The clinical and subclinical characteristics of tracheal stenosis after prolonged endotracheal intubation or tracheostomy which required tracheal reconstructive surgery

Nội dung text: The clinical and subclinical characteristics of tracheal stenosis after prolonged endotracheal intubation or tracheostomy which required tracheal reconstructive surgery

1. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 THE CLINICAL AND SUBCLINICAL CHARACTERISTICS OF TRACHEAL STENOSIS AFTER PROLONGED ENDOTRACHEAL INTUBATION OR TRACHEOSTOMY WHICH REQUIRED TRACHEAL RECONSTRUCTIVE SURGERY Nguyen Duc Thang1,2, Nguyen Truong Giang1, Tran Trong Kiem1 SUMMARY Objectives: To survey the clinical and paraclinical characteristics of tracheal stenosis (TS) after prolonged endotracheal intubation (PEI) or tracheostomy (TO). Subjects and methods: A cross - sectional study on 72 patients with TS after PEI and TO required the tracheal reconstructive operation at Military Central Hospital 108 and Cho Ray Hospital. Results: The most common cause leading to PEI or TO is traumatic brain injury (TBI), accounting for 52.8%. The cause of TS due to PEI was higher than due to TO, with 54.2% and 45.8%, respectively. Clinically, symptoms of dyspnea were present in 52 patients (72.22%) and laryngeal stridor in 22 patients (30.55%). Flexible endoscopy could only be performed in 63 cases of which, tracheal lesions were detected in 56 cases (77.8%), combined lesions of the trachea and subglottis in 7 cases (9.7%). The level of TS according to the Myer - Cotton classification on bronchoscopy and CT scan were mainly grade III, with 54.0% and 62.5%, respectively. The average length of TS on CT scan was 15.6 ± 6.6mm (range 0.5 - 32.7mm). Conclusion: In the patients with TS after PEI or TO which required tracheal reconstructive surgery, the most common cause of PEI and TO was TBI (52.8%). The most common clinical symptoms were dyspnea and laryngeal stridor, and tracheal lesions and level of TS (mainly grade III according to the Myer-Cotton classification) determined by flexible endoscopy and CT scan were mainly paraclinical symptoms. * Keywords: Iatrogenic tracheal stenosis; Endotracheal intubation; Tracheostomy. INTRODUCTION PEI or TO ranges from 0.6 - 22% of Acquired tracheal stenosis most commonly patients subjected to prolonged intubation results from iatrogenic injury, such as and ventilation. This type of TS remains post-intubation or/and post-tracheostomy one of the most common indications for complications [1]. Incidence of TS after tracheal reconstructive surgery [4]. 1Vietnam Military Medical University 2Military Central Hospital 108 Corresponding author: Nguyen Duc Thang (surgeonthang@gmail.com) Date received: 5/7/2021 Date accepted: 18/7/2021 207
2. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 Presentation of post intubation or post - Patients consented and voluntarily tracheostomy TS can be varied depending participated in the research. on the onset and severity of the stenosis. * Exclusion criteria: Early, TS can present very insidious or - Tracheal stenosis due to other causes: as the onset of an asthmatic attack. Congenital, autoimmune, tumors of all kinds, In many cases, the initial condition is vascular loops, thermal burns, exposed by an acute respiratory infection - Tracheal stenosis in patients at risk of as dry cough, cough with phlegm or even re-ventilation such as severe myasthenia hemoptysis... gravis, progressive COPD... or other The mainstay of diagnostic evaluation systemic diseases. includes cross-sectional CT scan imaging - The patient did not agree to participate and flexible endoscopy. Treatment in the research. encompasses a variety of endoscopic 2. Methods intervention and open surgical techniques and should be tailored to the individual * Study design: patient [3]. This is a cross - sectional study. Using Therefore, the initial assessment with convenient samples according to the taking an accurate look at features of actual random collected records. local and related trachea lesions plays an * General features: important role in designing effective - History: Reasons leading to require treatment strategies for patients. So, our endotracheal intubation or tracheostomy. study was carried out: To survey the - Clinical symptoms: Cough, dyspnea, clinical and paraclinical characteristics of pronunciation, laryngeal stridor, fever. TS after PEI or TO which required - Subclinical indicators: tracheal reconstructive surgery at Military + Flexible endoscopy of trachea Central Hospital 108 and