POSTINTUBATION TRACHEAL STENOSISPOSTINTUBATION TRACHEAL STENOSIS

Ulku YAZICI M.D.Ulku YAZICI M.D.

Atatürk Chest Disease and Thoracic Surgery Training and Research Hospital

   Son üç yıl içinde, sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşundan aşağıdakileri kabul ettiniz mi?Son üç yıl içinde, sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşundan aşağıdakileri kabul ettiniz mi?

Bir kongre, sempozyum, kurs, panel vb bilimsel programa katılmak için maddi destek aldınız mı? Bir kongre, sempozyum, kurs, panel vb bilimsel programa katılmak için maddi destek aldınız mı?

X Hayır X Hayır Evet - Kuruluş Adı / Adları: Evet - Kuruluş Adı / Adları:

Konuşmacı / Oturum Başkanlığı ücreti (Honoraryum) aldınız mı?Konuşmacı / Oturum Başkanlığı ücreti (Honoraryum) aldınız mı?

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Yöneticisi, oturum başkanı, düzenleyicisi olduğunuz eğitim toplantısı vb bir organizasyon için sponsorluk aldınız mı?Yöneticisi, oturum başkanı, düzenleyicisi olduğunuz eğitim toplantısı vb bir organizasyon için sponsorluk aldınız mı?

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Araştırmalarınız için fon kullandınız mı?Araştırmalarınız için fon kullandınız mı?

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Sizinle birlikte (aynı projede) çalışan personelden birisi, herhangi bir fon kullandı mı?Sizinle birlikte (aynı projede) çalışan personelden birisi, herhangi bir fon kullandı mı?

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Danışma ücreti aldınız mı?Danışma ücreti aldınız mı?

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Son üç yıl içinde sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşunun çalışanı oldunuz mu?Son üç yıl içinde sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşunun çalışanı oldunuz mu?

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Sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşuna ait herhangi bir hisse senediniz ya da hisseniz var mı?Sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşuna ait herhangi bir hisse senediniz ya da hisseniz var mı?

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Sunumunuz veya makalenizle ilgili, sağlık endüstrisinin taraf olduğu bir konuda uzman tanık / bilirkişi olarak hareket ettiniz mi?Sunumunuz veya makalenizle ilgili, sağlık endüstrisinin taraf olduğu bir konuda uzman tanık / bilirkişi olarak hareket ettiniz mi?

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Sunumunuzun / makalenizin içeriğiyle ilgili olarak bunların dışında çatışan başka herhangi bir mali çıkarınız var mı? Sunumunuzun / makalenizin içeriğiyle ilgili olarak bunların dışında çatışan başka herhangi bir mali çıkarınız var mı? Varsa lütfen belirtiniz. Varsa lütfen belirtiniz.

XHayır XHayır Evet - Açıklayınız: Kuruluş Adı / Adları: Evet - Açıklayınız: Kuruluş Adı / Adları:

Bir tütün endüstrisi kuruluşunun çalışanı oldunuz mu? Ya da böyle bir kuruluşunun taraf olduğu bir konuda uzman tanık veya bilirkişi oldunuz mu? Ya da böyle bir kuruluşa Bir tütün endüstrisi kuruluşunun çalışanı oldunuz mu? Ya da böyle bir kuruluşunun taraf olduğu bir konuda uzman tanık veya bilirkişi oldunuz mu? Ya da böyle bir kuruluşa ait hisseniz/hisse senediniz var mı? ait hisseniz/hisse senediniz var mı?

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HistoryHistory Dr.HC GrilloDr.HC Grillo Dr.PerelmanDr.Perelman Dr.PearsonDr.Pearson Dr.MathisenDr.Mathisen Dr.CooperDr.Cooper Dr.Erdoğan YalavDr.Erdoğan Yalav Dr.İlker ÖktenDr.İlker Ökten Dr.Güven ÇetinDr.Güven Çetin

40 cadaver40 cadaver Mean tracheal length11.8 cmMean tracheal length11.8 cm Resectable segment length 6.4 cmResectable segment length 6.4 cm

HC Grillo J Thorac Cardiovasc Surg 1964HC Grillo J Thorac Cardiovasc Surg 1964

Anatomical featuresAnatomical features

10-13 cm20-22 cartilage rings

lig. Anularesmooth muscle mucosa

Anatomical featuresAnatomical features Inferior thyroid, bronchial arteries…Inferior thyroid, bronchial arteries… Bilateral lateral vascular pedicleBilateral lateral vascular pedicle Submukozal capillary Submukozal capillary Rekürrent nervesRekürrent nerves

