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POSTINTUBATION TRACHEAL STENOSIS Ulku YAZICI M.D.

POSTINTUBATION TRACHEAL STENOSIS Ulku YAZICI M.D. Atatürk Chest Disease and Thoracic Surgery Training and Research Hospital. Son üç yıl içinde, sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşundan aşağıdakileri kabul ettiniz mi?

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POSTINTUBATION TRACHEAL STENOSIS Ulku YAZICI M.D.

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  1. POSTINTUBATION TRACHEAL STENOSIS Ulku YAZICI M.D. Atatürk Chest Disease and Thoracic Surgery Training and Research Hospital

  2. Son üç yıl içinde, sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşundan aşağıdakileri kabul ettiniz mi? Bir kongre, sempozyum, kurs, panel vb bilimsel programa katılmak için maddi destek aldınız mı? X Hayır  Evet - Kuruluş Adı / Adları: Konuşmacı / Oturum Başkanlığı ücreti (Honoraryum) aldınız mı? X Hayır  Evet - Kuruluş Adı / Adları: Yöneticisi, oturum başkanı, düzenleyicisi olduğunuz eğitim toplantısı vb bir organizasyon için sponsorluk aldınız mı? X Hayır  Evet - Kuruluş Adı / Adları: Araştırmalarınız için fon kullandınız mı? X Hayır  Evet - Kuruluş Adı / Adları: Sizinle birlikte (aynı projede) çalışan personelden birisi, herhangi bir fon kullandı mı? X Hayır  Evet - Kuruluş Adı / Adları: Danışma ücreti aldınız mı? X Hayır  Evet - Kuruluş Adı / Adları: Son üç yıl içinde sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşunun çalışanı oldunuz mu? X Hayır  Evet - Kuruluş Adı / Adları: Sunumunuzun / makalenizin içeriğiyle ilgili bir sağlık endüstrisi kuruluşuna ait herhangi bir hisse senediniz ya da hisseniz var mı? X Hayır  Evet - Kuruluş Adı / Adları: Sunumunuz veya makalenizle ilgili, sağlık endüstrisinin taraf olduğu bir konuda uzman tanık / bilirkişi olarak hareket ettiniz mi? X Hayır  Evet - Kuruluş Adı / Adları: Sunumunuzun / makalenizin içeriğiyle ilgili olarak bunların dışında çatışan başka herhangi bir mali çıkarınız var mı? Varsa lütfen belirtiniz. XHayır  Evet - Açıklayınız: Kuruluş Adı / Adları: Bir tütün endüstrisi kuruluşunun çalışanı oldunuz mu? Ya da böyle bir kuruluşunun taraf olduğu bir konuda uzman tanık veya bilirkişi oldunuz mu? Ya da böyle bir kuruluşa ait hisseniz/hisse senediniz var mı?   XHayır  Evet - Açıklayınız

  3. History • Dr.HCGrillo • Dr.Perelman • Dr.Pearson • Dr.Mathisen • Dr.Cooper • Dr.ErdoğanYalav • Dr.İlker Ökten • Dr.Güven Çetin

  4. 40 cadaver • Meantracheal length11.8 cm • Resectablesegmentlength 6.4 cm HC Grillo J ThoracCardiovascSurg 1964

  5. Anatomicalfeatures • 10-13 cm • 20-22 cartilage rings • lig. Anulare • smooth muscle • mucosa

  6. Anatomicalfeatures • Inferiorthyroid, bronchialarteries… • Bilateral lateralvascularpedicle • Submukozalcapillary • Rekürrentnerves

  7. Etiology • Intensivecareunit • Mechanicalventilators • Prolongedintubations • Highpressureintubationtubes • Tracheostomy

  8. Pathophysiology Pressureischemia Edema-ulceration Seconderinfection Perichondritis-chondritis-cartilagenecrosis Granulationtissueproliferation Fibrosis

