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A 54-Year-Old Woman With Postextubation StridorA Woman With Postextubation Stridor FREE TO VIEW

Eugene Shostak, MD; Adnan Majid, MD, FCCP; Colleen Channick, MD
Author and Funding Information

From the Department of Interventional Pulmonology (Drs Shostak and Majid), Beth Israel Deaconess Medical Center; and Department of Interventional Pulmonology (Drs Shostak and Channick) and Special Procedures Unit (Dr Channick), Massachusetts General Hospital, Boston, MA

CORRESPONDENCE TO: Colleen Channick, MD, Special Procedures Unit, 55 Fruit St, Bigelow 952, Boston, MA 02114; e-mail: cchannick@mgh.harvard.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):e163-e166. doi:10.1378/chest.13-3077
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Published online

A 54-year-old woman developed a witnessed generalized tonic clonic seizure at work. Paramedics recorded a blood glucose level of 30 mg/dL. Despite normalizing the blood glucose level, the patient’s mental status did not improve, and she was intubated in the field. Given the limited view of the glottis, a tracheal tube introducer (Bougie) was used to facilitate intubation.

On arrival to the ED, the patient was awake and following simple commands. She was extubated but 1 h later developed somnolence and respiratory distress. After two unsuccessful attempts with direct laryngoscopy, she was reintubated using a videolaryngoscope with a size 7.0 endotracheal tube. During reintubation, there was difficulty obtaining adequate exposure of the glottis but no difficulty advancing the endotracheal tube through the vocal cords into the trachea.

Evaluation for the cause of altered mental status, including a CT scan of the brain and EEG, was unrevealing. The patient’s mental status improved, and, on day 3, she was extubated. Seventy-two hours following extubation, the patient developed intermittent stridor, worse with exertion. She was treated with nebulized racemic epinephrine and IV corticosteroids for possible vocal cord edema.

The patient’s past medical history included poorly controlled type 1 diabetes complicated by renal failure, peripheral vascular disease, and diabetic retinopathy. She had multiple admissions for hypoglycemic seizures but no prior history of intubation.

Physical Examination Findings

On examination, the patient was anxious and unable to speak in full sentences. BP was 160/90 mm Hg, pulse was 110 beats/min, and the oxygen saturation was 92% on 50% Venturi mask. Physical examination was remarkable for inspiratory stridor auscultated over the trachea. Cardiac examination revealed regular heart sounds without a murmur. The remainder of the examination was normal.

Diagnostic Studies

Laboratory work revealed a normal basic metabolic panel and CBC count. On chest radiograph, the trachea was midline and did not appear narrowed. The lung fields were clear. Flexible bronchoscopy revealed two partially obstructing circular rubber-like membranes firmly adherent to the wall of the upper and mid trachea, beginning 2 cm below the vocal cords. A flap of tissue was noted on the anterior wall of the distal trachea, causing “ball-valve” obstruction (Fig 1).

Figure Jump LinkFigure 1 –  A-B, Circumferential rubber-like membranes adherent to the wall of (A) upper trachea and (B) mid trachea. C, Flap of tissue attached to the anterior wall of the distal trachea.Grahic Jump Location
What is the diagnosis?
Diagnosis: Obstructive fibrous tracheal pseudomembrane

Formation of pseudomembranes in the respiratory tract can result from inhalation injury, caustic burns, aspiration of gastric contents, and various infectious agents including Staphylococcus aureus, Bacillus cereus, Aspergillus, and Corynebacterium species. Obstructive fibrinous tracheal pseudomembrane (OFTP) is a term that refers to the development of tracheal pseudomembranes from noninfectious causes. OFTP is a rare and potentially fatal complication of endotracheal intubation. The incidence of this lesion remains unknown.

Proposed risk factors for the development of OFTP include tracheal injury during intubation, extended duration of intubation, and tissue ischemia from the use of inappropriately sized endotracheal tube or high-pressure tracheal tube cuffs. OFTP is commonly located at the site of the tracheal cuff. In this patient, we hypothesize that impaired microcirculation from poorly controlled diabetes mellitus combined with mucosal injury from two traumatic intubations caused an ischemic insult to the tracheal mucosa resulting in the development of multiple tracheal pseudomembranes.

