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An Unusual Cause of Dynamic Airway Obstruction
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2017 Ó 2017 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2017.04.030
Visual Diagnosis in Emergency Medicine AN UNUSUAL CAUSE OF DYNAMIC AIRWAY OBSTRUCTION Rajeev Sharma, MD and Abhity Gulia, MD Department of Anesthesiology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India Reprint Address: Rajeev Sharma, MD, Professor, Department of Anesthesiology, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
Flexible bronchoscopy through the endotracheal tube (ETT) revealed a normal tracheal lumen. It was then decided to perform tracheostomy and rigid bronchoscopy under general anaesthesia. Initial rigid bronchoscopy showed normal anatomy. Then it was decided to view the posterior part of the larynx after ETT removal. After tube removal, bronchoscopy under spontaneous respiration showed large, pale, irregular, pedunculated swelling over the bilateral arytenoid and interarytenoid region. This interarytenoid granulation tissue was getting sucked in and causing obstruction to the airway during inspiration. Tracheostomy was performed with 4-mm uncuffed T-tube, and repeat rigid bronchoscopy confirmed the presence of large interarytenoid granulation tissue (see Video Clip 1). The granulation tissue was excised by ear, nose, and throat surgeons and intragranulation triamcinolone was injected. Vitals were stable intraoperatively and at the end of surgery. The patient was transferred to the postoperative ward. A repeat flexible bronchoscopy done under sedation after 2 weeks showed that the granulation tissue did not regrow. The child was successfully decannulated after 2 weeks and remained stable thereafter.
CASE REPORT A 2½-year-old child was brought to our hospital with chief complaints of fast breathing, fever, and chest retraction for 1 week. The respiratory rate was 50 breaths/min with use of accessory muscles of respiration. On auscultation, crepitation was present in bilateral axillary and infraclavicular regions and oxygen saturation (SpO2) was 85% on room air. There was no history suggestive of foreign-body aspiration. Chest x-ray study showed bilateral bronchopneumonia. Mechanical ventilation was provided after tracheal intubation using a 3.5-mm endotracheal tube (ETT). The child gradually improved with antibiotics and ventilation. After 10 days, the child was weaned off the ventilator. After the child was maintaining stable vitals and normal respiration (SpO2 98%) on Tpiece, extubation trial was given. Post extubation, the child developed stridor and tachycardia along with suprasternal, subcostal, and intercostal retraction. There was not much improvement with oxygen by mask. The patient was reintubated after intravenous thiopentone and muscle relaxant. A large growth was seen in the interarytenoid region.
DISCUSSION The airway obstruction presented as respiratory distress after tracheal extubation. In this case, the airway obstruction was dynamic in nature because of closure of the
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 2 March 2017; FINAL SUBMISSION RECEIVED: 15 April 2017; ACCEPTED: 25 April 2017 1
2
R. Sharma and A. Gulia
airway during inspiration by granulation tissue. This could not be visualized initially when the ET tube was in situ; it was visualized after extubation and bronchoscopy. Interarytenoid granulation tissue is a rare complication of tracheal intubation. Factors implicated in the etiology of complications in intubated patients include tube size, characteristics of tube and cuff, skill of the physician performing endotracheal intubation, duration of intubation, metabolic and nutritional status of the patient, tube motion, and laryngeal motor activity (1–6). Based on our literature search, there is no case report that describes dynamic airway obstruction during inspiration due to this granulation tissue. Prolonged tracheal intubation can lead to development of interarytenoid granulation tissue, which can cause dynamic airway obstruction during inspiration and lead to respiratory distress and extubation failures. Tracheal intubation and mechanical ventilation is a common scenario in emergency care settings. We want to emphasize the importance of avoiding prolonged tracheal intubation. This could prevent the development
of granulation tissues in the interarytenoid region. The physician should also be aware of dynamic airway obstruction in which the airway obstruction occurs during inspiration due to interarytenoid granulation tissue. REFERENCES 1. Richard D, Susanto I. Long term complications of artificial airways. Clin Chest Med 2003;24:457–71. 2. Lindholm CE. Prolonged endotracheal intubation. Acta Anaesthesiol Scand Suppl 1969;32:25. 3. Whited RE. A study of endotracheal tube injury to the subglottis. Laryngoscope 1985;95:1216–9. 4. Gaynor EB, Greenberg SB. Untoward sequelae of prolonged intubation. Laryngoscope 1985;12:1461–7. 5. Kastanos N, Estopa MR, Marin PA, et al. Laryngotracheal injury due to endotracheal intubation: incidence evolution and predisposing factors. A prospective long term study. Crit Care Med 1983;11:362–7. 6. Colice GL. Resolution of laryngeal injury following translaryngeal intubation. Am Rev Respir Dis 1992;145:361–4.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2017.04.030.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
