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A5276 - Endotracheal Intubation for 940 Days Without Tracheal Ulcers, Stenosis or Excavation
Author Block: D. Damania1, M. Nandigam2, Z. Khan3, M. Bachan4; 1ICAHN School of Medicine at Mount Sinai (Bronx), Bronx, NY, United States, 2Internal Medicine, James J Peters VA Medical Center, Bronx, NY, United States, 3St Vincent Catholic Medcal Cntrs, South Richmond Hill, NY, United States, 4ICAHN school of Medicine at Mount Sinai (Bronx)/James J Peters Bronx VA Medical Center, Richmond Hill, NY, United States.
Introduction: Endotracheal (ET) intubation beyond 2 weeks is considered prolonged. Ideally, patients should be extubated as soon as the compelling indications for ventilator support are resolved. Patients requiring longer respiratory support should have tracheostomy early. Early tracheostomy prevents prolong ICU stay, lower the work of breathing, preserve laryngeal functions and prevent laryngeal injuries. Some patients, irrespective of the indications for ET Tube (ETT) placement are at risk for complications such as mechanical airway damage. But, there are some patients who tolerate ETT for prolonged periods. Case: An 89-year-old woman with a history of vascular dementia, cerebrovascular accident with residual hemiplegia and hypertension was electively intubated preoperatively for open reduction and fixation of the right intertrochanteric fracture. Post-operative day 2, she was extubated but required re-intubation within 15 minutes, because of respiratory distress. She continued to fail multiple extubation attempts. There were never more than 24 hours that she remained extubated. ETTs with self- expandable cuffs were used. The medical team discussed tracheostomy with her family on multiple occasions, but they continued to refuse the procedure. Her hospital course was complicated by ventilator associated pneumonia, sepsis, urosepsis, pneumothorax, paroxysmal atrial fibrillation and decubitus ulcers. Despite the complicated course and prolonged intubation, she did not develop tracheal excavation, ulcers or stenosis. Discussion: The longest reported uncomplicated ETT duration is approximately 10 weeks. Our patient remained intubated for 134 weeks without any mechanical laryngeal complication. Most patients who are extubated or undergo tracheostomy tend to develop tracheomalacia but the ones who develop ruptured airway, do so in less than 2 weeks. Currently there is no strong evidence of correlation between laryngotracheal injury and duration of endotracheal intubation; however, prolonged intubation should be avoided because of the risk of complications and mortality. Maybe the type of ETTs (self-expandable cuffs) used were protective to our patient trachea. Conclusions: Tracheostomy tends to offer some advantage over ETT in terms of the need for skilled house staff, however, ETT is viable option when specialized personnel are available to monitor for ETT placement, exchange and care. Currently there are no predictors of the risk of airway excavation or complication for patients undergoing prolonged tracheostomy or ETT. Probably long-term ETT intubation is a viable option in a selected few patients who does not want tracheostomy.