Stenting for the Management of Posttracheostomy Tracheomalacia: Case Report

doi:10.4236/ojrd.2013.31001

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Open Journal of Respiratory Diseases, 2013, 3, 1-3

http://dx.doi.org/10.4236/ojrd.2013.31001 Published Online February 2013 (http://www.scirp.org/journal/ojrd)

Stenting for the Management of Post-Tracheostomy

Tracheomalacia: Case Report

Demirhan Ozkan1, Hurkal Tugce2, Sener Sibel3, Ece Ferah2*

1Department of Thoracic Surgery, Medical School, Istanbul Bilim Unive rsity, Istanbul, Turkey

2Department of Chest Diseases, Medical School, Istanbul Bilim University, Istanbul, Turkey

3Department of Anesthesiology and Reanimation, Medical School, Istanbul Bilim University, Istanbul, Turkey

Email: *[email protected]

Received September 27, 2012; revised October 28, 2012; accepted November 10, 2012

ABSTRACT

In patients who undergo prolonged endotracheal intubation, tracheostomy is performed to prevent the tracheal and la-

ryngeal trauma which may be caused by the intubation tube. In this report, a patient who was intubated after a cere-

brovascular embolism and required a tracheostomy for 6 months due to decannulation problems is presented. The pa-

tient subsequently developed a tracheomalacia. A stent was inserted and seen to provide functional support. Upon re-

moval of the stent, the tracheomalacia improved. Although surgical therapy is claimed to provide higher success rate,

stenting may also be a viable option for the management of tracheomalacia and improve the quality of life in patients

with good general condition.

Keywords: Tracheostomy; Tracheomalacia; Stent

1. Introduction

The optimal timing of tracheostomy is controversial. It

may be delayed to facilitate extubation in intubated pa-

tients, or conversely, performed early to avoid long term

complications such as intubation granuloma, posterior

commissural stenosis, edema, and subglottic stenosis. The

complication rates of endotracheal intubation are corre-

lated with its duration. Prospective studies have shown

that 6% of patients intubated for 2 - 5 days had a tran-

sient, 5% of patients intubated for 6 - 10 days had ire-

versible, and 12% of patients intubated for 11 - 24 days

had widespread translaryngeal injury [1]. It has been

shown that use of a tracheostomy care protocol for pa-

tients with a tracheostomy lead to decreased morbidity

and mortality with a reduced average time to decannula-

tion [2]. Complications can be related to the pro cedure it-

self or the tracheostomy tube (TT) and can occur in the

early or late postoperative period [3]. Patients should be

evaluated between 7 and 10 days regarding the possibili-

ty of extubation. If long term intubation is necessary, a

tracheotomy should be made. The TT needs to be re-

moved as soon as possible in order to minimize the rates

of tracheobronchitis, tracheal ulceration, tracheomalacia,

and persistent tracheocutaneous fistula. There is a con-

sensus panel that made suggestions about a large number

of statements that dealt with a variety of subjects, in-

cluding the most appropriate TT type, suctioning, humi-

dification, patient and caregiver education, home care,

emergency care, decannulation, tube care (including use

of cuffs and sutures), and overall clinical airway mana-

gement [4]. Tracheostomy decannulation describes the

process of TT removal [5]. Decannulation can be carried

out when the patient no longer needs assistive respiratio n,

the tracheobronchial secretion is decreased or ceased, or

the infection has been managed [6]. Since all these fac-

tors are prerequisites of decannulation, there is no defi-

nite time for decannulation. If the patient can cough, has

good vital capacity, and can effectively take a deep breath,

then decannula t i on can be ca r ri ed o ut .

Late decannulation may be associated with laryngeal

stenosis, tracheal stenosis, and localized tracheomalacic

development. The use of low pressure baloon tubes in re-

cent years have enabled a significant decrease in the rate

of these complications. The pathologic process that be-

gins as a mucosal erosion and continues as an ulceration

and cartilage dissolution may lead to tracheomalacia, or

lead to tracheal obstru ction if there is more fibrotic tissue.

Therefore as mentioned in one study individualized plans

for tracheostomised patients as well as intensivist-led

follow-up on the ward may improve patient outcome and

safety [7].

In this report we aimed to note the success of stent de-

ployement method in the treatment of tracheomalacia

which occurred as a complication of tracheostomy.

*Corresponding a uthor.

D. OZKAN ET AL.

2. Case Report

A 70-year-old lady presented to the hospital on Decem-

ber 2008 following a sudden loss of consciousness. After

she was diagnosed with cerebrovascular embolism, she

transferred to the intensiv e care unit. She remained in the

intensive care unit for 10 days. During this period she de-

veloped a right sided hemiplegia, swallowing problem

and also respiratory failure that required intubation. She

was intubated for five days, and considering her present

condition, a tracheostomy was opened. She was followed

up for 10 more days and subsequently discharged home

with a tracheostomy. She suffered a decannulation pro-

blem after her discharge from the hospital, and was taken

her care for six months at home with obligatory tracheo-

stomy.

