Department of Cardiothoracic Surgery, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK
*Corresponding author. E-mail: adassa.savizon@stgeorges.nhs.uk
Accepted for publication: October 6, 2003
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Abstract |
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Br J Anaesth 2004; 92: 4379
Keywords: equipment, tracheal stent; complications, tracheal tear; surgery, percutaneous tracheostomy
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Introduction |
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Case report |
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Following a brief period of stabilization after transfer, and approximately 12 h after the tracheostomy, the patient was taken to the operating theatre where he was placed on a trolley in the supine position with a sandbag beneath the shoulders and the neck extended. Anaesthesia was maintained with a propofol infusion and bolus doses of alfentanil. Neuromuscular block was achieved with boluses of atracurium. The tracheostomy tube was removed and a rigid bronchoscope introduced. Ventilation was established using a Sanders jet ventilator. A fibreoptic bronchoscope was then introduced through the lumen of the rigid instrument and a 3.5 cm long tear of the middle third of the membraneous trachea was identified, extending to 2.5 cm above the carina. There was haemorrhage throughout the endobronchial tree.
An 8 cm (6.5 cm covered portion) expandable metallic stent (Fig. 1) was inserted under direct vision. This fully sealed the defect and did not obstruct either main bronchus. A 7 mm inside diameter armoured translaryngeal tracheal tube was introduced through the stent and the patient was effectively ventilated without a significant air leak. A post-procedure chest X-ray showed expansion of the right lung. The chest drain was removed 2 weeks following stent insertion by which time the right lung was expanded fully and there was no further air leak into the pleural cavity. Bronchoscopy at this time showed a satisfactory position of the stent with complete seal of the tracheal defect. The patient was weaned from mechanical ventilatory support over the following week.
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The patient was re-admitted 3 months later for planned fibreoptic bronchoscopy under general anaesthesia. This demonstrated a satisfactory stent position but some granula tion tissue lying proximally. This tissue was removed with forceps. Scheduled bronchoscopy under general anaesthesia at 6 months again revealed a small ridge of granulation tissue proximal to the stent. This was removed with low power (10 W) Nd:YAG laser therapy.
The patient has returned to work and remains asymptomatic apart from some halitosis, which is controlled with nebulized colistin sulphate.
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Discussion |
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Covered stents, in which a single layer of translucent polyvinyl chloride envelops the metallic frame (UltraflexTM, Boston Scientific, Watertown, MA, USA) (Fig. 1), have been developed recently.4 5 Their fine titanium mesh construction and mid-section covering leads to a uniform radial tension on the airway wall and prevents penetrating growth of granulation tissue. Furthermore, they can effectively seal defects. Tracheal or bronchial ischaemia, wall perforation, and migration of the stent are uncommon.1 5 These stents are usually deployed under direct vision using a rigid bronchoscope.
The development of these stents represents a significant step forward in the management of patients with large airway compromise because of intrinsic or extrinsic obstruction, or fistula formation. They offer an effective, direct and less invasive means of sealing tracheal tears.6 The procedure is straightforward and can be performed in the intensive care unit. Stent deployment commits the patient to prospective outpatient surveillance to monitor for complications. Although uncommon these include granulation tissue formation, stent migration, halitosis, and recurrent respiratory tract infection.5
Fibreoptic bronchoscopic inspection during percutaneous tracheostomy to confirm correct positioning of the guidewire within the tracheal lumen is likely to reduce the risk of inadvertent posterior tracheal damage and perforation. But it may not eliminate the incidence of this complication entirely.7
The employment of a covered expandable metallic stent should be considered for the treatment of a tear complicating percutaneous tracheostomy, particularly for those patients in whom the risk of surgery is unacceptably high.
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References |
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