EtiologyEtiology

Intensive care unit Intensive care unit Mechanical ventilatorsMechanical ventilators Prolonged intubationsProlonged intubations High pressure intubation tubesHigh pressure intubation tubes TracheostomyTracheostomy

PathophysiologyPathophysiologyPressure ischemiaPressure ischemia

Edema-ulcerationEdema-ulceration

Seconder infectionSeconder infection

Perichondritis-chondritis-cartilage necrosisPerichondritis-chondritis-cartilage necrosis

Granulation tissue proliferationGranulation tissue proliferation

FibrosisFibrosis

Low blood pressureLow blood pressure DiabetesDiabetes Cardiovascular diseasesCardiovascular diseases Steroid Steroid drugsdrugs RefluxReflux AnemiaAnemia NeutropeniaNeutropenia Female sexFemale sexPatient sensitivity to chemicals and instruments Patient sensitivity to chemicals and instruments during intubationduring intubation

Risk Factors for Stenosis

Cuff pressure plays a major role in the development of tracheal stenosis Extent of cuff inflation, low pressure cuffs, double cuff intubation tubes

Cuff and Lateral Tracheal Wall PressuresCuff and Lateral Tracheal Wall Pressures

•Laryngotracheal •Stoma level •Cuff level•Cannula level

Localization

Tracheal lesionsTracheal lesions

Granulation tissue and granuloma Granulation tissue and granuloma WebsWebs ““Bottleneck” kind lesionsBottleneck” kind lesions Complex stenosisComplex stenosis

Dilatation techniques are successful for Dilatation techniques are successful for diaphragma and web like lesions. (1-3 seance, diaphragma and web like lesions. (1-3 seance, 60% success) 60% success)

Mehta AC, Lee FY, Cordasco EM ve ark. ConcentricMehta AC, Lee FY, Cordasco EM ve ark. Concentric tr tracheal and subglottic acheal and subglottic stenosis. Managementstenosis. Management using the Nd-YAG laser for mucosalusing the Nd-YAG laser for mucosal sparing followed by sparing followed by gentle dilatation. Chestgentle dilatation. Chest1993; 104: 673-6771993; 104: 673-677

IncidenceIncidence

PITS incidence in chronic intubation cases PITS incidence in chronic intubation cases

calculated as 0.1-20% * calculated as 0.1-20% * Female predominance in two large Female predominance in two large

series** series**

*Papla B, Post-Intubation Tracheal Stenosis - Morphological-Clinical Investigations. Pol J Pathol 2003**McCaffrey TV: Classification of laryngotracheal stenosis. The Laryngoscope 1992; 102:1335-1340. Mehta AC. Concentric tracheal and subglottic stenosis. Chest 1993

Clinical PresentationClinical Presentation WheezingWheezing StridorStridor CoughCough ProgressiProgressiveve d dyspneayspnea

Effort Effort Lumen caliber decreases to 5-6 mm Lumen caliber decreases to 5-6 mm

Secretion retantionSecretion retantion PnPneueumonimoniaa

DiagnosisDiagnosis

X-raysX-rays CCTT,, 3D bronchoscopy3D bronchoscopy BronchoscopyBronchoscopy

BronchoscopyBronchoscopy

Usually mechanical dilatation is required Usually mechanical dilatation is required before surgery. before surgery.

Preoperative rigid brochoscopyPreoperative rigid brochoscopy First 71%First 71% Second 53%Second 53% Third 26%Third 26%

Bonette P. Resection anastomose tracheale pour stenose iatrogene. Une experience de 340 cas. Rev Mal Respir 1998Bonette P. Resection anastomose tracheale pour stenose iatrogene. Une experience de 340 cas. Rev Mal Respir 1998

Rigid BronchoscopyRigid Bronchoscopy

Level and length of stenosis Dilatation Endobronchial treatmentTreatment plan

ResectionConservative management

TreatmentTreatment

BronBronchchososccopiopicc dilata dilatationtion SurgicalSurgical re resseectction ion andand re recconstronstructuctionion Nd:yag laserNd:yag laser…… Stent Stent

Bronchoscopic dilatationBronchoscopic dilatation

Saving time for surgerySaving time for surgery Evaluation of length of stenotic Evaluation of length of stenotic

segmentsegment

Nd-YAG laserNd-YAG laser

Nd-YAG laser, electrocautery or stents are alternative Nd-YAG laser, electrocautery or stents are alternative methods for patients whom unsuitable to surgery.methods for patients whom unsuitable to surgery.