  9. Risk Factors for Stenosis Lowbloodpressure Diabetes Cardiovasculardiseases Steroid drugs Reflux Anemia Neutropenia Femalesex Patientsensitivitytochemicalsandinstrumentsduringintubation

  10. Cuff pressure plays a major role in the development of tracheal stenosis • Extent of cuff inflation, low pressure cuffs, double cuff intubation tubes

  11. CuffandLateralTrachealWallPressures

  12. Localization • Laryngotracheal • Stoma level • Cuff level • Cannula level

  13. Tracheallesions • Granulationtissueandgranuloma • Webs • “Bottleneck” kindlesions • Complexstenosis

  14. Dilatationtechniquesaresuccessfulfordiaphragmaand web likelesions. (1-3 seance, 60% success) Mehta AC, Lee FY, Cordasco EM ve ark. Concentric tracheal and subglotticstenosis. Managementusing the Nd-YAG laser for mucosalsparing followed by gentle dilatation. Chest1993; 104: 673-677

  15. Incidence • PITS incidence in chronicintubationcases calculated as 0.1-20% * • Femalepredominance in twolargeseries** *Papla B, Post-Intubation Tracheal Stenosis - Morphological-Clinical Investigations. Pol J Pathol 2003 **McCaffrey TV: Classification of laryngotracheal stenosis. The Laryngoscope 1992; 102:1335-1340. Mehta AC. Concentric tracheal and subglottic stenosis. Chest 1993

  16. ClinicalPresentation • Wheezing • Stridor • Cough • Progressive dyspnea • Effort • Lumencaliberdecreasesto 5-6 mm • Secretionretantion • Pneumonia

  17. Diagnosis • X-rays • CT,3D bronchoscopy • Bronchoscopy

  18. Bronchoscopy • Usuallymechanicaldilatation is requiredbeforesurgery. • Preoperativerigidbrochoscopy First 71% Second 53% Third 26% Bonette P. Resectionanastomosetrachealepourstenoseiatrogene. Uneexperience de 340 cas. Rev Mal Respir 1998

  19. Rigid Bronchoscopy • Level and length of stenosis • Dilatation • Endobronchial treatment • Treatment plan • Resection • Conservative management

  20. Treatment • Bronchoscopicdilatation • Surgical resection and reconstruction • Nd:yag laser… • Stent

  21. Bronchoscopicdilatation • Saving time forsurgery • Evaluation of length of stenoticsegment

  22. Nd-YAG laser Nd-YAG laser, electrocauteryorstentsarealternativemethodsforpatientswhomunsuitabletosurgery. DuringNd-YAG laserapplicationavoidinfiltrationtothebronchialwall. Cartilagedamage, stenosisafterfibrosis Marel M, Pekarek Z, Spasova I ve ark. Managementof benign stenoses of the largeairways in the universityhospital inPrague, Czech Republic, in 1998-2003. Respiration 2005; 72: 622-8 .

  23. İncision • 503 cases (Grillo et al) 350 Collarincision 145 Partialsternotomy 6 Posterolateral thoracotomy 2 Collar+partialsternotomy+ant. thoracotomy Grillo HC, Donahue DM. Postentubation tracheal stenosisChest Surg Clin N Am. 1996;6:725-31

  24. Tracheostomy+Stenosis

  25. Trachealreleasing • Flexion of neck • Anteriorcervicalapproach • Laryngealreleasing(proximallesion) • Infrahyoideal(thyrohyoidmuscle,membrane) • Suprahyoideal(stylohyoid,mylohyoid,genohyoid,genioglossus) • Hilarreleasing(distallesion) • Pulmonaryligamantreleasing • Pericardialdissection • Reanastomosis of leftmainbronchus

