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A Novel Airway Stabilization Technique for Respiratory Failure Associated With Tracheobronchomegaly FREE TO VIEW

Christopher Erb, MD; Kelsey Johnson, PA-C; Margaret Pisani, MD; Jonathan Puchalski, MD
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Yale University, Department of Internal Medicine, Section of Pulmonary and Critical Care Medicine, New Haven, CT

Chest. 2013;144(4_MeetingAbstracts):17A. doi:10.1378/chest.1702872
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SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheobronchomegaly (Mounier-Kuhn Syndrome) is a rare disease in which chronic ventilation poses unique challenges due to the airway diameter and collapsibility(1). Although a tracheostomy cuff may permit ventilation, this may be impeded by significant expiratory collapse of the airways into the distal tracheostomy with exhalation. We present a unique technique for stabilizing the airway and permitting long-term ventilation for this complex clinical scenario.

CASE PRESENTATION: A 73 year old was transferred to our facility after failed attempts to ventilate the patient due to a combination of tracheobronchomegaly, diffuse expiratory airway collapse and ongoing bronchopneumonia. His trachea measured 46 x 37 mm and his mainstem bronchi measured 22 mm on the right and 21mm on the left. Despite several tracheostomy attempts using standard and extra-long cuffed tracheostomy tubes, the expiratory airway continued to collapse into the distal tracheostomy prohibiting effective ventilation. Tracheoplasty was not feasible due to the patient’s critical illness. A silicone Y-stent (Boston Medical) measuring 18 x 14 x 14 mm was placed into his tracheobronchial tree. The stent provided bronchoscopically confirmed stabilization of his bronchomalacia, but ventilation remained problematic. Although the inspiratory airflow was sufficient, a large air leak with “back-flow” around the stent and tracheostomy tube was persistent due to inadequate apposition of tubes to the tracheobronchial airways. The patient’s true ventilation was less than 20% of that provided by the ventilator, with exhaled tidal volumes less than 100 ml with an inspiratory volume set at 500 ml. Due to persistent failure, a Bivona® Fome-Cuf® (Smiths Medical) tracheostomy tube was then intussuscepted into the tracheal limb of the Y stent. With approximately 50% of the tracheostomy inside of the stent, the superior portion of the cuff remained external to the stent and with inflation, provided complete apposition to the severely dilated tracheal wall. By stabilizing the distal trachea and mainstem bronchi with a Y stent and by using the cuff of the tracheostomy in the trachea, adequate ventilation was restored.

DISCUSSION: Chronic ventilation in patients with tracheobronchomegaly is complicated due to pathologically dilated and collapsible airways. We were able to provide ventilation when intussuscepting a Bivona® cuffed tracheostomy tube into a tracheobronchial Y stent, stabilizing the diffuse airway collapsibility while ensuring apposition of the tracheostomy tube to the tracheal wall.

CONCLUSIONS: To our knowledge, very few, if any, other options exist for this clinical scenario.

Reference #1: (1) Odell DD, Shah A, et al., Airway stenting and tracheobronchoplasty improve respiratory symptoms in Mounier-Kuhn syndrome. Chest. 2011 Oct;140(4):867-73.

DISCLOSURE: The following authors have nothing to disclose: Christopher Erb, Kelsey Johnson, Margaret Pisani, Jonathan Puchalski

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