Tracheobronchomalacia (TBM) is characterized by weakness of cartilaginous supporting structures of tracheal and bronchial walls, resulting in central airway obstruction. Here, we report a patient of 26-year-old, morbidly obese man presents with worsening upper airway obstruction (UAO) for two weeks. Previously, he was admitted to ICU with metabolic encephalopathy and multiple organ dysfunction syndromes. Initially, he had a brief episode of generalized tonic-clonic seizure due to alcohol withdrawal syndrome, and was intubated with a styletted 8.5 mm cuffed endotracheal tube (ETT) by an anesthesiologist with one attempt. At ICU, his blood culture was positive for Staphylococus Aureus. His hospital course was complicated by severe ARDS (PaO2/FiO2 40.1, Oxygen index 32.4), severe alcoholic hepatitis (requiring prolonged course of prednisone), fulminant hepatic failure (Albumin 2.9 g/dL, PT 18.5 secs, and INR 1.66, Hepatic encephalopathy grade 4), and acute kidney injury stage 1 (urine output 870 ml/24 hours, serum creatinine 1.5 mg/dL). He was on pressure-regulated volume controlled with lung protective strategies. His peak pressure was in the range of 23-37 cmH2O. Then, he was extubated successfully on ICU day 15 without any signs of upper airway obstruction. A 14-day course of antibiotics was completed and he was discharged on day 23 of hospitalization.
Two weeks later, he was re-admitted because of UAO. Biphasic stridor, hoarseness, productive cough and shortness of breath were appreciated. Physical exam showed stable hemodynamics but hypoxemia (SpO2 86%, on room air) and increase work of breathing. Chest X-ray showed no infiltration. Contrast-enhanced spiral CT of neck reveals mild subglottic wall thickening with patent airway. ENT performed direct laryngoscopy. It showed proximal tracheal stenosis of 6 cm, involving tissue just below cricoid. This stenosis is inclusive of the segment with dynamic airway collapse. Proximal trachea and subglottic area was subsequently dilated up to 8 French of endotracheal tube size. He was discharged with beclomethasone, proton pump inhibitor and ciprofloxacin.
The second bronchoscopy was performed at day 8 after discharge because of persistent shortness of breath. Tracheal stenosis was found with a diameter of 5 mm. Subsequently, narrowed airway was dilated by balloon, cauterized by Argon plasma coagulation and injected with mitomycin C.
The third bronchoscopy was repeated at day 14 after discharge because of recurrent UAO. It showed subglottic stenosis of approximately 1.5 cm below the vocal cords. Trachea was stenotic (90% occlusion) from 1.5 cm below the vocal cords to roughly 6 cm above the carina with near total collapse during expiration. Balloon dilation was performed in the trachea using a 6 cm (length) and 15 mm (diameter) CRE balloon with 50% dilatation of lumen size for management of tracheal stenosis. Cryotherapy was performed in the trachea for destruction of abnormal tissue. Mitomycin C was then injected into the granulation tissue. He was discharged with extended period of steroid taper and amoxicillin/clavulanic acid. The plan is to follow as outpatient for evaluation for possible stent placement and/or tracheostomy.