Balloon tracheoplasty for tracheal stenosis after prolonged intubation: a simple procedure, but is it effective?

Abstract

Background Tracheal stenosis following prolonged intubation is a relatively rare but serious problem. This condition is usually managed by surgical or endoscopic interventions. Bronchoscopic balloon dilatation for tracheal stenosis is considered a valuable tool used for the management of tracheal stenosis. In this article, we try to evaluate the role of balloon tracheoplasty in the management of tracheal stenosis and to assess the number of dilatation sessions usually needed as well as the short to midterm outcome. Results This study involved 40 patients with tracheal stenosis diagnosed by computed tomography (neck and chest) and bronchoscopy at the Security Force Hospital in Riyadh, KSA, between January 2013 and August 2018. Patients’ data were retrospectively reviewed and analyzed. Patients’ age ranged between 18 and 60 years. Thirty patients were males (75%); those patients underwent balloon tracheoplasty via dilatation of areas of narrowing using catheter balloon insufflation guided by fiber-optic bronchoscope. Ninety-five percent of the patients had initial success with acceptable dilatation of the stenotic area and improvement of the symptoms. There were no technical or major problems which resulted from the procedure, and no patient complained of severe pain or severe discomfort after the procedure. From the total of 81 BBD sessions, no in-hospital mortality is related to the procedure itself, and ICU stay ranged between 1 and 5 days post-procedure. Among those 40 patients, 16 patients (40%) needed one session, 10 patients (25%) needed two sessions, 8 patients (20%) needed three sessions, and 6 patients (15%) needed more than three sessions of balloon dilatation. Conclusion Balloon tracheoplasty is a simple, safe method and could be a promising and effective approach that offers immediate symptomatic relief for tracheal stenosis in cases with a history of prolonged intubation. It is worth mentioning that BBD is considered as a temporary measure, and most of the cases will need definitive or additional treatment either resection or stent placement.

Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema With Resultant Airway Obstruction Following Endotracheal Intubation

“…One rare but major complication of tracheal intubation and tracheostomy is post-intubation tracheal stenosis, yet the mechanism for intubation-induced tracheal stenosis is not fully understood [3,[16][17][18]. The underlying pathology of tracheal stenosis is thought to be attributed to cartilage ulceration and inflammatory reactions, leading to granulation and fibrous tissue formation, which ultimately causes stenosis [19]. Additionally, ischemia from direct contact with the endotracheal tube or via increased pressure with the cuff of the tube has been considered an underlying cause of this complication [19].…”

“…When the balloon is placed in the right location, it has a rapid expansive force on the stenotic location; this evenly distributes the force over the circumference of the stenosis while simultaneously minimizing the risk of airway rupture. The surgeon also has more flexibility and control of the force of the balloon, making this an advantageous procedure compared to alternative dilatation instruments [19]. In instances where tracheal stenosis is unresponsive to balloon dilation (which is a more conservative treatment option), tracheal resection is performed; resection is reported to have a success rate of 71-95% [20].…”

“…The underlying pathology of tracheal stenosis is thought to be attributed to cartilage ulceration and inflammatory reactions, leading to granulation and fibrous tissue formation, which ultimately causes stenosis [ 19 ]. Additionally, ischemia from direct contact with the endotracheal tube or via increased pressure with the cuff of the tube has been considered an underlying cause of this complication [ 19 ]. Tracheal intubation accounts for 19% of cases of iatrogenic subglottic tracheal stenosis while tracheostomies account for 65% of cases [ 16 ].…”

“…Furthermore, a higher incidence of this complication is found in patients who have keloids, since the abnormal proliferation of connective tissue in response to trauma or injury can lead to tracheal stenosis [ 16 ]. Tracheal stenosis can be repaired operatively, but successful results have also been obtained in a less invasive manner through balloon bronchoplasty [ 3 , 19 ]. Bronchoscopy balloon dilatation using an angioplasty balloon catheter was found to be most successful in children and select cases with adults.…”

A Different Approach to the Treatment of Tracheal Stenosis

“…Tracheal stenosis can occur from several malignant and non-malignant conditions, including vascular ring/aneurysms, tracheomalacia, bronchomalacia, endotracheal tubes (ETT), tracheostomy tubes, mucus plug, burn, trauma, tuberculosis, etc. Prolonged intubation is one of the most common causes, and the mechanism is thought to be due to decreased capillary perfusion pressure from the ETT cuff pressure, leading to ischemia and tissue damage [1,2]. Significant tracheal stenosis typically requires management by bronchoscopy, dilatation, or surgical resection.…”