Users Online: 761 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 


RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to [email protected] preferably by 30th June 2019.

 

 
Table of Contents
CASE REPORT
Year : 2012  |  Volume : 28  |  Issue : 2  |  Page : 235-238

Tracheal granulation as a cause of unrecognized airway narrowing


Department of Anaesthesiology and Critical Care, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication11-Apr-2012

Correspondence Address:
Gaurav Bhatia
Department of Anaesthesiology and Critical Care, Christian Medical College, Ludhiana, Punjab - 141 008
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.94907

Rights and Permissions
  Abstract 

Tracheostomy is one of the most common elective surgical procedures performed in critically ill patients. The most frequent late complication after tracheostomy is the development of granulation tissue, a complication that may cause airway occlusion or result in airway stenosis. We report the successful management of a patient with tracheal granulation presenting as an unrecognised cause of difficulty breathing.

Keywords: Airway, tracheal granuloma, tracheostomy


How to cite this article:
Bhatia G, Abraham V, Louis L. Tracheal granulation as a cause of unrecognized airway narrowing. J Anaesthesiol Clin Pharmacol 2012;28:235-8

How to cite this URL:
Bhatia G, Abraham V, Louis L. Tracheal granulation as a cause of unrecognized airway narrowing. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2020 Dec 6];28:235-8. Available from: https://www.joacp.org/text.asp?2012/28/2/235/94907


  Introduction Top


Tracheostomy is one of the most common elective surgical procedures performed in critically ill patients. [1] It can be associated with numerous complications, some of which continue to be relevant well after placement. The most frequent late complication is the development of granulation tissue, a complication that may cause airway occlusion or result in airway stenosis. [2] We report the successful management of a patient with tracheal granulation presenting with difficulty in breathing.


  Case Report Top


A 20-year-old man, presented to the emergency department (ED) with a history of difficulty in breathing through a tracheostomy tube (TT) since 2 days. Patient gave a history of a road traffic accident (RTA) 10 months ago, in which he sustained a head injury (diffuse axonal injury) which left him quadriplegic and bed-bound. He required prolonged hospitalization and was tracheostomized 7 days after his RTA to facilitate prolonged mechanical ventilation. He was weaned off mechanical ventilation and discharged home with a metallic TT. Tracheostomy care and suction was done by caregivers at home. He was regularly followed up at a hospital nearby where his TT was changed every month. Four months prior to present admission to our hospital, the patient had difficulty breathing and was taken to the nearby hospital, where his TT was changed. He was mechanically ventilated for 2 days and discharged once stable.

The present episode also began with difficulty breathing. The patient's caregiver tried to change the TT but failed. The patient turned blue and was rushed to the nearby hospital. The doctor there attempted changing the TT but could not, but he successfully intubated the trachea with a 5-mm ID endotracheal tube (ETT) and referred him to our hospital for further management.

In the ED, his heart rate (HR) was 120/min, regular and blood pressure (BP) 110/70 mmHg. He was breathing at a rate of about 40/min despite being ventilated with an Ambu bag. Air entry was decreased bilaterally and expiratory phase was prolonged. A suction catheter could be passed down the ETT but encountered resistance distally. An arterial blood gas (ABG) showed pH 7.12, pCO 2 69, pO 2 320, HCO 3 38, and saturation 99%.

He was shifted to the ICU but the oxygen saturation by the time he was admitted to ICU had fallen to 84-86%. An urgent bronchoscopy was done through the ETT which showed a collapsible, bleeding, soft-tissue mass causing near-complete obstruction of the trachea, with only a small hole visible during air movement into and out of the lungs. The mass was vascular, bleeding to touch, and the bronchoscope could not be guided beyond the obstruction. 2-3 ml of adrenaline 1:200,000 solution was the sprayed through the bronchoscope which subsequently reduced the vascularity of the mass. Thereafter, the bronchoscope could be guided, though with some difficulty, through the visible hole. The growth was found to be about 1.5 cm long and beyond it the trachea was of normal calibre. The 5-mm ID ETT was pushed through the mass without significant bleeding. After this, the ventilation became considerably easier and the oxygen saturation picked up to about 94-96%. The patient was given dexamethasone 4 mg intravenous q6h for 24 h to reduce the edema. Computerized tomography (CT) scan confirmed luminal narrowing at the level of the sternoclavicular joint 4 cm from the carina with thickening of the posterior and right lateral walls of the trachea. Bilateral pneumothorax and extensive pneumomediastinum were also noted.

