INTRODUCTION: Upper airway injury can be propagated by intubation and tracheostomy, leading to a vicious cycle of ventilator dependence or, depending upon the location of obstruction, to death. We report a case of upper airway injury causing ventilatory failure that was healed with bypass using a trans-tracheal catheter and high-flow humidified tracheal insufflation.
CASE PRESENTATION: A 62-y-o woman was accepted in transfer because of upper airway lesions felt to require laser ablation. She had been intubated and extubated 4 times over 6 weeks. Bronchoscopy had shown necrotic granular tissue in the upper trachea with partial airway obstruction (Figure 1). The patient was intubated upon arrival. Bronchoscopy through the ETT without pull-back demonstrated granulation tissue (seen through the tube) around the sub-glottic and carinal areas. The upper tracheal process was felt to be the reason for recurrent respiratory failure. The area of inflammation/stenosis was low for a traditional tracheostomy tube. The patient was re-bronchoscoped, a pull-back was done to define the distal end of the upper tracheal process, and a trans-tracheal catheter (Trans-Tracheal Systems, Denver, Colorado) was placed into the trachea under direct bronchoscopic guidance. The skin insertion site was just above the sternal notch, and the entry site was about 4 cm distal to the vocal cords, much lower than a traditional trans-tracheal approach (Figure 2). Two days after insertion of the trans-tracheal catheter, the catheter was connected to high-flow humidified heliox 70/30 at 15 liters and 39o using a Vapotherm system ( ) and the patient was extubated. She was stable upon extubation; a blood gas demonstrated a pH of 7.39 with a pCO2 of 41 and a pO2 of 74. The patient remained stable off mechanical ventilation. After several days, the trans-tracheal gas mixture was changed to standard oxygen/nitrogen without clinical deterioration. Three bronchoscopies were performed with argon tissue ablation of upper airway tissue. Complete healing of the upper airway lesions was documented. The patient was verbal with a stable respiratory status for 3 weeks, when she was intubated again, this time for congestive heart failure. The trachea was normal at the time of intubation.
DISCUSSIONS: This case has several features which we believe to be relatively unique. First, tracheal stenosis can be a serious management problem. Very high lesions can be bypassed with tracheostomy and low tracheal lesions can be stented, but “upper mid” tracheal stenosis is a serious and potentially fatal process because neither approach may be viable. Persistent endotracheal intubation may contribute to ongoing injury and is not a viable long-term solution. We are unaware of any case in which a small trans-tracheal catheter and tracheal insufflation have been used to overcome these obstacles. Our approach not only succeeded in bypassing the stenosis, it also caused minimal new trauma (no propogation of injury) due to the gasses delivered. Warm, 100% humidified gasses may have been one factor in healing, as this bathed the injured tissues in a “physiologically neutral” gas mixture.The use of a very small distal trans-tracheal catheter gave full access to the trachea with a bronchoscope and allowed tissue ablation procedures in the upper trachea. This would have been impossible with an indwelling endotracheal tube and difficult to impossible with a tracheostomy tube.
CONCLUSION: Tracheal insufflation with warm, highly humidified gasses can be delivered below the traditional tracheostomy access site and may allow healing of upper airway injuries and may also permit upper airway interventions.
DISCLOSURE: Wissam Abouzgheib, None.