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Case 2. Stridor David Ost, M.D., M.P.H.

Case 2. Stridor David Ost, M.D., M.P.H.

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Case 2. Stridor David Ost, M.D., M.P.H.

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  1. Case 2. StridorDavid Ost, M.D., M.P.H. A patient presents to the office with a complaint of stridor. She was discharged three months ago after a prolonged hospitalization for pneumonia , MI, and congestive heart failure. During that hospitalization she was intubated for 12 days. Her flow-volume loop demonstrates fixed airway obstruction. What is the diagnosis?

  2. Bronchoscopic Findings 6 cm Below Vocal cords

  3. Case 2. Diagnosis: Post-intubation Tracheal Stenosis What is the next intervention for this patient: 1. Tracheal reconstruction 2. Balloon dilation and metal stent placement 3. ND-YAG used to totally destroy all granulation tissue. 4. Radial Laser incisions followed by gentle dilation 5. Nd-YAG laser with Silicone stent placement

  4. Question 2. Tracheal Stenosis • Correct answer is 4. • Simple web-like stricture (< 1cm in length) • Radial incisions at 3 and 9 o’clock • Follow with dilation

  5. Successful Treatment of Simple Tracheal Stenosis PRE POST Balloon Dilation Incision with electrocautery knife

  6. 45 Days later: Tracheal Stenosis & Restenosis

  7. Case 2 Question 2. Restenosis Recurrent stenosis after treatment of a simple tracheal stricture: 1. Occurs greater than 80% of the time 2. Occurs less than 10% of the time 3. Is greatest early on and warrants follow-up bronchoscopy beginning 3-4 weeks later. 4. If stenosis recurs after the first treatment, tracheal reconstructive surgery is the best option.

  8. Case 2 Part II Answer • Correct Answer is 3. • Repeating the procedure is often necessary but can be successful.

  9. Restenosis: Treated with Electrocautery-Loop Post-Electrocautery Loop

  10. Multimodality Algorithms vs.Single Modality Interventions • Tracheal Stenosis: • Radial Incision • Balloon dilation • Stenting • Surgery • Shapshay SM, Beamis, Hybels, et al., Ann Otol Rhinol Laryngol 1987; Mehta AC, Lee FY, Cordasco EM, et al. Chest 1993; • Brichet A, Verkindre C, Dupont J, et al. Eur Resp J 1999.

  11. Tracheal Stenosis • Multidisciplinary Approach • Tracheal Reconstruction • Tracheostomy • Rigid Bronchoscopy • Study the Validity of this Approach Brichet A, et al. Eur Resp J 1999; 13:888

  12. Multidisciplinary Approach I Simple (Web-Like) Stenosis Rigid Bronch with Nd-YAG Incision and Dilation (Repeat x 2 if recurs) 3rd Recurrence Cured Operative Candidate Not Operative Candidate Tracheal Reconstruction Tracheal Reconstruction

  13. Multidisciplinary Approach to Complex Stenosis Complex Stenosis (Hourglass) Rigid Bronch with Silicone Stent Observe for 6 months Operative Candidate Not Operative Candidate Stent Removal No Recurrence Recurrence Leave Stent in and F/U Cured Tracheal Reconstruction

  14. Simple Stenosis (Web) Cure 9 of 15 (64%) without surgery Failures managed with trach, reconstruction, or stent Complex (Hourglass) Cured or sleeve resection in 35% Left in Place or reinserted in 9 Key Findings Brichet A, et al. Eur Resp J 1999; 13:888

  15. Teaching Points • Distinguish between simple and complex strictures • Multi-modality approach • Algorithm depends on type of stricture • Most recurrences occur within 90 days • For simple stenosis repeat procedures are wothwhile

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