A novel use of silicon stenting to manage tracheomalacia (TM) and tracheal defect in a tracheostomy patient, a case report.
AlJasmi M, Sengupta R, Shah SK, Ray C, Simoff MJ, and Diaz-Mendoza J. A novel use of silicon stenting to manage tracheomalacia (TM) and tracheal defect in a tracheostomy patient, a case report. Am J Respir Crit Care Med 2015; 191.
Am J Respir Crit Care Med
Tracheomalacia refers to diffuse or segmental weakness of the tracheal wall. Common causes include tracheostomy and endotracheal intubations (ET). The use of stents for treatment of symptomatic TM is advocated by multiple studies that show improvement in airflow and symptoms after airway stabilization. We describe a unique technique in which a silicon stent was used to maintain the airway of a patient with TM and a tracheal defect. Case Description: A 48-year-old male with amyotrophic lateral sclerosis (ALS) was referred for a chronic cuff leak. He is ventilator dependent for 15 years and due to persistent air leak seen on the ventilator it was challenging to maintain adequate minute ventilation, this lead to hypoxia and subjective shortness of breath. He underwent evaluation by otolaryngology including a computed tomography of the neck that revealed severe dilation of the trachea at the level of the tracheostomy cuff. He had a Bivona-FlexTend adjustable tracheostomy tube with the distal end just proximal to the carina. Significant air leak was seen on the ventilator with only 20% of his inspired tidal volume recorded on expiration. Airway examination via rigid bronchoscopy showed partial absence of the posterior wall of the trachea, below the level of the tracheal stoma and extending distally for almost 2 cm. The anterior wall of the esophagus was seen through this defect, but no evidence of a tracheoesophageal fistula was present. Decision was made to place a silicone Y-stent to cover the tracheal posterior wall defect. The stent helped improve the seal between the tracheostomy tube cuff and the trachea to reduce the ventilator cuff leak. A Novatech 20x14x14mm Y-stent was chosen and customized to fit the patient's anatomy. The proximal end of the tracheal arm was cut with a U notch to allow placement of the tracheostomy tube. An 8.0 Distal XLT-Shiley tracheostomy tube was replaced through the stoma under fiber-optic bronchoscopic visualization. Following inflating the tracheostomy tube balloon, the ventilator leakage improved significantly, with residual leakage of less than 10% of inspired volume. Discussion: Tracheal dilation due to prolonged tracheostomy can lead to difficulty in mechanically ventilated patients. When conservative means such as specialized tracheostomy tubes fail to resolve the situation, placement of a silicone stent with a tracheostomy tube through the stent may be useful. To our knowledge, this is the first reported case of using tracheal stenting for this problem. (Figure Presented).