Foster, K.A.

Abstract Introduction: Prolonged mechanical ventilation can often be complicated with post-intubation tracheal stenosis (PITS). It usually manifests within few weeks following extubation. However, delayed presentations are rare and have disastrous outcomes if not identified. Early recognition of stridor and dyspnea post-extubation is crucial for timely intervention. We report a case of late presentation of PITS in a 67-year-old female patient with new-onset stridor after prolonged intubation. Case: A 67-year-old female with past medical history of coronary artery disease, type 1 diabetes, obstructive sleep apnea presented with a six-week history of progressive dyspnea on exertion and stridor. This occurred in the context of a three-week intubation following a pulseless electrical activity (PEA) arrest over five months prior. Immediately post-extubation, the patient had developed stridor without hypoxia or exertional symptoms and was subsequently discharged home without further investigation. On this presentation, she was afebrile and saturating 95% on room air with audible inspiratory stridor at bedside. Respiratory viral panel and autoimmune work up was negative. Computed tomography (CT) scan noted a significant circumferential narrowing in the proximal portion of the trachea measuring 2.5 cm in length with 0.5 cm in width with associated wall thickening. She was managed with 2.25% racemic epinephrine as needed and prednisone 10 mg daily with rescue continuous positive airway pressure (CPAP) until intervention could be safely performed after clopidogrel washout. On Day 5, she underwent rigid bronchoscopy with extensive CO2 laser vaporization (Fig. B) of scar release and paclitaxel-coated balloon dilation of the 3 mm narrowing (Fig. A) to 12 mm (Fig. C). Her stridor resolved with significant improvement in dyspnea and exercise tolerance. She was subsequently discharged on a steroid taper with outpatient interventional pulmonology follow up for repeat rigid bronchoscopy in 4 weeks to evaluate for restenosis. Discussion: Tracheostomy is often considered when extended period of intubation is anticipated as it can lead to increased risk of complications like PITS. It is important to have a high index of suspicion for tracheal stenosis in patients with a history of prolonged mechanical ventilation presenting with new-onset stridor, even when the symptoms are mild or intermittent. Early recognition and timely intervention can prevent the progression of stenosis and improve morbidity and clinical outcomes. Additionally, these patients tend to have an increased incidence of recurrence which requires close follow up for restenosis.