Cho Ray Hospital. (including flexible tracheobronchoscopy SUBJECTS AND METHODS and flexible laryngoscopy): Location of stenosis, level of stenosis by Myer-Cotton 1. Subjects classification... Including 72 patients with a diagnosis + CT scan: Location of stenosis, length of TS after PEI or TO which required of stenosis, level of stenosis by Myer - tracheoplasty surgery at Military Central Cotton classification). Hospital 108 and Cho Ray Hospital from 3. Statistical analysis January 2014 to December 2017. Data were analyzed with SPSS * Selection criteria: program 20.0. Values were presented as - Patients were diagnosed TS after PEI mean values, SD, percentage rate and p or TO which had indications for resection values of under 0.05 were considered as and reconstruction of TS. significant. 208
3. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 RESULTS 1. Causes of prolonged endotracheal intubation or tracheotomy Table 1: Causes of prolonged endotracheal intubation or tracheostomy. Causes of PEI or/and TO Number of cases (n) % TBI 38 52.8 Coma by many different reasons 9 12.5 Poisoning by pesticides, sleeping drugs, chemicals 5 6.9 Endotracheal intervention 5 6.9 Neck trauma or injury 4 5.6 Respiratory infection 3 4.2 Chest trauma 1 1.4 Others 7 9.7 Total 72 100.0 Among all 72 cases, TBI was the most common cause leading to PEI or/and TO, accounting for 52.9%. There were 39 cases (54.2%) with TS after PEI and 33 cases (45.8%) with TS after TO. 2. Clinical characteristics There were 52 cases (72.22%) experiencing dyspnea and 22 cases (30.55%) with stridor symptoms. Besides, the number of patients who couldn’t pronounce accounted for the largest proportion with 56.9% (41 cases) and the number of patients with a normal pronunciation accounted for 30.6% (22 cases) (chart 1). Chart 1: Distribution of patients according to pronunciation status. 209
4. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 Table 2: Clinical symptoms. Clinical symptoms Number of cases (n) % Without cough 10 13.9 Dry cough 41 56.9 Cough Sputum cough 21 29.2 Hemoptysis 0 00.0 Yes 2 02.8 Fever No 70 97.2 Yes 22 30.6 Stridor No 50 69.4 Total 77 100.0 The patients with dry cough accounted for 56.9%. There was not any patient with hemoptysis. Among 72 patients participating in the study, the patients without fever accounted for 97.2%. 3. Subclinical characteristics * Characteristics of TS determined by flexible endoscopy of trachea: To assess tracheal lesions can use both flexible laryngoscopy and flexible bronchoscopy. Both of them were named generally flexible endoscopy of the trachea (FET). Chart 2: Tracheal stenosis via FET. Among 72 cases, there were 63 patients (87.5%) who were performed preoperative FET. Tracheal lesions were determined in all those 63 cases in which 56 cases had tracheal lesions only (accounting for 77.8% of all patients and 88.9% of cases were performed PET) and 7 cases had combined subglottic-tracheal lesions (accounting for 9.7% of all patients and 11.1% of cases were performed PET). 210
5. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 Table 3: The location and level of tracheal lesions in 63 patients who performed PET. Location and level of tracheal lesion Number of cases (n) (%) Upper 34 53.9 Location of tracheal lesions Middle 29 46.1 Lower 0 0.0 Grade I 0 0.0 Grade II 6 9.5 Level of TS according to the Myer - Cotton classification Grade III 34 54.0 Grade IV 23 36.5 In 63 cases performed PET, the most common location of TS was the upper segment with 34 cases (accounting for 53.9%). The most common level of TS was Grade III according to the Myer - Cotton classification with 34 cases (accounting for 46.1%). * Characteristics of TS determined by computer tomography: On CT scan, the shortest stenosis segment of TS was 5.0 mm and the longest was 32.7 mm. The average length of the TS segment was 15.6 ± 6.6 mm. The most common stenosis length group was 10 - 20 mm with 36 cases (accounting for 50.0%). The least common length group was > 20 mm with 12 cases (accounting for 16.6%). The serious level of TS, according to the Myer-Cotton classification determined by CT scan was mainly grade III with 45 cases (accounting for 62.5%) (chart 3). Chart 3: Myer - Cotton classification on CT scan. 211
6. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 DISCUSSION respectively. Grillo et al. (2004) in a 1. Causes of prolonged endotracheal 27-year study on 503 patients undergoing intubation or tracheostomy leading to TO and reconstruction due to post-intubation tracheal stenosis injury at Massachusetts General Hospital (MGH) showed that there were 251/503 The causes leading to require PEI or (49.9%) lesions of the endotracheal TO were given in table 1. Among them, balloon of PEI and 178 cases (35.4%) of TBI was the most common cause with 38 stenosis at the TO site and 38 cases with cases (accounting for 52.9% of all patients both lesions [6]. In the study of Ahn HY et in our study). This result was consistent al (2015), there were 18 cases of TS due with some domestic studies such as the to PEI and TO, 10/18 (55.55%) stenosis report "Surveying the characteristics of at balloon position of PEI, 6/18 (33.33%) laryngotracheal stenosis after prolonged stenosis at the TO site and stenosis in 2 endotracheal intubation" by Nguyen Thi positions were 2/18(11.11%). In his study, My Tham et al. (2010), in which the main Ahn H Y et al. (2015) identified lesions cause of PEI due to traumatic brain injury caused by 2 combined causes: intubation (TBI) was 63.2% [1]. Do Quyet et al. and endotracheal intubation [7]. In fact, it (2015) in his report "Studying on clinical was difficult to identify these two lesions and subclinical characteristics and initial separately at the time of hospitalization, treatment of tracheal stenosis by we combined time line and stenosis location interventional endoscopic therapy" had to determine which is the main cause. also found that the main cause of tracheal stenosis was TBI, accounting for 60.1% 2. Clinical characteristics while other causes, such as respiratory The clinical symptoms of TS are disease, cardiovascular disease, cerebral generally insidious. Most arise 1 - 6 weeks stroke, myasthenia gravis... accounted after extubation, and early symptoms are only for 7 - 16% [2]. Z Totonchi et al. often not recognized. The most common showed that regardless of the reasons for symptoms include shortness of breath, hospitalization such as motor accidents, cough, recurrent pneumonia, wheezing, fall from height, intoxication, cardiovascular stridor, and cyanosis over time. Dyspnea is often the symptom until the tracheal disorders, surgical procedures, pulmonary diameter is 50% smaller than normal. infections or cerebrovascular accident, When the tracheal diameter is 25% of its any patients who have been intubated normal size, dyspnea and stridor may and have undergone mechanical ventilation occur even at rest. These symptoms for some time may increase the number can be confused with other respiratory of TS and its incidence varies from 0.1 to diseases [8]. 20% [5]. In this study, 52 cases (72.22%) had a In our study, there were 39 cases with symptom of dyspnea and only 22 cases TS due to PEI and 33 case with TS due (30.55%) had stridor symptoms. Dyspnea to TO, accounting for 54.2% and 45.8%, on exertion appeared when about 50% of 212
7. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 the airway is narrowed. Dyspnea at rest of upper airway obstruction: dyspnea on occurs when 75% of the airway is exertion, wheezing, or stridor. Unfortunately, stenosed. Typically, in adults, exertional this presentation is frequently misinterpreted dyspnea occurs when the airway diameter as adult onset asthma. It is not is reduced to about 8 mm; resting dyspnea occurs at a diameter of 5 mm, at uncommon for patients to undergo which point stridor also occurs [9]. treatment with corticosteroids for months In some cases, dyspnea can be to years before the correct diagnosis understood as shortness of breath or (7.5%) was finally made. Therefore, any dyspnea is an early feeling of the patient patient with obstructive airway and history during processing of tracheal stenosis. of tracheal intubation must be considered Dyspnea, or shortness of breath, may to have airway stenosis until proven indicate that your body is hungry for air. otherwise [11]. It tells you that something is not working Besides, the number of patients who right. Shortness of breath is the most couldn’t pronounce was 41 (accounting common complaint of patients with TS. for the largest proportion with 56.9%). Increased airway stenosis may worsen The number of patients with normal pronunciation was 22 (accounting for 30.6%) dyspnea and cause wheezing and stridor. (chart 1). When TS has developed When the airway diameter decreases to seriously at point force it has to require a less than 8 mm, wheezing starts to occur TO to save the patient’s life. This is very with effort dyspnea, and when it is below popular situation of TS transferred to 5 mm, stridor develops. In the study by specialized centers