INTRODUCTION: Severe central airway obstruction (CAO) is rarely encountered during pregnancy. CAO could be well tolerated in an otherwise healthy individual, and signs of obstructive airway disease might not become evident until later in pregnancy. Early tracheostomy has been proposed in previous studies, as has airway balloon dilatation1, 2. We report a case of a pregnant female with severe tracheal and bilateral main stem bronchial stenosis caused by tuberculosis.
CASE PRESENTATION: A 33 year old Korean female in the 34th week of her first pregnancy was transferred to our hospital with a 5 day history of stridor, cough with clear sputum production and dyspnea on exertion. At age 19, she was diagnosed with tuberculosis and received 6 months of anti-tuberculosis chemotherapy, followed by a new diagnosis of asthma for which she had been treated unsuccessfully for 5 years. After immigration to the United States, she was disgnosed with tracheobronchial stenosis and had undergone balloon bronchoplasty with some symptomatic relief. The early stages of her pregnancy had been uneventful, and at her 24th week of pregnancy she was seen by a pulmonologist who recommended prophylactic airway dilatation and stenting, but she refused any invasive procedures. Her FEV1 at that time was 0.98 L (28% predicted). Her past medical history was otherwise unremarkable. At the time of transfer, her heart rate was 95, respiratory rate 18, and oxygen saturation 95% on room air. Her exam was notable only for mild stridor. The patient refused bronchoscopy, and a low-dose, non-contrast CT scan of the chest was obtained to evaluate her airway anatomy in anticipation of the possible need for intubation. Just proximal to the carina, the trachea measured 10 x 8 mm in diameter. The right and left main stem bronchi measured 2.8 mm and 5.5 mm, respectively. A thin web within the proximal portion of the intrathoracic trachea narrowed the trachea to 6 mm in diameter. Repeat spirometry showed that her FEV1 had decreased to 0.71 L. The patient was started on intravenous corticosteroids and azithromycin. After 3 days of treatment, there was no significant clinical improvement, prompting the decision to proceed with delivery of her baby. An intrathecal catheter was placed very early in the course, with plans for vaginal delivery as per the patient’s request. Over a period of 20 hours the patient did not progress beyond 1 cm, and the decision was made to proceed with cesarean section under spinal anesthesia. At this point she began to experience worsening dyspnea, and Heliox was initiated with immediate, dramatic symptomatic relief. The Heliox was continued until after the delivery of her baby. She underwent an uncomplicated C-section and gave birth to a healthy infant. Following the delivery of her baby, her symptoms of dyspnea and increased mucus secretion subsided completely.
DISCUSSION: In this patient with severe tracheobronchial stenosis, bronchorrhea and bronchial edema due to increased estrogen levels associated with pregnancy likely exacerbated the symptoms of CAO. Given the patient’s refusal of invasive airway interventions, our use of Heliox for ventilation and spinal anesthesia for pain control were the cornerstones in this patient’s successful delivery. The combination of severe tracheal stenosis and pregnancy is extremely rare, with only 9 prior case reports in the literature. There are no reports of concomitant tracheal and bronchial stenosis in pregnancy, and to the best of our knowledge, this is the first reported case of tuberculosis-induced tracheobronchial stenosis.
CONCLUSIONS: In the event of CAO in pregnancy, close monitoring of respiratory and hemodynamic alterations are paramount, as patients are at increased risk of air trapping and hemodynamic embarrassment. Heliox may assist in the management of these patients.
Reference #1 Kuczkowski KM and Benumof JL. Subglottic tracheal stenosis in pregnancy: anaesthetic implications. Anaesth Intensive Care 2003; 31:576-577
Reference #2 Salama DJ and Body SC. Management of a term parturient with tracheal stenosis. Br J Anaesth 1994; 72:354-357
DISCLOSURE: The following authors have nothing to disclose: Samira Shojaee, Harold Manning
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