She presented to the emergency department of our hos-

pital on May 2009, with stertorous respiratio n and severe

dyspnea. On physical examination she was awake but un-

cooperative, agitated, tachypneic, and had stertorous brea-

thing. A tracheostomy incision was inspected. She did

not have a fever, her blood pressure was 150/90 mmHg,

respiratory rate 32/minute, and pulse rate 110/minute.

Widespread rhonchi and inspiratory stridor were auscul-

tated bilaterally. Physical examinations of other organ

systems were normal. Chest X ray showed increased bron-

chovascular markings. Body temperature was normal, ar-

terial blood gas analysis sh owed PaO2 54 mmHg, PaCO2

64 mmHg, and oxygen saturation 75%. Complete blood

count and biochemistry were normal. The patient was

taken to the ICU and mechanical ventilation was initiated.

A deep tracheal aspiration was made through the tracheo-

stomy cannula, and a bronchoscopy was planned due to

the presence of copious and dense secretions. She lacked

adequate swallowing reflex, therefore an empiric intra-

venous antibiotherapy was initiated against a possible

infection secondary to aspiration. During bronchoscopy,

a narrowing in the proximal aspect of the trachea and

widespread collapse of the anterior tracheal wall toward

the lumen du ring in spira tion (tracheomalacia) was obser-

ved. Decannulation was considered to be impossible, and

due to her good general co ndition and the possibility that

her quality of life could have been improv ed, insertion of

a tracheal stent instead of using a home type ventilator

was decided. Using a fiber-optic bronchoscope, a tra-

cheal stent (Alveolus 16 × 60 mm TB-STSTM, Alveolus

Inc., Charlotte, NC, USA) was inserted. She was dischar-

ged after prescription of mucolytic treatment (N-acetyl

cystein 1 × 600 mg) and recommendation of hydration.

Her quality of life and respiration improved, with 98%

SaO2 at room air.

She presented to the hosp ital 4 weeks later, with severe

cough, bloody sputum, and respiratory distress. She had

stertorous breathing on physical examination. No infec-

tious foci were detected. A control bronchoscopy was

made, which revealed a breakage in the posterior wall of

the stent, measuring approximatel y 15 mm in leng th. The

stent was removed, and a second stent (Alveolus 16 × 80

mm, TB-STSTM, Alveolus Inc., Charlotte, NC, USA) was

placed. A control bronchoscopy was performed 4 weeks

later, and no problems were observed. The patient was

kept on the same stent for the next 3 months.

She presented to the emergency department again 3

months later, with stertorous breathing and copious dis-

charge. Because physical examination showed wide-

spread rhonchi, a fiberoptic bronchoscopy was made in

an attempt to clear the secretions. During bronchoscopy,

folding in the proximal part of the stent and migration in

this area were noted. The stent was removed, and the

patient was intub ated an d transferred to th e inten siv e care

unit. Two days later a tracheostomy was made. She was

then transferred to the in-patient unit, and later dis-

charged home after her saturation remained at 98% -

99%. During her follow up she did not have respiratory

distress, therefore the tracheostomy was occluded inter-

mittently, and her saturation was monitored under normal

spontaneous breathing. Decannulation was carried out af-

ter it was seen that she did not experience any decrease in

O2 saturation values. She is still under normal spontane-

ous breathing.

3. Discussion

As long as the tracheal length is adequate, the treatment

of postintubation stenosis or problems that may be cau-

sed by prolonged decannulation is resection and recon-

struction [8]. However, surgical resection is difficult in

tracheal stenoses, and even impossible in some cases.

Particularly many elderly patient with underlying con-

ditions are inoperable and require endobronchial palli-

ation. These methods include bronchoscopic dilation,

laser ablation, argon plasma coagulation, stent deploye-

ment or the application of a T tube [9]. However, success-

ful management with these methods may be difficult in

lesions located at or close to the subglottic area [10]. Al-

though stenting is a simple procedure, it may potential-

ly result in severe complications. Therefore, it must be

performed meticulously and by experienced teams. Fatal

complications such as vascular erosion, fatal hemoptysis,

bronchial wall necrosis may be observed. Other compli-

cations include incorrect location, migration, stent brea-

kage, secretion and occlusion of the stent with granula-

tion tissue, fistula formation, and pneumothorax [11].

In conditions where the initial treatment is inadequate

and there are no medical contraindications, surgical me-

thods are considered as appropriate methods [12]. How-

ever when compared to surgical treatment or home ven-

tilators, tracheal stent placement increases the quality of

life, and may be preferred in appropriate patients who

cannot be decannulated after prolonged intubation or tra-

D. OZKAN ET AL.

cheostomy. Lim et al. reported that the stent could be

successfully removed in patients undergoing stenting due

to initially inoperable post-intubation tracheal stenosis

[13].

As a conclusion, it should be kept in mind that stent

deployed by fiberoptic bronchoscopy provides functional

support to tracheal cartilages, and the tracheomalacia may

regress after removal of the stent.

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