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General Thoracic Surgery > Tracheal Stenosis and Postintubation Injury > Flashcards

Tracheal Stenosis and Postintubation Injury Flashcards

1
Q

Only complete tracheal ring

A

Cricoid cartilage

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2
Q

Categories of tracheal stenosis and post-tububation injury

A
  • Congenital tracheal stenosis
  • Infectious lesions
  • Extrinsic tracheal compression
  • COPD
  • Postintubation injuries
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3
Q

Morphologies of congential tracheal stenosis

A
  • web-like diaphragm at subcricoid level (MC)
  • generalized tracheal hypoplasia
  • funnel-shaped narrowing
  • segmental stenosis
    • due to complete circular rings associated with other bronchial anomalies (RUL bronchus origin above stenosed segment)
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4
Q

Infectious etiologies that can cause tracheal stenoiss

A
  • TB
    • lengthy circumferential submucosal fibrosis and narrowing of distal trachea
  • Histoplasmosis:
    • mediastinal fibrosis with enlarged LN (compression, invasion, or erosion of RMS bronchus or carina)
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5
Q

Causes of external compression resulting in secondary tracheal stenosis

A
  • Large goiters
  • Vascular rings
  • Innominate artery aneurysms
  • Anomalous SC artery
  • Mediastinal masses
  • Postpneumonectomy syndrome (right sided)
    • medistinal shift wih obstruction at carina or proximal LMB
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6
Q

TOC for inflammatory strictures (i.e. strictures due to infectious etiology)

A

Repeated tracheal dilation

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7
Q

Define “saber sheath” trachea

A
  • Side-to-side diameter of the trachea diminishes progressively and anterior-posterior diamter increases
    • Posterior aspect of cartilages approximate with coughing, causing obstruction and inability to clear secretions

Associated with COPD

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8
Q

Define tracheomalacia

A
  • Tracheal rings take on shape of archer’s bow:
    • Posterior membranous trachea enlongates, becomes redundant, and approaches the anterior flattened cartilage, causing near total obstruction.
  • Associated with COPD
  • Tx: tracheoplasty with Marlex mesh
    • restores rigidity to the tracheal cartilage and plicates the redundant posterior membrane
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9
Q

Surgical treatment of tracheomalacia

A

Tracheoplasty with Marlex mesh

  • Reinforce rigidity of cartiage
  • Plicate redundant posterior membrane
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10
Q

Types of postintubation injury

A
  • Granuloma
  • Stricture
  • Cuff stenosis
  • Tracheomalacia
  • Trachoinnominate fistula
  • Tracheoesophageal fistula
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11
Q

Cause of tracheal granuloma

A
  • Proliferative and cicatricial response to tracheal injury.
  • Tracheostomy stoma made too large:
    • turning a large flap or excising a large tracheal window
    • excessive leverage placed on trachostomy tube
    • infection or stoma erosion
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12
Q

Definiton of tracheal granuloma

A

A-shaped stricture due to the approximation of anterior and lateral tissue defects after tracheostomy

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13
Q

Definition of cuff stenosis

A

Tight circumferential stenosis developing 3-6 weeks after endotracheal tube removal.

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14
Q

Describe development of cuff stenosis

A
  • Pressure necrosis by cuff
  • Transmural erosion of all layers of trachea
  • Destroys mucosa, blood supply to area
  • Cartilage necrosis
  • Cicatricial healing with stenosis
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15
Q

Tracheomalacia after intubatation occurs in what segment of the trachea

A

Tracheal segment between the tracheostomy stoma and the cuff

(mucosa reveals squamous metaplasia, cartilage is thinned)

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16
Q

Signs and symptoms of trachel stenosis/malacia

A
  • Dyspnea on exertion
  • Stridor
  • Cough
  • Obstructive episodes
17
Q

Abnormal voice or strider is indictive of

A

glottic or subglottic stenosis

18
Q

Cause of tracheoinnominate fistula

A
  • Angulation of tube tip or erosion of a high-pressure cuff directly through trachea
  • Low placed tracheostomy (in immiediate proximity with innominate artery)
19
Q

Presentation of tracheoinnominate fistula

A
  • Premonitory bleed (must be distinguished from granulation bleeding or irritaiton)
  • Bronchoscopy with temporary removal of tracheostomy tube to confirm diagnosis
20
Q

Managment of tracheoinnominate fistula

A
  • Control of exsanguination:
    • Overinflation of tracheostomy cuff
    • Digital pressure against sternum through tracheostomy site
    • Oral re-intubation
    • Proximal debridement of artery (to healthy tissue) with vessel ligation
21
Q

MCC of tracheoesophagel fistula after intubation

A

Ventilating cuff in trachea with feeding tube in esophagus

  • Two foreign bodies compress common wall, leading to inflammation and perforation
  • Often a circumferential cuff injury
22
Q

Presentation of tracheoesophageal fistula after intubation

A

Increased tracheal secretions

Gastric distention (if positive pressure ventilation)

23
Q

Managment of tracheoesophageal fistula after intubation

A
  • Placement of new, longer tracheostomy tube with balloon below fistula
  • Placement of draining g-tube and feeding j-tube
  • Staged repair after patient weaned from mechanical ventilation
    • Tracheal resection, closure of esophagus, interposed muscle flap
24
Q

Diagnostic studies for tracheomalacia

A

Inspiratory/expiratory CT scans

Virtual bronchoscopy with 3D reconstructions

25
Q

Temporizing measures used in managment of tracheal stenosis or airway obstruction include:

A

Sterioids

Racemic epinepherine

(minimize airway inflammation, edema, bronchospasm)

26
Q

Method to accurately assess tracheal lesion

A

Intraoperative rigid bronchoscopy with serial dilation

27
Q

Reason to avoid tracheal stents for stenosis

A

May cause severe granulations and worsen stenosis

28
Q

Preferred treatment for benign tracheal obstruction

A

Tracheal resection and reconstruction

29
Q

Reasons to delay definitive surgery for tracheal stenosis

A
  • Acute airway inflammation
  • PNA
  • High dose steroids (> 10 mg prednisone / day)
30
Q

Important sugical principles during tracheal resection and reconstruction

A
  • Accurate preoperative assessmetn of location and length of stenosis
  • Preservation of lateral blood supply
  • Avoidance of RLN injury
31
Q

Surgical approach for tracheal resection and reconstruction

A
  • Low collar incision
  • Intraoperative bronchoscopy can identify strictured segment
  • Anterior dissection is peformed to ID strictured segmetn and preserve blood supply
  • Circumferential dissection limite to 1-1.5 cm length at the stricture
  • Traction sutures placed in distal trachea
  • Tracheal transection and then intubation
  • Cervical flexion to assess tension
  • Proximal trachea lifted and separated from esophagus then resected
  • End-to-end, tension-free anatomosis
  • Strap muscles placed over suture line to buttress

General Thoracic Surgery (36 decks)

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