SESSION TITLE: Bronchology Case Report Posters
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM
INTRODUCTION: Post-extubation stridor is a life-threatening condition. A variety of their causes has been established and includes obstructed secretion, vocal cord edema, vocal cord dysfunction, and tracheomalacia. In this report, we report herein a rare incidence of post-extubation stridor caused by obstructive fibrinous tracheal pseudomembrane (OFTP).
CASE PRESENTATION: A 29-year-old man was admitted with respiratory failure and diabetic ketoacidosis. 5-day before admission, he presented with fever, productive cough and shortness of breath. A day before admission, he had a worsening dyspnea and requiring endotracheal intubation and mechanical ventilation. He had history of smoking and alcoholic drinking. Physical examination revealed high temperature, cyanosis and bilateral inspiratory fine crackles in lower lung zone. Chest radiograph revealed patchy infiltration at right upper lobe and right lower lobe. Severe pneumonia had been diagnosed in this patient. Then, he was immediately treated with broad spectrum antibiotic and intraveneous insulin injection. 10 days after admission, he was liberated from mechanical ventilation. 8 hours after extubation he complained of dyspnea and inspiratory stridor. Laryngoscopy revealed no evidence of angioedema or vocal cord dysfunction. During clinical observation, he had a clinical worsening therefore, he was substantially re-intubated. At that time, the nurse reported that he could not absolutely ventilate the ambu bag into the lung. Endotracheal tube was immediately removed. At the tip of endotracheal tube, there was a tubular membrane of necrotic debris (~3 cm long x 1.5 cm thick) (Fig 1). This membrane totally obstructed terminal lumen of endotracheal tube. His stridor resolved immediately Histopathology revealed “membranous fragments of fibrino-inflammatory debris with focal areas of reactive squamous epithelium”. He was discharged on day 25 of admission.
DISCUSSION: Although there have been several etiology in the knowledge of post-intubation tracheal stenosis, OFTP is still a rare and less known complication of endotracheal intubation. We presented a case of a worsening dyspnea with clinical post-exubation stridor, and diagnosed as OFTP by observation of a thick red-whitish tubular pseudomembrane molded within the tip of endotracheal tube resulting in complete luminal obstruction. OFTP is postulated that may be the initial stage in a process triggered by ischemic damage from high pressure endotracheal cuffs. Generally, high pressure cuff particular more than 30 cmH2O leads to inflammation, infarction and ultimately necrosis of the tracheal mucosa that may eventually result in tracheal stenosis. The pathological findings of tracheal pseudomembranes are superficial abrasions of the mucosa and desquamated necrotic tracheal epithelium. The OFTP are usually located at the site of tracheal cuff and can then be detached and removed by reintubation and/or tracheal suctioning and thus might remain unrecognized. Diagnosis of OFTP can be a challenge because the clinical picture is often misleading when symptoms of dyspnea and stridor are positional and intermittent secondary to the ball-valve obstruction from the pseudomembrane. Symptoms can be misdiagnosed as bronchial asthma, vocal cord dysfunction or glottic edema. However, Fiberoptic bronchoscopy is frequent method to diagnose and reveal a thick, circular, rubber-like membrane adhering to the tracheal wall at the site of the cuff. However, our patient was diagnosed by reintubation and OFTP detach from tracheal wall to obstruct the tracheal lumen.
CONCLUSIONS: In conclusion, this report highlights the potential fatal complication of considering OFTP in patient presenting with dyspnea and inspiratory stridor after extubation, and the physician should alert and perform bronchoscopy for the precise diagnosis to allow early detection.
Reference #1: Deslee G, Brichet A, Lebuffe G, Copin MC, Ramon P, Marquette CH (2000) Obstructive fibrinous tracheal pseudomembrane. A potentially fatal complication of tracheal intubation. Am J Respir Crit Care Med 162:1169-1171
DISCLOSURE: The following authors have nothing to disclose: Narongwit Nakwan
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