In the largest published OFTP case series to date, Lins and colleagues examined the cases of 24 patients diagnosed with OFTP; the duration of intubation ranged from 1 h to 16 days and the delay from extubation to development of symptoms ranged from 3 h to 14 days. In this series, only one patient had a clear history of laryngeal trauma requiring long-term intubation and tracheostomy. In the remainder of the patients, no predisposing factors or illnesses were identified.

Bronchoscopy is critical for both the diagnosis and management of OFTP. Pseudomembranes appear as white, thick, tubular, and rubbery lesions, firmly molding to the tracheal wall. Pseudomembranes located at the site of endotracheal tube cuff may be difficult to diagnose bronchoscopically in patients who are intubated. Over time, these lesions can undergo partial detachment and may obstruct the tracheal lumen.

OFTP has a variable clinical presentation depending on the extent of detachment of the pseudomembranes and the degree of tracheal obstruction. OFTP can present as intermittent postextubation stridor via a valve-like obstruction but may also be clinically silent if the membrane firmly adheres to the tracheal wall.

Microscopic examination of the pseudomembrane typically demonstrates fibrinous material with mucosal and submucosal polymorphonuclear cell infiltration and necrotic tracheal epithelium. This observation supports the notion that OFTP represents an early stage of ischemic tracheal wall injury.

Treatment of OFTP requires mechanical removal of pseudomembranes, which is best accomplished via rigid bronchoscopy. Debulking with rigid forceps and cryodebridement may facilitate pseudomembrane removal.

Long-term complications from OFTP, such as tracheal stenosis and tracheomalacia, are uncommon. Lins and colleagues reported only one case of subglottic stenosis, which occurred in an asymptomatic infant. Therefore, unlike in tracheal stenosis, stent placement and surgery are not typically needed.

The presence of multiple pseudomembranes and incomplete removal at the time of the initial bronchoscopy are risk factors for short-term complications, such as tracheal obstruction from detachment of pseudomembranes. In contrast to the long-term complications, the prevalence of short-term complications from OFTP is not well described in literature. The optimal timing and frequency of follow-up bronchoscopy in patients with OFTP are unknown. According to published case reports, initial surveillance bronchoscopies have been performed 13 days, 15 days, 3 weeks, and 3 months following endoscopic treatment of OFTP. Only one case study reports performing a second surveillance bronchoscopy. Guerrero and associates described a patient with Corynebacterium-necrotizing tracheitis who underwent successful removal of tracheal pseudomembranes. The patient was lost to follow-up and returned 3 weeks later with near complete tracheal obstruction from recurrent pseudomembranes and tracheal stenosis requiring emergent tracheostomy.

Clinical Course

Rigid bronchoscopy was performed with successful removal of the tissue flap and debridement of the loosely attached pseudomembranes. Attempts at removal of pseudomembranes firmly adherent to the tracheal wall resulted in bleeding. Histopathologic examination revealed fibrinous material with necrotic epithelial cells. Cultures showed no bacterial or fungal growth. Following the procedure, the patient’s respiratory symptoms immediately improved.

Bronchoscopy performed 3 days later showed a moderate degree of mucosal sloughing along the posterior tracheal wall. This tissue was successfully removed with forceps. Adherent pseudomembrane could not be removed during this procedure but was easily removed on bronchoscopy 10 days later. The presence of multiple pseudomembranes with variable degrees of adherence to the tracheal wall, as well as inability to completely remove them at the time of initial bronchoscopy, made it necessary to perform subsequent bronchoscopies. A follow-up bronchoscopy 30 days after initial diagnosis showed a normal trachea with no residual fibrinous tissue and no evidence of tracheal stenosis or tracheomalacia.

  • 1. OFTP is a rare cause of postextubation stridor and has a variable clinical presentation depending on the extent of pseudomembrane detachment and the degree of tracheal obstruction.

  • 2. If unrecognized, OFTP may result in respiratory failure and death from tracheal obstruction. Prompt bronchoscopic examination is the key to early diagnosis and can be lifesaving.

