Post Intubation Tracheal Stenosis

28 year-old male. Long term intubation 2 months ago secondary to COVID pneumonia. Presents with shortness of breath, difficulty speaking and stridor for the past 2 weeks • Xray of the Week

Figure 1. What is the diagnosis?

Figure 2. CT scan of the neck and chest demonstrating circumferential hourglass-like narrowing of the trachea (red arrows). Note the normal diameter of the trachea on the axial images proximal (green arrows) and distal (yellow arrows) to the stenosis.

Figure 3. Myer Classification of tracheal stenosis (5).

Discussion:

The most severe complication of COVID-19 has been acute respiratory distress syndrome, which requires oxygen and ventilation therapy for a median of 17 days (1). However, this prolonged intubation also comes with the risk of tracheal stenosis. Post-intubation tracheal stenosis is a rare but serious condition that occurs after long-term intubation. The stenosis occurs when compression from the endotracheal tube (ETT) cuff causes ischemia of the tracheal mucosal tissue, resulting in fibrotic scarring (2). According to Ramalingam et al, tracheal stenosis can also be caused by ETT size relative to the tracheal lumen, ETT material, intubation duration, hemodynamics, tube movement, steroids, and age/sex of the patient (2). It presents as gradual onset dyspnea and dry cough (2). Additional symptoms include shortness of breath, difficulty speaking, and stridor as seen in this patient.

Tracheal stenosis can be diagnosed using bronchoscopy (2) or CT scan (3,4). The degree of stenosis can be described using the classification grades established by Myer et al. (Fig. 3) (5). Chest radiography shows focal luminal narrowing with hourglass stenosis about 3-4 cm below the cricoid cartilage (Fig.2) (4). Acute stenosis presents with edema and granulation tissue with concentric soft tissue thickening while chronic stenosis shows focal expiratory airway collapse on dynamic CT (4). Stenosis can usually be prevented by using low pressure cuffs. Treatment includes surgical intervention, bronchoscopic balloon dilation, or laser coblation (2,4). Endoscopic or radiologic guided metallic stent placement has also been used as a first line treatment in cases of simple stenoses. However, it is usually only used if surgery or dilatation are unsuccessful (5).

References:

1. Mattioli F, Marchioni A, Andreani A, Cappiello G, Fermi M, Presutti L. Post-intubation tracheal stenosis in COVID-19 patients [published online ahead of print, 2020 Oct 3]. Eur Arch Otorhinolaryngol. 2020;1-2. doi:10.1007/s00405-020-06394-w

2. Ramalingam H, Sharma A, Pathak V, Narayanan B, Rathod DK. Delayed Diagnosis of Postintubation Tracheal Stenosis due to the Coronavirus Disease 2019 Pandemic: A Case Report. A A Pract. 2020;14(8):e01269. doi:10.1213/XAA.0000000000001269

3. Webb EM, Elicker BM, Webb WR. Using CT to diagnose nonneoplastic tracheal abnormalities: appearance of the tracheal wall. AJR Am J Roentgenol. 2000;174(5):1315-1321. doi:10.2214/ajr.174.5.1741315

4. Heidinger BH, Occhipinti M, Eisenberg RL, Bankier AA. Imaging of Large Airways Disorders. AJR Am J Roentgenol. 2015;205(1):41-56. doi:10.2214/AJR.14.13857

5. Myer CM 3rd, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes. Ann Otol Rhinol Laryngol. 1994;103(4 Pt 1):319-323. doi:10.1177/000348949410300410

6. Galluccio G, Lucantoni G, Battistoni P, et al. Interventional endoscopy in the management of benign tracheal stenoses: definitive treatment at long-term follow-up. Eur J Cardiothorac Surg. 2009;35(3):429-934. doi:10.1016/j.ejcts.2008.10.041

Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends.

Follow Amara Ahmed on Twitter @Amara_S98

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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