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Successful Treatment of Postintubation Tracheal Stenosis With Balloon Dilation, AOC Electrocautery, and Application of Mitomycin C FREE TO VIEW

Audra Fuller, MD; Mark Sigler, MD; Shrinivas Kambali, MD; Raed Alalawi, MD
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Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX

Chest. 2014;146(4_MeetingAbstracts):778A. doi:10.1378/chest.1994941
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SESSION TITLE: Bronchology/Interventional Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Tracheal stenosis is a rare but known complication of endotracheal (ET) intubation. We present our experience of using balloon dilation (BD), Argon Plasma Coagulation (APC) endoscopic electrosurgery (EES) and application of Mitomycin C (MMC) as treatment for tracheal stenosis.

CASE PRESENTATION: Case 1: 54 y/o woman was intubated for three days secondary to acute respiratory failure from acute asthma exacerbation and Influenza A. Four weeks later she presented with stridor. Bronchoscopy showed tracheal stenosis with diameter of 5mm. Rigid bronchoscopy and BD was performed followed by excision of granulation tissue with EEC. After successful dilation, topical MMC was applied at the site of granulation tissue. Post-procedure tracheal diameter was 1.2 cm with a lumen size >75% normal. Follow-up bronchoscopy revealed normal tracheobronchial tree. Case 2: 49 y/o woman was intubated for acute respiratory failure. She presented with stridor and significant dyspnea. Bronchoscopy was performed and revealed granulation tissue causing >50% tracheal stenosis. Rigid bronchoscopy, EEC, BD, APC and cryotherapy were then used to obtain >75% normal tracheal size. Topical MMC was then applied at the site of granulation tissue with resolution of the patient’s symptoms. Case 3: 39 y/o woman had open tracheostomy after prolonged mechanical ventilation for acute stroke. A month later she developed respiratory distress. Bronchoscopy showed >90% narrowing of the trachea secondary to granulation tissue. The granulation tissue was debrided using cryotherapy and CRE balloon dilation. Repeat bronchoscopy three weeks later showed recurrence of granulation tissue which was again treated with cryotherapy and balloon dilatation. Topical mitomycin was applied at the site of granulation tissue. Patient presented 4 weeks later to ER with acute dyspnea secondary to recurrence of tracheal stenosis and died before any intervention could be done.

DISCUSSION: Tracheal stenosis is a rare serious complication after intubation. Common treatments for this complication include: Nd:YAG laser, EES, APC electrocautery, balloon dilation, stenting, cryotherapy and surgical intervention. Surgery is a more definitive treatment but also carries significant higher risk involving complex procedure. Addition of topical MMC has recently been described as a potential addition to the treatment of tracheal stenosis. Our experience with 3 cases shows a good success (66%) with topical mitomycin application as definitive treatment for tracheal stenosis.

CONCLUSIONS: The topical application of mitomycin following endoscopic electrosurgery can be used for successful treatment of post intubation tracheal stenosis.

Reference #1: Simpson, C. Blake, and Joshua C. James. "The Efficacy of Mitomycin-C in the Treatment of Laryngotracheal Stenosis." The Laryngoscope 116.10 (2006): 1923-925. Online.

DISCLOSURE: The following authors have nothing to disclose: Audra Fuller, Mark Sigler, Shrinivas Kambali, Raed Alalawi

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