Tracheal stenosis is an abnormal narrowing of the trachea that can develop from prolonged intubation causing scarring due to pressure injury. It can also occur due to high cuff pressures from either the tracheostomy tube or the endotracheal tube cuff. Tracheal stenosis commonly develops at the stoma site or at the level of the cuff. When stenosis occurs at the stoma, it is usually due to bacterial infection and chondritis. Granulation tissue can develop at the stoma site and may obstruct the airway at the stoma site. The tissue can cause difficulty with replacing the tracheostomy tube (Epstein, 2005).
Overinflation of the cuff can result in scarring and narrowing of the trachea and it is preventable by managing cuff pressures. The development of high-volume low-pressure tracheostomy-tube cuffs has led to a significant reduction in tracheal stenosis at the cuff site (Epstein, 2005). Appropriate tracheostomy tube size and providing cuffless tracheostomy tubes as soon as feasible are also ways to reduce tracheal stenosis.
Diagnosis of tracheal stenosis is often delayed. It may present as increased cough or difficulty clearing secretions. If the individual is on mechanical ventilation, the presentation may be difficulty weaning with intermittent high peak airway pressures,
There are several ways to image the tracheal air column, including chest radiography, tracheal tomography, CT, and magnetic resonance imaging. However, bronchoscopy is indicated in patients with suspected tracheal stenosis (Mitchell, 2013).
An extra long distal tracheostomy tube can be used to bypass the tracheal stenosis. In a retrospective study by Rosenbeck, he reviewed 37 patients who had tracheally obstruction, confirmed by bronchoscopy. They all initially failed to wean, had difficulty in breathing and developed intermittent high peak airway pressures either early or during the weaning process or just on being ventilated. The insertion of a longer tracheal tube bypassed the obstruction, reestablished the airway, decreased peak airway pressures, and allowed the patient to breathe more easily. Treatment consisted of either placement of a longer tracheal tube (34 of 37 patients) or placement of a tracheal stent. All but two of the patients (5.4%) were able to be weaned within a week. This study shows the importance of identifying tracheal stenosis.
Depending on the location and severity of the stenosis, surgery may be necessary. Approximately 3 to 12% of all tracheostomized patients will develop clinically significant stenosis that will require intervention (Epstein, S., 2005). Common options include tracheal resection and reconstruction, bronchoscopic tracheal dilation, laser bronchoscopy, or tracheal broncial airway stent.