  • 3. The optimal timing for follow-up bronchoscopy is unknown. Repeat bronchoscopy may be necessary, especially in patients with extensive obstructive pseudomembranes.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Channick has served as a consultant for Medtronic. Drs Shostak and Majid have reported that no potential conflictsof interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Strauss R, Mueller A, Wehler M, et al. Pseudomembranous tracheobronchitis due toBacillus cereusClin Infect Dis. 2001;33(5):E39-E41. [CrossRef] [PubMed]
 
Yamazaki Y, Hirai K, Honda T. Pseudomembranous tracheobronchitis caused by methicillin-resistantStaphylococcus aureusScand J Infect Dis. 2002;34(3):211-213. [CrossRef] [PubMed]
 
Talwar A, Patel N, Omonuwa K, et al. Postintubation obstructive pseudomembrane. J Bronchol. 2008;15(2):110-112. [CrossRef]
 
Kang HH, Kim JW, Kang JY, et al. Obstructive fibrinous tracheal pseudomembrane after tracheal intubation: a case report. J Korean Med Sci. 2010;25(9):1384-1386. [CrossRef] [PubMed]
 
Lins M, Dobbeleir I, Germonpré P, Waelput W, Pauwels P, Jorens PG. Postextubation obstructive pseudomembranes: a case series and review of a rare complication after endotracheal intubation. Lung. 2011;189(1):81-86. [CrossRef] [PubMed]
 
Fernández-Ruiz M, Silva JT, San-Juan R, et al. Aspergillus tracheobronchitis: report of 8 cases and review of the literature. Medicine (Baltimore). 2012;91(5):261-273. [CrossRef] [PubMed]
 
Manassero A, Ugues S, Bertolaccini L, Bossolasco M, Terzi A, Coletta G. A very early stage of obstructive fibrinous tracheal pseudo-membrane formation. J Thorac Dis. 2012;4(3):320-322. [PubMed]
 
Trisolini R, Coniglio C, Patelli M. Life-threatening postextubation obstructive fibrinous tracheal pseudomembrane. Ann Thorac Surg. 2013;95(4):e103. [CrossRef] [PubMed]
 
Guerrero J, Mallur P, Folch E, et al. Necrotizing tracheitis secondary toCorynebacteriumspecies presenting with central airway obstruction. Respir Care. 2014;59(1):e5-e8. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  A-B, Circumferential rubber-like membranes adherent to the wall of (A) upper trachea and (B) mid trachea. C, Flap of tissue attached to the anterior wall of the distal trachea.Grahic Jump Location

Tables

Suggested Readings

Strauss R, Mueller A, Wehler M, et al. Pseudomembranous tracheobronchitis due toBacillus cereusClin Infect Dis. 2001;33(5):E39-E41. [CrossRef] [PubMed]
 
Yamazaki Y, Hirai K, Honda T. Pseudomembranous tracheobronchitis caused by methicillin-resistantStaphylococcus aureusScand J Infect Dis. 2002;34(3):211-213. [CrossRef] [PubMed]
 
Talwar A, Patel N, Omonuwa K, et al. Postintubation obstructive pseudomembrane. J Bronchol. 2008;15(2):110-112. [CrossRef]
 
Kang HH, Kim JW, Kang JY, et al. Obstructive fibrinous tracheal pseudomembrane after tracheal intubation: a case report. J Korean Med Sci. 2010;25(9):1384-1386. [CrossRef] [PubMed]
 
Lins M, Dobbeleir I, Germonpré P, Waelput W, Pauwels P, Jorens PG. Postextubation obstructive pseudomembranes: a case series and review of a rare complication after endotracheal intubation. Lung. 2011;189(1):81-86. [CrossRef] [PubMed]
 
Fernández-Ruiz M, Silva JT, San-Juan R, et al. Aspergillus tracheobronchitis: report of 8 cases and review of the literature. Medicine (Baltimore). 2012;91(5):261-273. [CrossRef] [PubMed]
 
Manassero A, Ugues S, Bertolaccini L, Bossolasco M, Terzi A, Coletta G. A very early stage of obstructive fibrinous tracheal pseudo-membrane formation. J Thorac Dis. 2012;4(3):320-322. [PubMed]
 
Trisolini R, Coniglio C, Patelli M. Life-threatening postextubation obstructive fibrinous tracheal pseudomembrane. Ann Thorac Surg. 2013;95(4):e103. [CrossRef] [PubMed]
 
Guerrero J, Mallur P, Folch E, et al. Necrotizing tracheitis secondary toCorynebacteriumspecies presenting with central airway obstruction. Respir Care. 2014;59(1):e5-e8. [CrossRef] [PubMed]
 
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