During Nd-YAG laser application avoid infiltration to During Nd-YAG laser application avoid infiltration to the bronchial wall. Cartilage damage, stenosis after the bronchial wall. Cartilage damage, stenosis after fibrosis fibrosis

MMarel M, Pekarek Z, Spasova I ve ark. Managementarel M, Pekarek Z, Spasova I ve ark. Management of benign stenoses of the largeof benign stenoses of the large airways in the airways in the uuniversityhospital inniversityhospital in Prague,Prague,

Czech Republic, in 1998-2003. RespirationCzech Republic, in 1998-2003. Respiration 2005; 72: 622-8 2005; 72: 622-8

..

İncisionİncision

•503 cases (Grillo et al) 503 cases (Grillo et al) 350 Collar incision350 Collar incision145 Partial sternotomy145 Partial sternotomy6 Posterolateral thoracotomy6 Posterolateral thoracotomy2 Collar+partial sternotomy+ant. thoracotomy2 Collar+partial sternotomy+ant. thoracotomy

Grillo HC, Donahue DM. Postentubation tracheal stenosisChest Surg Clin N Am. 1996;6:725-31

Tracheostomy+StenosisTracheostomy+Stenosis

Tracheal releasingTracheal releasing

Flexion of neckFlexion of neck Anterior cervical approachAnterior cervical approach Laryngeal releasing(proximal lesion)Laryngeal releasing(proximal lesion)

Infrahyoideal Infrahyoideal (thyrohyoid muscle,membrane)(thyrohyoid muscle,membrane)

Suprahyoideal(Suprahyoideal(stylohyoid,mylohyoid,genohyoid,genioglossus)stylohyoid,mylohyoid,genohyoid,genioglossus)

Hilar releasing(distal lesion)Hilar releasing(distal lesion) Pulmonary ligamant releasing Pulmonary ligamant releasing Pericardial dissection Pericardial dissection Reanastomosis of left main bronchusReanastomosis of left main bronchus

Surgical techniqueSurgical technique

Supine positionSupine positionCollar incisionCollar incision

Stenotic trachea Stenotic trachea Anterior dissectionAnterior dissection

Upper and lower edges of stenotic segmentUpper and lower edges of stenotic segment

Esophagus (nasogastric)Esophagus (nasogastric)rekurrent nerves rekurrent nerves stenotic segment resection stenotic segment resection

cervical flexioncervical flexionabsorbable (3-0,4-0) suture absorbable (3-0,4-0) suture

Restriction of cervical extantion Restriction of cervical extantion Early extubationEarly extubation

Subglottic stenosisSubglottic stenosis

Subglottic stenosis are at the level of cricoidal cartilage and circumferential

Postoperative complicationsPostoperative complications

InfectionInfection Dehiscence of sutur (%3.6-7.5)Dehiscence of sutur (%3.6-7.5) Major hemorrhage (%1-2.5)Major hemorrhage (%1-2.5) Aspiration pneumoniaAspiration pneumonia Recurrent laryngeal nerve paralyzis(%0-5)Recurrent laryngeal nerve paralyzis(%0-5) Restenosis (%5.4-15)Restenosis (%5.4-15)

Tension of anastomosis Tension of anastomosis devascularizationdevascularization

RestenosisRestenosis

1-2 weeks after surgery1-2 weeks after surgery Conservative treatment is initial stepConservative treatment is initial step Await untill inflammation disappears (4-6 Await untill inflammation disappears (4-6

months) months) Half of the cases recover with dilatationsHalf of the cases recover with dilatations

ReoperationReoperation ””T” tubeT” tube StentStent tracheostomytracheostomy

901 cases901 cases 81 cases had anastomotic problem (9%)81 cases had anastomotic problem (9%)

Long segment resectionLong segment resection Tracheostomy before surgery Tracheostomy before surgery Pediatric patientPediatric patient ReoperationReoperation Diabetes Mellitus Risk factors for anastomotic problems.Diabetes Mellitus Risk factors for anastomotic problems.

D. Wright, Hermes C. Grillo, et al.D. Wright, Hermes C. Grillo, et al. Anastomotic complications after tracheal resection: Anastomotic complications after tracheal resection:Prognostic factors and ManagementPrognostic factors and Management

J Thorac Cardiovasc Surg 2004;128:731-9J Thorac Cardiovasc Surg 2004;128:731-9

MortalityMortality

2.5 -5% 2.5 -5% Grillo et al. has lowest mortality rates 1.8%Grillo et al. has lowest mortality rates 1.8%

*Brichet A, Multidisciplinary approach to management of postintubation tracheal stenoses. Eur Respir J 1999 **Grillo HC: Surgical management of tracheal strictures. Volume 68. Edited by: Farrell EM, keon WJ. Philadelphia: WB Saunders; 1988:511-524.

