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Department of Anaesthesia and Intensive Care; Postgraduate Institute of Medical Education and Research; Chandigarh, India; ykbatra{at}glide.net.in
To the Editor:
Tracheomalacia is a rare complication that may occur after trauma (long-term intubation), infection, and chronic external compression of the trachea (1). We report a case in which intubation of a short duration precipitated tracheomalacia in a patient with an asymptomatic goiter.
A 74-yr-old woman was scheduled for total hip arthroplasty because of severe painful osteoarthritis. Her medical history was significant for an asymptomatic goiter (except for a hard swelling of 6–8 cm) of 12 yr duration (clinically and biochemically euthyroid). The surgery was completed uneventfully under combined spinal epidural technique. In the postanesthesia care unit, she became hypotensive and disoriented after 1.5 L of blood loss and her trachea was intubated with a 7.5-mm cuffed tracheal tube and mechanical ventilation initiated. The patient was adequately resuscitated and the trachea was extubated on the first postoperative day. About 2 h later, she developed dyspnea, stridor, and the trachea was reintubated. A repeat extubation attempt on the second postoperative day failed similarly and bronchoscopy revealed the presence of tracheomalacia. A thyroidectomy was performed and no retrosternal extension was found. The patient was discharged with tracheostomy in situ.
Stridor secondary to tracheomalacia usually becomes evident only when the tracheal diameter is reduced to <3.5 mm, signaling critical functional obstruction (2). This unusual collapse of the trachea may be attributed to some subtle change in the structure of the soft tissues of the tracheal wall produced by the presence of a long-standing goiter. This condition may also occur as a manifestation of the general aging process, since acquired tracheomalacia is more frequent in older people (3). Risk factors for tracheomalacia are a preoperative history of stridor, radiological evidence of tracheal deviation or compression, retrosternal goiter, and difficult intubation. There were no findings in our patient’s history, or on the preoperative examination except for the presence of a goiter, suggesting the respiratory difficulty. Long-term intubation with a cuffed endotracheal tube may cause tracheomalacia. In the case of our patient, however, intubation of only 24 h produced tracheomalacia, presumably by altering the integrity of the already thinned out tracheal wall that predisposed it to collapse probably because of cyclical friction during mechanical ventilation. Hypotension in the postanesthesia care unit might have decreased tracheal blood flow further contributing to the development of tracheomalacia. Increase in respiratory effort, coughing and retention of secretions might have caused a vicious cycle worsening the collapse and producing stridor after extubation.
REFERENCES
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