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Tracheal stenosis in prolonged mechanically ventilated patients: prevalence, risk factors, and bronchoscopic management.

ABSTRACT:

Background

Various complications may arise from prolonged mechanical ventilation, but the risk of tracheal stenosis occurring late after translaryngeal intubation or tracheostomy is less common. This study aimed to determine the prevalence, type, risk factors, and management of tracheal stenoses in mechanically ventilated tracheotomized patients deemed ready for decannulation following prolonged weaning.

Methods

A retrospective observational study on 357 prolonged mechanically ventilated, tracheotomized patients admitted to a specialized weaning center over seven years. Flexible bronchoscopy was used to discern the type, level, and severity of tracheal stenosis in each case. We described the management of these stenoses and used a binary logistic regression analysis to determine independent risk factors for stenosis development.

Results

On admission, 272 patients (76%) had percutaneous tracheostomies, and 114 patients (32%) presented mild to moderate tracheal stenosis following weaning completion, with a median tracheal cross-section reduction of 40% (IQR 25-50). The majority of stenoses (88%) were located in the upper tracheal region, most commonly resulting from localized granulation tissue formation at the site of the internal stoma (96%). The logistic regression analysis determined that obesity (OR 2.16 [95%CI 1.29-3.63], P < 0.01), presence of a percutaneous tracheostomy (2.02 [1.12-3.66], P = 0.020), and cricothyrotomy status (5.35 [1.96-14.6], P < 0.01) were independently related to stenoses. Interventional bronchoscopy with Nd:YAG photocoagulation was a highly effective first-line treatment, with only three patients (2.6%) ultimately referred to tracheal surgery.

Conclusions

Tracheal stenosis is commonly observed among prolonged ventilated patients with tracheostomies, characterized by localized hypergranulation and mild to moderate airway obstruction, with interventional bronchoscopy providing satisfactory results.

SUBMITTER: Ghiani A

PROVIDER: S-EPMC8740413 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundSeveral studies have assessed predictors of weaning and extubation outcome in short-term mechanically ventilated patients, but there are only few studies on predictors of weaning from prolonged mechanical ventilation.MethodsRetrospective, single-center, observational study at a specialized national weaning center in Germany. Patients' medical records were reviewed to obtain data on demographics, comorbidities, respiratory indices, and the result of a prospectively documented, standardized spontaneous breathing trial (SBT) upon admission to the weaning center. Respiratory indices assessed were the ventilatory ratio (VR) and parameters derived from calculated mechanical power (MP). Predictors associated with failure of prolonged weaning and failure of the SBT were assessed using a binary logistic regression model.ResultsA total of 263 prolonged mechanically ventilated, tracheotomized patients, treated over a 5-year period were analyzed. After 3 weeks of mechanical ventilation, patients with unsuccessful weaning failed a SBT more frequently and showed significantly increased values for inspiratory positive airway pressure, driving pressure, VR, absolute MP, and MP normalized to predicted body weight and dynamic lung-thorax compliance (LTC-MP). In the logistic regression analyses, variables independently correlated with weaning failure were female gender (adjusted odds ratio 0.532 [95% CI 0.291-0.973]; p = 0.040), obesity (body mass index ≥ 30 kg/m2) (2.595 [1.210-5.562]; p = 0.014), COPD (3.209 [1.563-6.589]; p = 0.002), LTC-MP (3.470 [1.067-11.284]; p = 0.039), PaCO2 on mechanical ventilation (1.101 [95% CI 1.034-1.173]; p = 0.003), and failure of the SBT (4.702 [2.250-9.825]; p < 0.001). In addition, female gender (0.401 [0.216-0.745]; p = 0.004), LTC-MP (3.017 [1.027-8.862]; p = 0.046), and PaCO2 on mechanical ventilation (1.157 [1.083-1.235]; p < 0.001) were independent risk factors for an unsuccessful SBT.ConclusionsIn the present study, the derived predictors of weaning point to a crucial role of the workload imposed on respiratory muscles during spontaneous breathing. Mechanical power normalized to lung-thorax compliance was independently correlated with weaning outcome and may identify patients at high risk for weaning failure.