for tracheal surgery. Sahin, M. F et al. (2021) with 40 cases of The purpose of this technique is to ensure complex TS, the most common symptom safety during transport, to solve the risk of was stridor (62.5%). These authors noted respiratory failure. Due to tracheostomy, that lumen diameter in the narrowest part the patient is almost unable to speak or of TS was observed to differ significantly pronounce. depending on the symptoms (stridor, Among 72 patients participating in the wheezing, dyspnea) and the lumen study, the patients with dry cough diameter in the narrowest part of TS in symptoms accounted for 56.9%, the fever a patient with stridor was narrower than symptom was fewer with 6.8%, and there others (with p < 0.001). According to was no patient with hemoptysis (Table 2). the lumen diameter measurement, the Cough was a protective reaction of the airway as a foreign body or obstruction in stridor's cut-off value in the narrowest part the airway, especially in patients with an of the stenotic segment was calculated to endotracheal cannula after tracheostomy. be 6.5 mm [10]. In this case, a respiratory infection can Patients with pathologic lesions of the appear and be accompanied by symptoms trachea usually exhibit signs and symptoms of sputum cough and fever. 213
8. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 3. Subclinical characteristics (25%), grade III was 10 (41.7%). and Bronchoscopy is one of the most grade IV was 8 (33.3%). Of which, only 15 valuable diagnostic approaches used to (62.5%) had cervical stenosis and 9 (37.5 evaluate airway stenosis. However, the %) were related to the subglottis and effectiveness of bronchoscopic approaches cricoid cartilage [12]. alone in the treatment of complex strictures Among 72 patients, the level of TS is controversial. In our study, only 63 patients according to the Myer-Cotton classification were performed preoperative FET and 9 on CT scan was mainly grade III (45 cases, patients (12.5%) were not. Tracheal accounting for 62.5%) (chart 3). The lesions were only 77.8%, subglottic and shortest stenosis segment of TS on CT tracheal combined lesions accounted for scan was 5.0 mm and the longest was 9.7%. In fact, many patients couldn’t 32.7 mm. The average length of the perform flexible endoscopy of trachea trachea stenosis segment on CT scan because the dyspnea symptom had been was 15.6 ± 6.6 mm. The length group developing. They were forced to a safe 10 - 20 mm was most common (50.0%). plan quickly as tracheostomy or an This result was lower than other domestic operation to resolve airway obstruction. and foreign studies. The reason for this During 27 years, Grillo (2004) had 503 different finding was that the priorities in patients undergone tracheal resection and selecting patients for our study were to reconstruction for post intubation lesions ensure initially the safety and effectiveness at Massachusetts General Hospital. In of surgery, so that the TS lesions were 441 patients, the lesions were principally not too long. Nguyen Thi My Tham et al. tracheal. Sixty-two had involvement of the subglottic larynx as well as the upper (2010) through CT results noted that the trachea [6]. average length of the glottis, subglottis and trachea were 4.3 ± 1.3 mm, 19.5 ± 9 In this report, the most common TS mm and 18.4 ± 7.8 mm, respectively. The segment was the upper segment (53.9%). narrow section length < 3 cm accounted The most common group was grade III for the majority (89.5%). The authors according the Myer - Cotton classification found a correlation between the intubation by endoscopy (46.1%). When a patient has grade III of TS, it means that patients time and the development of laryngotracheal are in a dangerous condition, at high risk stenosis [1]. Ahn H. Y et al. (2015) in of experiencing all the symptoms of 18 cases of TS due to TO and PEI, the severe TS such as severe dyspnea, total mean length of the stenotic segment was respiratory muscle contraction, even 2.24 cm (range: 1 to 6 cm) and the mean cyanosis of respiratory failure. From our diameter of stenotic lesion was 5.4 mm experience, patients with TS in grade III (range: 2 to 9 mm) [7]. All authors had according to the Myer-Cotton classification noted that accurate assessment of the TS were usually required tracheostomy for length was the most important to make to safety. Negm H. et al (2013) observed TS prognosis of TS as well as the setup of a in 24 cases through FET: Grade II was 6 treatment plan. 214
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