The granulation tissue was resected endoscopically the next day and the ETT was changed uneventfully to a distal-long stem TT to bypass the remaining obstruction. The patient was discharged next day in a satisfactory condition.


  Discussion Top


A number of mechanisms can cause late complications after tracheostomy. [3] Complications can be directly related to placement of the tube, leaving the tube in place for a prolonged period of time, or abnormal healing at the site of injured tracheal mucosa. They may be related to the inflated cuff of the TT or the tip of the TT, especially when it impinges on the posterior tracheal wall. [2]

Granulation tissue may obstruct the airway at the level of the stoma and cause difficulty in replacing the TT if accidental decannulation occurs. Alternately, this granulation tissue can occlude tube fenestrations and lead to difficulty to decannulate. As the granulation tissue matures, it becomes fibrous and covered with a layer of epithelium. With the development of fibrosis, stenosis develops as the anterior and lateral aspects of the tracheal wall become narrowed at the level of the stoma.

Multiple risk factors are associated with stomal stenosis, including sepsis, stomal infection, hypotension, advanced age, male sex, steroids, tight fitting or oversized cannula, excessive tube motion (mechanical irritation), prolonged placement, and disproportionate excision of anterior tracheal cartilage during the creation of the tracheostomy. [4]

Suprastomal stenosis may occur when there is guidewire-related injury to the posterior tracheal wall with subsequent development of granulation tissue. Dilators used to enlarge the percutaneous dilatational tracheostomy stoma can injure the anterior tracheal cartilage (including tracheal ring fracture), causing these deformed structures to invaginate and protrude into the tracheal lumen, causing obstruction. [5],[6]

Tracheal stenosis may occur at the site of the tracheal-tube cuff, where ischemic injury to the tracheal mucosa can take place when cuff pressure exceeds the perfusion pressure of the capillaries of the tracheal wall. With prolonged ischemia, mucosal ulceration, chondritis, and cartilaginous necrosis may ensue, leading to the formation of granulation tissue. Shearing forces from the tube or the cuff may aggravate injury to the airway. [2] Despite improvements in the design of tracheal tubes, however, tracheal stenosis after intubation remains an important cause of tracheal obstruction, which may be life threatening. [7]

Tracheal stenosis may occur near the distal tip of the TT. Depending on the positioning of the tube, the tip may rub against either the anterior or the posterior tracheal wall. The latter may occur because standard TTs may be too short in patients with abundant soft tissue in the anterior neck. The resulting injury to posterior membranous wall may lead to stenosis or to trachea-esophageal fistula.

The granulation tissue in our patient may have been caused by prolonged mucosal irritation from the sharp edge of the metal TT and the trauma due to repetitive monthly changes of the tube.

Tracheal stenosis can occur while the patient remains mechanically ventilated. A retrospective study of 756 patients who had been ventilated for at least 15 weeks (3 weeks with an endotracheal tube followed by 12 weeks with a TT) [8] showed that 37 patients (5%) developed failure to wean secondary to tracheal stenosis or obstruction from granulation tissue, often manifested as higher peak airway pressures or difficulty in passing a suction catheter.

An important aspect to diagnose tracheal stenosis early is to have a high index of suspicion, especially when a patient with a history of intubation or tracheostomy is under evaluation. Tracheal stenosis may produce no symptoms until the lumen has been reduced by 50-75%. [4] Once the tracheal lumen has been reduced to ≤10 mm, exertional dyspnea occurs and if narrowed to ≤5 mm, dyspnea at rest or stridor may occur.

