|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 4 | Page : 229
An usual cause of postextubation airway obstruction and its management in a low-resource setting
Akwasi Antwi-Kusi1, Wilfred Sam-Awortwi1, Gabriel Boakye2, Anna Konney1
1 Department of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
2 Departments of Ear, Nose and Throat, Komfo Anokye Teaching Hospital, Kumasi, Ghana
|Date of Web Publication||7-Oct-2014|
Department of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Antwi-Kusi A, Sam-Awortwi W, Boakye G, Konney A. An usual cause of postextubation airway obstruction and its management in a low-resource setting. Ann Afr Med 2014;13:229
|How to cite this URL:|
Antwi-Kusi A, Sam-Awortwi W, Boakye G, Konney A. An usual cause of postextubation airway obstruction and its management in a low-resource setting. Ann Afr Med [serial online] 2014 [cited 2020 Jan 25];13:229. Available from: http://www.annalsafrmed.org/text.asp?2014/13/4/229/142297
Endotracheal intubation is a life-saving airway management commonly performed on critically ill patients. It is, however, associated with a lot of complications some of which can be fatal.  We present a case of a 25-year-old woman admitted to the intensive care unit of Komfo Anokye Teaching Hospital with eclampsia. Three days after mechanical ventilation, she was extubated, but developed severe stridor 2 h postextubation which did not respond to nebulization with salbutamol and adrenaline. She was subsequently reintubated for another 24 h after which extubation was tried again. She went into severe respiratory distress leading to cardiac arrest. She was resuscitated and reintubated. Chest x-ray was normal; fiberoptic bronchoscopy done did not reveal any pathology. A consult was sent to the department of ear, nose, and throat. Since they did not have a rigid bronchoscope for examination, a decision was made to do a tracheostomy based on the history and physical examination. After the tracheostomy was done, a strip of mucosa was suctioned out through the tracheostomy stoma. The patient's respiratory symptoms subsided. This gave us a clue as to the cause of the airway obstruction. The patient was subsequently decannulated and was sent to the ward without any problems.
This was the first time we had experienced such postextubation complication due to a mucosal flap causing airway obstruction in our unit. We failed in sending the tissue for histology to confirm the nature of the tissue. A similar case was reported by Alfonso et al.,  here a 25-year-old male who developed acute stridor with progressive respiratory failure after extubation following 4 days of intubation. A diagnosis of subglottis edema was made which did not respond to treatment. Bronchoscopy showed a mass attached to the anterolateral tracheal wall, 4 cm below the subglottis which obstructed the tracheal lumen in a valve-like manner. This mass was coughed out by the patient spontaneously after which the patient's respiratory symptoms completely resolved. On histological examination, the mass was found to compose mainly of fibrinopurulent exudates with necrotic epithelium cells. This was a case of obstructive fibrinous tracheal pseudomembrane which was first diagnosed as subglottis edema.
The gold standard for the diagnosis of post extubation stridor is rigid bronchoscope.  If this is inconclusive, then computed tomographic scan can be done to confirm the diagnosis. The definitive management will be to remove the mucosa flap through rigid bronchoscopy if moving freely in the trachea. For a flap partially attached to the trachea, an inflated tracheostomy tube cuff should be kept in place for an adequate period to act as a stent and help keep the mucosa in place while healing occurs.  In a low-resource setting like ours where there is no rigid bronchoscope for the diagnosis and possible treatment, tracheostomy should be done to save the situation.
| References|| |
|1.||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. |
|2.||Fiorelli A, Vicidomini G, Messina G, Santini M. Spontaneous expectoration of an obstructive fibrinous tracheal pseudomembrane after tracheal intubation. Eur J Cardiothorac Surg 2011;40:261-3. |
|3.||Tan KL, Chong AW, Amin MA, Raman R. Iatrogenic flap mimicking tracheal stenosis with resultant stridor. J Laryngol Otol 2012;126:751-5. |
|4.||Farr MJ, Cyna AM. Subacute airway obstruction from a tracheal mucosal flap. Anaesthesia 2006;61:285-90. |