Bronchoscopy demonstrated a large granuloma attached anteriorly and obstructing 80% of RESULTS OF TREATMENT OF TRACHEAL STENOSIS IN 6 PATIENTS Location of No. of Stricture Patients Treatment Recurrence Subglottic 1 Resection Immediate Tracheostomy site 3 Bronchoscopic None to date resection & dilation Cuff site 2 Resection One required postop. dilation

3 LEFEMINE, MAC DONNELL, AND MOON A FIG. I. (A) Oblique view of a thin, membranous obstruction of the trachea following use of a cufled endotracheal tube. (B) The same patient as in A, following resection through a bronchoscope. the lumen of the cervical trachea. This was removed using a biopsy forceps; a nearly normal caliber was restored, and the lesion has not recurred. B RESECTION OF THE TRACHEA Resection with end-to-end anastomosis was used for the more complicated lesions. Two types of lesions were observed in 3 patients. Two had severe strictures involving the trachea distal to the tracheostomy site (Fig. Z), and 1 had a subglottic stricture involving the tracheostomy site and cricoid cartilage. It was presumed that the distal lesions were the result of high-pressure cuffs and the prolonged use of positive-pressure ventilation. In 2 patients a tracheostomy was present at the time of resection: in 1 patient the original metal tube, to provide an adequate lumen through the strictured area, and in the second patient a tube inserted for emergency resuscitation after respiratory arrest. The presence of a tracheostomy has the advantage of providing an adequate airway but the disadvantage of involving a more complicated bacteriological risk. Two of these patients experienced cardiac standstill during induction of anesthesia. Both responded to external pounding or compression and tolerated the remainder of the procedure well. The subglottic lesion (see Table) was thought to be the result of the technique of tracheostomy plus infection during three weeks of positivepressure ventilation and poor nutrition. The opening may have been inadequate for the tube, with resultant compression of the upper lip of the 458 THE ANNALS OF THORACIC SURGERY

4 Treatment of Tracheal Stenosis A B FIG. 2. (A) Low cewical stenosis following prolonged cuffed tube tracheostomy. (B, C) Preoperative and postoperative oblique views of the trachea shown in A, following segmental resection (3 cm.). (B and C are retouched.) C tracheostomy. This lesion, with deformity and partial destruction of the cricoid cartilage, was the most difficult and technically represents the only failure to relieve stenosis.

5 LEFEMINE, MAC DONNELL, AND MOON The results of segmental resections bear some comment because they were not free of morbidity. The patient with a low cervical stenosis 3 cm. in length did not have a preoperative tracheostomy and had an uneventful recovery with no evidence of recurrence in 12 months (see Fig. 2). The patient with a low cervical stenosis, tracheostomy, and resection of a 4 cm. length of trachea with anastomosis at the cricoid level had a recurrence of stenosis at the anastomosis three weeks after resection. This was treated by bronchoscopic dilation and removal of exposed sutures and granulation tissue. The third patient, who had the subglottic stenosis, had residual stenosis following a 3 cm. resection and required restoration of the tracheostomy and subsequently a Montgomery Silastic tube to stent the subglottic trachea. She did well but died suddenly 2 months later. The exact cause of death is not known, but the possibility of respiratory obstruction by occlusion of this tube must be considered. Technique A cervical approach was adequate for resection of up to 4 cm. of trachea in our patients. A long collar incision and partial or total division of the sternocleidomastoid muscles provide excellent exposure from the cricoid to the clavicles. Dissection around a current or old tracheostomy may be difficult. Damage to the recurrent laryngeal nerves is avoided by staying on the trachea. The dissection anteriorly and posteriorly may be carried into the mediastinum; dissection laterally or circumferentially is limited to the area of stricture to preserve blood supply. The operating table should be equipped with a variety of cuffed endotracheal tubes, connections, and sterile tubing for intubation of the trachea distal to the stenosis when the trachea is opened. Traction sutures on the distal and proximal segments are used to approximate the ends, aided by flexion of the neck. The peroral endotracheal tube is passed from the proximal trachea distally when the posterior half of the anastomosis is completed. Simple sutures of 3-0 Teflon-impregnated Dacron are used to make an airtight approximation of the ends. Knots are tied on the outside of the trachea. The strap muscles are reapproximated, and the wound is drained by closed, sterile suction. The endotracheal tube is removed as soon as safety permits. Preoperative preparation should give attention to treating infection with the appropriate antibiotics and restoring nutritional balance. Comment Tracheal stricture is a serious complication of high-pressure cuffed tube tracheostomy. Grillo [3] and Pearson and Andrews [5] have defined the fundamentals of cause, incidence, and treatment in this problem. Prospective studies predict a 16 to 20yo incidence of stricture following prolonged cuffed tube ventilation [l, 2, 51. The reported mortality has been surprisingly low 460 THE ANNALS OF THORACIC SURGERY