A CT scan provides precise information about the exact location and extent of the granulation/obstruction/stenosis. Laryngotracheoscopy or bronchscopy should be done to define the exact site of stenosis and the length of the involved trachea and also rule out other coexisting pathology. History of inability to insert a TT or an adequate sized ETT, tachypnea, decreased air entry bilaterally, high airway pressures required to ventilate lungs, prolonged expiratory phase, and desaturation in the patient prompted us to do a bronchoscopy on him.

To prevent formation of granulation tissue, strategies have looked at avoiding excess mechanical irritation, placement of tubes of proper size and the use of swivel adapters and ventilator tubing support. Prevention of stomal infection is important, because infection may impair tissue healing. Meticulous stomal care is recommended to prevent bacterial contamination. [9]

A number of therapeutic approaches have been described in patients with granuation tissue. [2] In symptomatic patients, neodymium-yttrium-aluminum garnet (Nd-YAG) laser excision, with or without rigid bronchoscopic dilation may be the preferred approach. Suprastomal granulation can be excised by sharp dissection under bronchoscopic guidance. When a short web-like band of tracheal stenosis exists, laser excision can prove useful in reestablishing an adequate tracheal lumen with success rates as high as 60% after 1-3 sessions. [10] In cases where laser resection is not feasible, stenting of airway or surgical repair are the best options.

A simple bronchoscopy procedure for tracheal stenosis had been developed by Freitag et al. [11] for the classification of tracheobronchial stenosis. Treatment of granulation tissue depends on the underlying cause and the extent of the tissue. If a considerable amount of granulation tissue needs to be eliminated quickly, an option is to remove the tissue surgically with small instruments such as forceps or a soft tissue debrider, a tool that can cut the tissue and suction it away at the same time. Dilating the narrow part of the airway also is an option. If the need to remove the tissue is not as urgent, medication may be a treatment option. For example, in case of granulation tissue formation due to chronic infection, antibiotics may help minimize the tissue. At times, excessive secretions or saliva in the trachea can increase granulation tissue, so medications to dry up secretions can help to decrease the tissue. Medications to treat acid reflux, if present, may also reduce formation of granulation tissue in the airway.

Application of topical medications to shrink the granulation tissue can be effective too. These medications may include steroids, which can be applied directly to the tissue or injected just beneath the granulation tissue. In addition, other medications decrease the number of fibroblast cells, which help to create granulation tissue. Tracheal stents have been used in the management of benign tracheal granulation tissue formation. [12] An expandable metallic stent stops granulation or neoplastic tissue from proliferating through the mesh. Argon plasma coagulation and Tranilast have been successfully used to treat granulation tissue obstructing the airway after tracheal anastomosis. [13] Endobronchial brachytherapy has been used successfully for long-term control of recurrent granulation tissue following tracheal stenosis. [14] Mitomycin C (an antimetabolite known to inhibit fibroblast proliferation) has also been used for the treatment of tracheal cicatrix after tracheal reconstruction. [15]

We report the successful management of a patient experiencing breathing difficulty with a TT in situ. The granulation tissue in our patient may have been caused by prolonged irritation by the sharp edge of the metal TT and the trauma due to repetitive monthly changes of the tube. Bronchoscopy played an important role in its early diagnosis and management.