  26. Surgicaltechnique

  27. SupinepositionCollarincision

  28. StenotictracheaAnteriordissection

  29. Upperandloweredges of stenoticsegment

  30. Esophagus (nasogastric)rekurrentnervesstenoticsegmentresection

  31. cervicalflexionabsorbable (3-0,4-0) suture

  32. Restriction of cervicalextantionEarlyextubation

  33. Subglotticstenosis Subglottic stenosis are at the level of cricoidal cartilage and circumferential

  34. Postoperativecomplications • Infection • Dehiscence of sutur (%3.6-7.5) • Majorhemorrhage (%1-2.5) • Aspirationpneumonia • Recurrentlaryngealnerveparalyzis(%0-5) • Restenosis (%5.4-15)

  35. Tension of anastomosisdevascularization

  36. Restenosis • 1-2 weeksaftersurgery • Conservativetreatment is initial step • Awaituntillinflammationdisappears (4-6 months) • Half of thecasesrecoverwithdilatations • Reoperation • ”T” tube • Stent • tracheostomy

  37. 901 cases • 81 cases had anastomotic problem (9%) • Longsegmentresection • Tracheostomybeforesurgery • Pediatricpatient • Reoperation • DiabetesMellitus Risk factorsforanastomoticproblems. D. Wright, Hermes C. Grillo, et al.Anastomotic complications after tracheal resection:PrognosticfactorsandManagement J ThoracCardiovascSurg 2004;128:731-9

  38. Mortality • 2.5 -5% • Grillo et al. has lowestmortalityrates 1.8% *Brichet A, Multidisciplinary approach to management of postintubation tracheal stenoses. Eur Respir J 1999 **Grillo HC: Surgical management of tracheal strictures. Volume 68. Edited by: Farrell EM, keon WJ. Philadelphia: WB Saunders; 1988:511-524.

  39. Preventionfromtrachealstenosis Stomalevel • Minimal stomadiameter • Suitabletubelengthandangle • Verticalincisionpreferable • Asepticfieldduringsurgery Cufflevel • Extent of cuffinflation, lowpressurecuffs • Suitablecufffollow-up

  40. Conclusions • Rigid bronchoscopy: evaluation, dilatation • Collarincision is sufficient in most of cases • Corporationbetweensurgeonandanesthetist • Apneicperiods, jet ventilationand sterile intubation • Preventingtrachealbloodflow • PreventingEsophagusandRecurrentnerves • Absorbablesutures • Bronchoscopicanastomosiscontrol • Earlyextubation • 24 hrintensivecareunit • Neckflexionduring 1 week

  41. ATATURK CHEST DISEASE AND THORACIC SURGERY TRAINING AND RESEARCH HOSPITAL Trachealstenosis, 38 cases (2003-2010)

  42. 55 year-old, Female 13 daysmechanicalventilation 3 cm distalstenosisfromvocalcords Mechanicaldilatation Resectionandend-to-endanastomosis

  43. 50 year-old, Female • 4 daysmechanicalventilation • 2 cm distalstenosisfromvocalcords • Mechanicaldilatation • Resectionandend-to-endanastomosis

  44. 40 year-old, Male • 5 daysmechanicalventilation • 2 cm distalstenosisfromvocalcords • Mechanicaldilatation • Resectionandend-to-endanastomosis

  45. 37 year-old, Female • 25 daysmechanicalventilation • 3 cm distalstenosisfromvocalcords (3 cm length) • Mechanicaldilatation • Resectionandend-to-endanastomosis

  46. 55 year-old, Male • 3 daysmechanicalventilation • 2.5cm distalstenosisfromvocalcords (2.5 cm length) • Mechanicaldilatation • Resectionandend-to-endanastomosis

  47. 54 year-old, Male • 39 daysmechanicalventilation • 4cm distalstenosisfromvocalcords (1 cm length) • Resectionandend-to-endanastomosis

  48. 75 year-old, Female • 12 daysmechanicalventilation • 3 cm distalstenosisfromvocalcords • Mechanicaldilatation • Resectionandend-to-endanastomosis • On post-op 15th day, cardiopulmonaryarrestandexitus

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