Prevention from tracheal Prevention from tracheal stenosisstenosis

Stoma levelStoma level Minimal stoma diameterMinimal stoma diameter Suitable tube length and angleSuitable tube length and angle Vertical incision preferableVertical incision preferable Aseptic field during surgeryAseptic field during surgery

Cuff levelCuff level Extent of cuff inflation, low pressure cuffsExtent of cuff inflation, low pressure cuffs Suitable cuff follow-upSuitable cuff follow-up

ConclusionsConclusions Rigid bronchoscopy: evaluation, dilatationRigid bronchoscopy: evaluation, dilatation Collar incision is sufficient in most of casesCollar incision is sufficient in most of cases Corporation between surgeon and anesthetistCorporation between surgeon and anesthetist Apneic periods, jet ventilation and sterile intubationApneic periods, jet ventilation and sterile intubation Preventing tracheal blood flowPreventing tracheal blood flow Preventing Esophagus and Recurrent nervesPreventing Esophagus and Recurrent nerves Absorbable sutures Absorbable sutures Bronchoscopic anastomosis controlBronchoscopic anastomosis control Early extubationEarly extubation 24 hr intensive care unit24 hr intensive care unit Neck flexion during 1 weekNeck flexion during 1 week

ATATURK CHEST DISEASE AND THORACIC SURGERY ATATURK CHEST DISEASE AND THORACIC SURGERY TRAINING AND RESEARCH HOSPITALTRAINING AND RESEARCH HOSPITAL

Tracheal stenosis, 38 cases (2003-2010Tracheal stenosis, 38 cases (2003-2010))

55 year-old, Female55 year-old, Female 13 days mechanical ventilation13 days mechanical ventilation3 cm distal stenosis from vocal cords3 cm distal stenosis from vocal cordsMechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis

50 year-old, Female50 year-old, Female 4 days mechanical ventilation4 days mechanical ventilation 2 cm distal stenosis from vocal cords2 cm distal stenosis from vocal cords Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis

40 year-old, Male40 year-old, Male

5 days mechanical ventilation5 days mechanical ventilation 2 cm distal stenosis from vocal cords2 cm distal stenosis from vocal cords Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis

37 year-old, Female37 year-old, Female

25 25 days mechanical ventilationdays mechanical ventilation 3 cm distal stenosis from vocal cords (3 cm length)3 cm distal stenosis from vocal cords (3 cm length) Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis

55 year-old, Male55 year-old, Male 3 3 days mechanical ventilationdays mechanical ventilation 2.5cm distal stenosis from vocal cords (2.5 cm length)2.5cm distal stenosis from vocal cords (2.5 cm length) Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis

54 year-old, Male54 year-old, Male 39 39 days mechanical ventilationdays mechanical ventilation 4cm distal stenosis from vocal cords (1 cm length)4cm distal stenosis from vocal cords (1 cm length) Resection and end-to-end anastomosisResection and end-to-end anastomosis

75 year-old, Female75 year-old, Female

12 12 days mechanical ventilationdays mechanical ventilation 3 cm distal stenosis from vocal cords3 cm distal stenosis from vocal cords Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis On post-op 15th day, cardiopulmonary arrest and exitusOn post-op 15th day, cardiopulmonary arrest and exitus

15 year-old, Male15 year-old, Male 15 15 days mechanical ventilationdays mechanical ventilation 11cm distal stenosis from vocal cords (3 cm length)cm distal stenosis from vocal cords (3 cm length) Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis

17 year-old, Female17 year-old, Female

25 25 days mechanical ventilationdays mechanical ventilation 2 2 cm distal stenosis from vocal cords (3 cm length)cm distal stenosis from vocal cords (3 cm length) Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis

19 year-old, Female19 year-old, Female 2 2 months mechanical ventilationmonths mechanical ventilation 3-4 cm stenosis beyond distal tracheal stoma3-4 cm stenosis beyond distal tracheal stoma Mechanical dilatation Mechanical dilatation Resection and end-to-end anastomosisResection and end-to-end anastomosis Dilatation of the suture line was performed after 1 month Dilatation of the suture line was performed after 1 month ReoperationReoperation

20 year-old, Male 20 year-old, Male 3 days mechanical ventilation 2 2 cm distal stenosis from vocal cm distal stenosis from vocal cords cords DilatationDilatationEnd-to-end anastomosisEnd-to-end anastomosis