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The advent of intensive care unit management has increased the potential opportunities for post intubation and post tracheostomy airway complications. Since the 1960s, research on the causes and prevention of these airway problems has diminished but not eliminated the problems.
The most common problems associated with long-term intubation include laryngeal dysfunction and tracheal stenosis. Many variations are seen: stenosis at the site of tracheostomy, narrowing caused by granulation tissue, and tracheomalacia or stenosis at the level of the cuff. Proper attention to placement of the tracheostomy appliance and prevention of cuff overinflation are essential to prevent iatrogenic cervical tracheal stenosis. Human and animal studies have demonstrated that overinflation of the endotracheal tube can create circumferential full-thickness ischemic necrosis of the tracheal wall in a very short time. The subsequent healing of the ulcerated surface results in a circumferential stenosis. Improper placement or leverage of the tracheostomy appliance may result in partial erosion of a portion of the tracheal wall. This partial wall collapse and subsequent healing after the appliance is removed results in a triangular-shaped lesion. As these lesions are full thickness, and often circumferential, effective long-term treatment is accomplished by resection of the affected segment, or placement of an appliance to stent open the obstruction in nonsurgical candidates. In this article, we discuss the unique challenges of correcting cervical tracheal stenosis that do not directly affect the immediate subglottic region.
A significant narrowing of the airway must exist before the development of dyspnea or stridor in patients with cervical tracheal stenosis. Once the patient becomes symptomatic, it is essential to ensure a stable and patent airway. This may be accomplished by intraoperative assessment and dilation of a focal stenosis by rigid bronchoscopy, or by replacement of the tracheostomy appliance while planning for a definitive procedure. Emergent operation of the trachea is to be avoided, as preoperative assessment and planning is essential to long-term success.
Computed tomographic imaging is useful in defining the extent of the lesion and to rule out extrinsic compression from a goiter or other mass. Bronchoscopy remains the procedure of choice for preoperative evaluation. Vocal cord dysfunction should be assessed because repair of a tracheal stenosis is doomed to failure if upper airway motor dysfunction is not addressed. The precise location and length of the stenosis may be defined by bronchoscopy, as well as the degree of inflammation at the site of proposed repair.
Reasons to defer operative management in favor of placing an airway appliance are extensive comorbidities that preclude the safe conduct of general anesthetic, overall deconditioning of the patient such as those who will remain dependent on the ventilator or those who are unable to participate in rehabilitation, and patients on high doses of steroids. In these patients, airway obstruction may be relieved by bronchoscopy and dilation, or replacement of the stoma appliance or a t-tube.
A number of investigators for different countries have reported excellent results with resection of the cervical trachea for iatrogenic stenosis.
Ninety-five percent of patients achieved a good response to treatment, without need for an airway appliance. The authors achieved a 1% mortality rate with a 9% rate of anastomotic complications. Complications occurred in the form of stenosis, separation of the suture line, or excessive granulation tissue at the site of anastomosis. Anastomotic complications were more likely in patients undergoing extended length resection (>4 cm), reoperation, preoperative dependence on tracheostomy, pediatric patients, and diabetic patients. Of the patients with anastomotic complications, most patients were treated by placement of an airway appliance.