6 Treatment of Tracheal Stenosis despite the fact that some of these cases are complex, with multiple other problems. Though we did not have any deaths associated with the operative procedures, 1 late death may have been the result of a prosthetic stent that was used for treating subglottic stricture. This group of patients with tracheal stricture differs from other series in that half were treated by transbronchoscopic resection. All those treated by bronchoscopy had developed granulation tissue or thin, membranous diaphragms at the site of the tracheostomy rather than the hourglass type of deformity found at cuff lesions or in subglottic deformities. In at least 1 patient treated by transbronchoscopic resection, a mild narrowing of the tracheal lumen, 4 cm. in length, remained at later bronchoscopy. It is presumed that the rate of recurrence in this group will be higher; however, the magnitude of the procedure and the option of subsequent segmental resection make this a desirable approach in the selected patient. The application of this approach to the hard, fibrotic stenosis that is not granulation tissue or thin membrane would be fraught with all the dangers of making the obstruction worse or complicating the ventilation problem by bleeding. The cuff lesion usually involves several rings of the trachea. This lesion results from ulceration, necrosis, and infection followed by formation of fibrous strictures that usually appear within forty days after removal of the tracheostomy tube [l]. It has been suggested that use of low-pressure cuffs would greatly diminish the incidence of this complication [4]. While use of a low-pressure cuff will not eliminate all the complications of cuffed tube tracheostomy, it may indeed reduce the high incidence of low and lengthy strictures. Strictures may still occur at the tracheostomy level due to loss of cartilaginous support because of infection, tube pressure, or growth of granulation tissue. The subglottic stricture represents a special and very difficult problem that does not always lend itself to the simple solution of resection. Deformity or destruction of the cricoid cartilage is essential for this type and limits resection because of the support and attachment of the arytenoid cartilage. In the patient presented here, anterior collapse of the cartilaginous support associated with a high tracheostomy appeared to be the mechanism of pl-oduction. We believe that a cruciate incision in the trachea at the time of tracheostomy may fold in portions of the tracheal wall when the tracheal tube is inserted. Circular openings with removal of a piece of tracheal wall for positioning a right-angled tracheostomy tube without pressure on the adjacent wall is preferable. If one is not attuned to the possibility of tracheal stenosis, it is easily missed. Many of the patients treated by intubation or tracheostomy have significant underlying chronic obstructive lung disease that may distract the clinician. Monophonic wheezing was characteristic in our patients. This was prominent over the trachea and became more distant over the peripheral

7 LEFEMINE, MAC DONNELL, AND MOON lung fields. An abnormality of the inspiratury limb of the vital capacity curve suggests the presence of stricture. Even with advanced chronic obstructive lung disease, the inspiratory limb of the flow curve is usually well maintained. The reason for obstruction during the inspiratory phase in tracheal stenosis is the same as in croup, namely, there is a strong negative pressure below the area of obstruction produced by a vigorous inspiratory effort and consequent collapse of the airway. Symptoms of dyspnea and wheeze at rest occur only with severe obstruction, and treatment becomes urgent. Any person who has a tracheostomy or endotracheal tube is a candidate for tracheal stricture. Low-pressure cuffed tubes must be employed. The routine use of digital or bronchoscopic examination of the tracheostomy may be helpful in pinpointing the problem cases. The care of the tracheostomy should include careful recording of the amount of air used to inflate the cuff. If the cuff requires increasing volumes of air to provide a seal, tracheal erosion or dilatation must be suspected. Finally, for the posttracheostomy patient suspected of having stenosis, laminagrams of the trachea are indicated. We have found bronchoscopy safe, though the potential hazards of the procedure must be weighed for each patient. The results of segmental resection are good, but mortality, morbidity, and recurrence require consideration of a lesser procedure in the properly selected patient. The fact that half of this group was treated by the more conservative bronchoscopic resection does not make this a preferred approach: it is merely a reasonable and safe approach in a select few. References 1. Crosby, W. M. Automatic intermittent inflation of tracheostomy-tube cuff. Lancet 2~509, Gibson, P. Aetiology and repair of tracheal stenosis following tracheostomy and intermittent positive pressure respiration. Thorax 22: 1, Grillo, H. Surgery of the trachea. Curr. Probl. Surg., July, Grillo, H. C., Cooper, J. D., Geffin, B., and Pontoppidan, H. A low pressure cuff for tracheostomy tubes to minimize tracheal injury: A comparative clinical trial. J. Thorac. Cardiovasc. Surg. 62:898, Pearson, F. G., and Andrews, M. J. Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann. Thorac. Surg. 12:359, THE ANNALS OF THORACIC SURGERY