Urgent Management

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A number of patients will have been treated previously for acute respiratory arrest in a hospital from which they were referred. Others will arrive with high degrees of obstruction in very tenuous status. Respiratory decompensation can occur very soon after admission.

If a hospitalized patient develops nearly complete obstruction of the airway after failure to recognize the severity of the problem, or suddenly deteriorates while under observation, emergency endotracheal intubation may be required. No effort should be made to push a tube through the stenosis. Rather, the endotracheal tube should be placed above the stricture and the airway suctioned. With positive pressure ventilation, it is almost always possible to maintain the patient with a Venturi-like flow through the stenosis. A laryngeal mask airway can be used for a subglottic stenosis where proximal intubation is not possible. The patient should be moved promptly to the operating room, where a rigid bronchoscopy and dilation of the stenosis can be done under general anesthesia without respiratory paralysis.

Very few patients, even those in borderline state, require such urgent intubation. Immediately upon arrival to the hospital, the patient should be placed in a high-level intensive care facility, preferably a respiratory unit, where intubation can be done at a moment's notice and where there is constant attendance by appropriately trained physicians. With gentle physiotherapy, suctioning, adequate humidification, and supplemental oxygen or heliox, and with light medication to control anxiety, the patient usually settles down and is quite comfortable. The time gained may be used for obtaining appropriate diagnostic x-rays and ini-

Subglottic Stenosis Ray

figure 11-21 Roentgenographic delineation of postintubation stenosis. A, Filtered view of entire upper airway, in a 60-year-old man with recurrent upper tracheal stenosis after prior resection of the stomal stenosis elsewhere. Stenosis followed ventilation via tracheostomy for respiratory failure after coronary artery surgery. Easily identifiable are the false vocal cords, glottis (arrow), subglottic larynx, stenosis (arrow), and the length of normal trachea remaining. B, Evolution of a cuff stenosis for ventilation with an endotracheal tube only. On the left is a detail from a chest x-ray showing the endotracheal tube and the distended balloon cuff (arrows). On the right is the stenosis (arrows) in the same tracheal segment, from another plain chest x-ray. C, The stenotic lesion from B shown on a computed tomography scan. The left image shows the beginning of the stenosis whereas the right image shows the middle of the lesion. Note the nearly complete destruction of the cartilage, and the massive scar tissue contracting the lumen to a fraction of normal cross section.

tial clarification of the patient's medical condition. An elective corrective surgical procedure may be planned and performed under ideal circumstances. This will minimize errors in appraisal of the lesion and of the larynx. If the patient's condition fails to improve or deteriorates, the surgical team should move promptly to bronchoscopic evaluation and dilation under general anesthesia.

A technique for safe emergency tracheal dilation is detailed in Chapter 19, "Urgent Treatment of Tracheal Obstruction." Dilation is also a method of temporizing while a patient is further evaluated and

figure 11-21 (continued) D, Tomograms outlining areas of stomal stenosis and anastomosis pre- and postoperatively (left and right images, respectively). Note the irregularity of the right side of the subglottic larynx preoperatively. There is slight narrowing at the anastomosis. E, Computed tomography scans comparing a nearly normal trachea at left image with side-to-side narrowing of a stomal stenosis on the right image. Indentation of the cutaneous scar is seen. At bronchoscopy and operation, the anterior cricoid cartilage proved to be completely eroded, and thus required laryngotracheal resection and reconstruction. Imaging and endoscopy are both essential before an operation.

medical or other surgical problems are corrected. Dilation may be ineffective in a patient with stomal stenosis, but such patients usually do not obstruct so totally. In circumferential cuff stenosis, dilation is essentially always only transiently effective. In most patients, dilation is effective for days to weeks or longer. Tra-

cheostomy is best avoided if it appears possible to move ahead soon to a definitive surgical treatment. A fresh tracheostomy usually delays surgical repair and, worse, may damage normal trachea necessary for reconstruction, if the tracheostomy is mistakenly placed other than through the lesion itself. Dilation, performed carefully by an experienced endoscopist, is also a procedure that may be used in an institution where there is little experience in tracheal reconstruction. A patient may then be transferred safely to a center where such work is done regularly, without the delaying or potentially damaging effect of tracheostomy. Transfer should be expeditious since the duration of relief from dilation is unpredictable. A small endotra-cheal tube may be inserted through the dilated lesion, if necessary, for transportation. Dilation through an existing stoma is described in Chapter 19, "Urgent Treatment of Tracheal Obstruction."

There is little practical use for lasers in these situations. Some improvement may be obtained by lasering away small amounts of granulation tissue or scar, but this should be no more than is usually obtained by dilation with, sometimes, use of bronchoscopic biopsy forceps. Radial lasering and dilation seem to have little benefit greater than dilation alone. It must be recalled that the pathology of a tracheal stenosis most often involves hourglass or side-to-side narrowing of the trachea, so that aggressive destruction of tracheal wall can result in perforation.

If for any reason surgical treatment is not elected, or if the patient is nontransportable, a tracheostomy may be necessary for longer-term management, even if not as the definitive treatment. Bronchoscopic dilation is done first under general anesthesia. The rigid ventilating bronchoscope used for dilation should remain in place for ventilation and as a guide for tracheostomy. If there was a prior tracheostomy, it is often advisable to reinstitute the tracheostomy at precisely the same point where the previous opening was made, especially if it lies in the stenotic segment (Figure 11-22A). If the stricture is stomal, no additional trachea will be damaged by a second tracheostomy. A cuff stenosis that lies in the cervical trachea is the best site for a necessary tracheostomy (Figure 11-225). If the lesion is a cuff stenosis and lies at or below the sternal notch, then the least damage will be done, with few exceptions, if the old tracheostomy site is carefully reopened (Figure 11-22C). The procedure is minimal since the scar leads directly to the trachea. A transverse incision about 1 cm in length in the prior tracheostomy scar will usually suffice. The tracheostomy tube must be passed through the stenosis, confirmed by flexible bronchoscopy through the tracheostomy tube. Otherwise, a false sense of security will be obtained while the stenosis may close down below the tip of the tracheostomy tube. If a prior surgeon had recently placed a new tracheostomy inferior to an obstructing stenosis, which threatens to increase the extent of tracheal damage, then this length of potentially useful trachea may be recaptured, by replacing a tracheostomy through the stenotic segment and permitting the new, inferior stoma to heal (Figure 11-22D). If operation must be delayed a T tube provides a patient with a more normal airway and with voice. Dilation of a tracheal stenosis, reinstitution of a tracheostomy at an appropriate level, and reinsertion of a tube of proper length or a T tube is also a method of permanent management of a tracheal stenosis where repair is contraindicated. If early reconstruction is envisaged, peroral dilation is the method of choice. Rarely would a silicone stent be considered as a bridge to later resection, and never should an expandable stent be considered at all.

Postintubation tracheoesophageal fistula and tracheo-innominate fistula are discussed in Chapter 12, "Acquired Tracheoesophageal and Bronchoesophageal Fistula," and Chapter 13, "Tracheal Fistula to Brachiocephalic Artery."

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