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A5339 - A Case of Delayed Diagnosis: Late Onset Tracheal Stenosis After Multiple Short Term Intubations
Author Block: X. Gao1, M. Bachan1, Z. Khan1, R. E. Siegel2; 1James J. Peters VA Medical Center, Bronx, NY, United States, 2Bronx VA Medical Ctr, Bronx, NY, United States.
Introduction: Tracheal stenosis is a common complication in patients undergoing endotracheal intubation and can cause life threatening complications. However its presentations may be atypical and lead to delay in diagnosis. We present a case of late onset tracheal stenosis which was initially misdiagnosed as anxiety. Case Description: A 44-year-old man was admitted to Medical Intensive Care Unit (MICU) for 2 weeks’ history of intermittent dyspnea. His history was significant for motor vehicle accident (MVA) which was complicated with thoracic spine fracture, paraplegia and multiple rib fracture with pneumothorax. He was intubated 5 times over a month while he was comatose. The intubations last from 2 to 6 days. He was successfully extubated one month after MVA and had no respiratory issues until his admission to MICU. He complained of generalized chest tightness and shortness of breath. A trial of bronchodilator failed to relieve symptoms. On examination patient was very anxious but speaking in full sentences, oxygen saturation was well maintained above 98% on room air and lungs were clear without any wheezing. His chest x ray was grossly normal. A bedside flexible fiberoptic laryngoscopy was performed for suspicion of possible airway stenosis, but it was reported as normal. Therefore his symptoms were considered more due to anxiety also since he responded to Lorazepam. However, during the next few days his symptoms worsened and a biphasic respiratory stridor developed. A CT of chest and neck showed possible tracheal stenosis. An urgent rigid bronchoscopy was performed and showed excessive granulation tissue in trachea leading to profound narrowing. He underwent emergent tracheostomy with tracheal tube placement. Symptoms were significantly relieved afterwards, and oral steroid was started to suppress granulation tissue formation.
Discussion: In spite of improvement in the design of tracheal tubes, almost all patient undergoing translarygneal intubation develop airway stenosis, and severe stenosis (>50%) still occurs in approximate 19% patients. However, symptoms usually are not prominent especially at rest until the narrowing is more than 70% and can be very atypical, such as in our patient. It is crucial to maintain a high suspicion for tracheal stenosis in any patients with a history of intubation and exertional dyspnea, particularly not improving with bronchodilators, as immediate evaluation is needed.