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LETTER TO THE EDITOR

A Severe Complication of Short-Term Tracheal Intubation

Department of Diseases of the Thorax, GB Morgagni-Pierantoni Hospital, Forlì, Italy, casonig1970{at}libero.it (Casoni) Department of Anaesthesia and Intensive Care Unit, GB Morgagni-Pierantoni Hospital, Forlì, Italy (Coffa) Department of Diseases of the Thorax, GB Morgagni-Pierantoni Hospital, Forlì, Italy (Gurioli) Department of Anaesthesia and Intensive Care Unit, GB Morgagni-Pierantoni Hospital, Forlì, Italy (Terzitta, Gambale) Department of Diseases of the Thorax, GB Morgagni-Pierantoni Hospital, Forlì, Italy (Poletti)

To the Editor:

We report a case of an 84-yr-old woman presenting with a poorly known but potentially fatal complication of endotracheal intubation: obstructive fibrinous tracheal pseudomembrane (OFTP) (1,2). The patient was admitted to the hospital’s Emergency Department for exacerbated chronic obstructive pulmonary disease. Because of respiratory failure, we intubated her trachea with a high volume-low pressure cuffed tube ("Blue Line" Tube, Portex Limited, Hythe, Kent, England) for 18 h. The first symptoms of OFTP occurred 6 h after extubation. She developed symptoms of acute airway obstruction with stridor, progressive respiratory failure, and hypercapnia. Fiberoptic bronchoscopy showed typical OFTP, with a thick, tubular, milky, rubber-like opaque pseudomembrane molding covering 2–3 cm of the tracheal wall at the level of the endotracheal cuff. We were able to detach the pseudomembrane "en bloc" from the tracheal wall and remove it using a rigid bronchoscope and forceps.

OFTP could be the first step of a process towards tracheal stenosis. OFTP’s pathological features (superficial abrasion of the mucosa, thick fibrinous material with polymorphonuclear infiltration, and desquamated necrotic tracheal epithelium) suggest this lesion as an early stage of tracheal ischemic damage related to cuff-induced injury. Unexplained occurrence of respiratory failure with symptoms of upper airway obstruction shortly after extubation should lead to consideration of the diagnosis of OFTP. Fiberoptic and rigid bronchoscopy is both diagnostic and potentially curative (3).

REFERENCES

1. Deslee G, Brichet A, Lebuffe G, et al. Obstructive fibrinous tracheal pseudomembrane. A potentially fatal complication of tracheal intubation. Am J Respir Crit Care Med 2000;162:1169–71.[Abstract/Free Full Text]
2. Harbison J, Collins D, Lynch V, McNicholas WT. Acute stridor due to upper tracheal membrane following endotracheal intubation. Eur Respir J 1999;14:1238.[Web of Science][Medline]
3. Brichet A, Verkindre C, Dupont J, et al. Multidisciplinary approach to management of post-intubation tracheal stenoses. Eur Respir J 1999;13:888–93.[Abstract]

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