 
  References Top

1.Madden BP, Stamenkovic SA, Mitchell P. Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation. Ann Thorac Surg 2000;70:1191-3.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Epstein SK. Late complications of tracheostomy. Respir Care 2005;50:542-9.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheostomy. A prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76.  Back to cited text no. 3
[PUBMED]    
4.Sue RD, Susanto I. Long term complications of artificial airways. Clin Chest Med 2003;24:457-71.  Back to cited text no. 4
[PUBMED]    
5.van Heurn LW, Theunissen PH, Ramsay G, Brink PR. Pathologic changes of the trachea after percutaneous dilatational tracheotomy. Chest 1996;109:1466-9.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Briche T, Le Manach Y, Pats B. Complications of percutaneous tracheostomy. Chest 2001;119:1282-3.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Spittle N, McCluskey A. Tracheal stenosis after intubation. BMJ 2000;321:1000-2.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Rumbak MJ, Walsh FW, Anderson WM, Rolfe MW, Solomon DA. Significant tracheal obstruction causing failure to wean in patients requiring prolonged mechanical ventilation: A forgotten complication of long-term mechanical ventilation. Chest 1999;115:1092-5.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Sasaki CT, Horiuchi M, Koss N. Tracheostomy related Subglottic stenosis: Bacteriologic pathogenesis. Laryngoscope 1976; 89:857-65.  Back to cited text no. 9
    
10.Mehta AC, Lee FY, Cerdasco EM, Kirby T, Eliachar I, De Boer G. Concentric tracheal and subglottic stenosis management using the Nd-YAG laser for mucosal sparing followed by gentle dilation. Chest 1993;104:673-7.  Back to cited text no. 10
    
11.Freitag L, Ernst A, Unger M, Kovitz K, Marquette CH. A proposed classification system of central airway stenosis. Eur Respir J 2007;30:7-12.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Madden B, Stamenkovic S, Mitchell P. Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation. Ann Thorac Surg 2000;70:1191-3.  Back to cited text no. 12
    
13.Sato M, Terada Y, Nakagawa T, Li M, Wada H. Successful use of argon plasma coagulation and Tranilast to treat granulation tissue obstructing the airway after tracheal anastenosis. Chest 2000;118:1829-31.  Back to cited text no. 13
[PUBMED]  [FULLTEXT]  
14.Abdelrahaman NM, Allen A, Silvern D, Fenig E, Kramer M. Endobronchial Brachytherapy (EBB) provides excellent long term control of recurrent granulation tissue following tracheal stenosis. Int J Radiat Oncol Biol Phys 2009;75 (Suppl): S485-6.  Back to cited text no. 14
    
15.Ward RF, April MM. Mitomycin C in the treatment of tracheal cicatrix after tracheal reconstruction. Int J Pediatr Otorhinolaryngol 1998;44:221-6.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  



This article has been cited by
1 Death Due to Obstruction of Airways by a Hyperplastic Polyp: An Unusual Complication of Treated Desmoid Fibromatosis
Natasha Richards,Jayantha Herath
Academic Forensic Pathology. 2020; 10(2): 97
[Pubmed] | [DOI]
2 Dilation of tracheal stenosis below tracheostomy tube with Dolphin percutaneous tracheostomy kit
Alfonso Fiorelli,Mary Bove,Antonio Noro,Angela Iuorio,Mario Santini,Fausto Ferraro
General Thoracic and Cardiovascular Surgery. 2020;
[Pubmed] | [DOI]
3 Diagnosis and conservative management of late tracheotomy complications in chronic ventilator-dependent patients
Ophir Ilan,Menachem Gross,Yacov Zaltzman,Ady Sasson,Esther-Lee Marcus
Head & Neck. 2014; : n/a
[Pubmed] | [DOI]
4 Optical imaging of subacute airway remodeling and adipose stem cell engraftment after airway injury
Yeh-Chan Ahn,Sung Won Kim,Sang Seok Hwang,Yu-Gyeong Chae,Andrew Sungwan Lee,Maan Hong Jung,Bong Kwon Chun,Sang Joon Lee,Eun-Kee Park,Chulho Oak
Biomedical Optics Express. 2014; 5(1): 312
[Pubmed] | [DOI]
5 Surgical Management for Complications of Pediatric Lung Injury
T.K. Pandian,Chad Hamner
Seminars in Pediatric Surgery. 2014;
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
   References

 Article Access Statistics
    Viewed8494    
    Printed123    
    Emailed2    
    PDF Downloaded525    
    Comments [Add]    
    Cited by others 5    

Recommend this journal