We present a 25 year old lady, recently diagnosed asthmatic who presented to Emergency Department (ED), with sudden onset of difficulty breathing associated with noisy breathing for 3 days and hoarseness of voice for 6 months. A year ago, she was treated as PTB and had completed treatment. Since then, she had multiple episodes of bronchospasm that required nebulization at a local clinic precipitating the diagnosis of bronchial asthma.
On presentation, she was in respiratory distress with silent chest and marked use of accessory respiratory muscles. An arterial blood gas revealed a severe respiratory acidaemia. She received treatment including hydrocortisone, continuous nebulised beta-2 agonists, magnesium, antibiotics, and a salbutamol infusion. As her bronchospasm was not responding, ED team decided for intubation. Multiple attempts at intubation at ED before an alert to ICU was made, as although the larynx was visualized as Cormack-Lehane I, they were unable to advance the Endotracheal Tube (ETT) beyond more than 1 cm past the vocal cord. Finally, she was intubated with ETT size 6.0mm Internal Diameter where cuff was just after the vocal cord and anchored at 16 cm. We had difficulty ventilating her as her peak airway pressure's was persistently high with severe respiratory acidosis.
With the abnormal laryngoscopy and life-threatening bronchospasm and alternative diagnoses were explored. She underwent flexible nasopharyngolaryngoscope (FNPLS) that revealed subglottic stenosis (Fig. 1). CT Thorax/Neck showed features of tracheobronchial stenosis with post primary PTB changes (Fig. 2). Patient was subsequently treated successfully with anti TB medication and underwent multiple sessions of tracheal dilatation (Fig. 3a-c).
CT Thorax pre intervention, Sagittal plane: Trachea narrowing 4.6 cm from hyoid bone, 0.8 cm length and 9.5 cm from hyoid bone, 8.7cm length. Right main bronchus narrowest diameter was 0.3 cm.