http://dx.doi.org/10.1016/j.jemermed.2017.04.030
Visual Diagnosis in Emergency Medicine AN UNUSUAL CAUSE OF DYNAMIC AIRWAY OBSTRUCTION Rajeev Sharma, MD and Abhity Gulia, MD Department of Anesthesiology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India Reprint Address: Rajeev Sharma, MD, Professor, Department of Anesthesiology, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
Flexible bronchoscopy through the endotracheal tube (ETT) revealed a normal tracheal lumen. It was then decided to perform tracheostomy and rigid bronchoscopy under general anaesthesia. Initial rigid bronchoscopy showed normal anatomy. Then it was decided to view the posterior part of the larynx after ETT removal. After tube removal, bronchoscopy under spontaneous respiration showed large, pale, irregular, pedunculated swelling over the bilateral arytenoid and interarytenoid region. This interarytenoid granulation tissue was getting sucked in and causing obstruction to the airway during inspiration. Tracheostomy was performed with 4-mm uncuffed T-tube, and repeat rigid bronchoscopy confirmed the presence of large interarytenoid granulation tissue (see Video Clip 1). The granulation tissue was excised by ear, nose, and throat surgeons and intragranulation triamcinolone was injected. Vitals were stable intraoperatively and at the end of surgery. The patient was transferred to the postoperative ward. A repeat flexible bronchoscopy done under sedation after 2 weeks showed that the granulation tissue did not regrow. The child was successfully decannulated after 2 weeks and remained stable thereafter.
CASE REPORT A 2½-year-old child was brought to our hospital with chief complaints of fast breathing, fever, and chest retraction for 1 week. The respiratory rate was 50 breaths/min with use of accessory muscles of respiration. On auscultation, crepitation was present in bilateral axillary and infraclavicular regions and oxygen saturation (SpO2) was 85% on room air. There was no history suggestive of foreign-body aspiration. Chest x-ray study showed bilateral bronchopneumonia. Mechanical ventilation was provided after tracheal intubation using a 3.5-mm endotracheal tube (ETT). The child gradually improved with antibiotics and ventilation. After 10 days, the child was weaned off the ventilator. After the child was maintaining stable vitals and normal respiration (SpO2 98%) on Tpiece, extubation trial was given. Post extubation, the child developed stridor and tachycardia along with suprasternal, subcostal, and intercostal retraction. There was not much improvement with oxygen by mask. The patient was reintubated after intravenous thiopentone and muscle relaxant. A large growth was seen in the interarytenoid region.
DISCUSSION The airway obstruction presented as respiratory distress after tracheal extubation. In this case, the airway obstruction was dynamic in nature because of closure of the
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.
RECEIVED: 2 March 2017; FINAL SUBMISSION RECEIVED: 15 April 2017; ACCEPTED: 25 April 2017 1
2
R. Sharma and A. Gulia
airway during inspiration by granulation tissue. This could not be visualized initially when the ET tube was in situ; it was visualized after extubation and bronchoscopy. Interarytenoid granulation tissue is a rare complication of tracheal intubation. Factors implicated in the etiology of complications in intubated patients include tube size, characteristics of tube and cuff, skill of the physician performing endotracheal intubation, duration of intubation, metabolic and nutritional status of the patient, tube motion, and laryngeal motor activity (1–6). Based on our literature search, there is no case report that describes dynamic airway obstruction during inspiration due to this granulation tissue. Prolonged tracheal intubation can lead to development of interarytenoid granulation tissue, which can cause dynamic airway obstruction during inspiration and lead to respiratory distress and extubation failures. Tracheal intubation and mechanical ventilation is a common scenario in emergency care settings. We want to emphasize the importance of avoiding prolonged tracheal intubation. This could prevent the development
of granulation tissues in the interarytenoid region. The physician should also be aware of dynamic airway obstruction in which the airway obstruction occurs during inspiration due to interarytenoid granulation tissue. REFERENCES 1. Richard D, Susanto I. Long term complications of artificial airways. Clin Chest Med 2003;24:457–71. 2. Lindholm CE. Prolonged endotracheal intubation. Acta Anaesthesiol Scand Suppl 1969;32:25. 3. Whited RE. A study of endotracheal tube injury to the subglottis. Laryngoscope 1985;95:1216–9. 4. Gaynor EB, Greenberg SB. Untoward sequelae of prolonged intubation. Laryngoscope 1985;12:1461–7. 5. Kastanos N, Estopa MR, Marin PA, et al. Laryngotracheal injury due to endotracheal intubation: incidence evolution and predisposing factors. A prospective long term study. Crit Care Med 1983;11:362–7. 6. Colice GL. Resolution of laryngeal injury following translaryngeal intubation. Am Rev Respir Dis 1992;145:361–4.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jemermed.2017.04.030.
Streaming video: One brief real-time video clip that accompanies this article is available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1.