Airway Management of a Post Tracheostomy Stenosis Patient With Respiratory Difficulty: Make Sure You Have Fibre Optic Guidance Before Administering a Muscle Relaxant!

Dear Editor, Post-tracheostomy stenosis is a rare but serious complication that may be encountered in the emergency department (ED). The incidence of severe tracheal stenosis (TS) with symptoms is seen in 1-2% of patients (1-3). Patients with severe TS may present with respiratory difficulty, requiring emergency intubation in the ED. A 35-year-old male was a follow-up case of an exploratory laparotomy for a blunt injury to his abdomen. He had stayed 25 days in the ICU with a tracheostomy. His decannulation was done a week prior to his presentation to the ED. The patient had a respiratory rate of 24/minute; air entry was present bilaterally but decreased, and stridor was present. Computed tomography (CT) (Figure 1), revealed TS with a constriction band of 9 mm, 3 cm distal to the larynx and 6.9 cm proximal to the carina. The patient was shifted to the ICU and was posted for tracheal resection anastomosis the next day. In the operating theater, all routine monitoring was attached. Based on CT findings, it was decided to do a fiber optic bronchoscopy (FOB), 5.7 mm in size, both for identifying the stricture and for intubation. The patient was given a superior and transtracheal nerve block and awake FOB intubation was tried. On the first attempt, a fibrous web was seen (Figure 2) a short distance below the larynx and a small constriction was present. Despite several attempts, we were not able to negotiate the FOB through the constriction. Any patient with Post tracheostomy stenosis presenting with respiratory difficulty should be approached with caution in emergency department. No muscle relaxant and deep sedation should be given without adequate back up like fibre optic bronchoscope and preparation of emergency tracheostomy. Therefore, we decided to puncture the fibrous web Figure 1. Computed Tomography Image of Lateral Neck, Showing Tracheal Stenosis (White Arrow)