Answers:
After undergoing a tracheotomy, a patient has been intubated in the ICU for the past two weeks. A resident rounding on the patient notices that the trach tube cuff is overinflated and that the trach tube is poorly positioned. Suddenly the patient begins to bleed profusely from their mouth and trach site? What is the most likely diagnosis?
A) Aortic Arch Aneurysm
B) Coagulopathy
C) Tracheoesophageal Fistula
D) Tracheoinnominate Fistula
Tracheoinnominate, a complication of tracheal intubation. Initial management should include overinflatting the tracheal cuff to attempt to stop bleeding as well as manually compressing the artery against the sternum. Then proceed directly to the OR as prognosis is poor.
What are the three types of postintubation stenosis?
Stomal Stenosis
-due to prior trach
-most common cause of benign tracheal stenosis
-once trach removed, granulation tissue forms at opening and scarring creates an A-shaped lumen.
-Lumen must decrease 70-75% for pts to be symptomatic
-dilation often works transiently but ultimately surgery is often needed.
Cuff Stenosis
-due to transmural ischemia below the cricoid.
-requires surgery
Subglottic Stenosis
-due to trauma to endolaryngeal structures distal to vocal cords.
-often caused by improperly placed cricothyroidotomy tube or oversized ETT.
A) Hemoptysis
B) increased tracheal secretions
C) presence of gastric secretions in airway
D) recurrent pneumonia
E) gastric dilation
Free Response Questions:
Name several ways to prevent tracheoinnominate fistula formation.
Quick Facts:
Tracheomalacia
-Weakness of the trachea leading to collapse of airway.
-Commonly acquired via trach or ETT intubation.
-Dx w/ endoscopic visualization and cross sectional CT.
Treatment
-Control bronchospasms
-Bipap may be effective.
-Multiple surgical options
-Mesh tracheoplasty appears to be operation of choice currently.
A) Aortic Arch Aneurysm
B) Coagulopathy
C) Tracheoesophageal Fistula
D) Tracheoinnominate Fistula
Tracheoinnominate, a complication of tracheal intubation. Initial management should include overinflatting the tracheal cuff to attempt to stop bleeding as well as manually compressing the artery against the sternum. Then proceed directly to the OR as prognosis is poor.
What are the three types of postintubation stenosis?
Stomal Stenosis
-due to prior trach
-most common cause of benign tracheal stenosis
-once trach removed, granulation tissue forms at opening and scarring creates an A-shaped lumen.
-Lumen must decrease 70-75% for pts to be symptomatic
-dilation often works transiently but ultimately surgery is often needed.
Cuff Stenosis
-due to transmural ischemia below the cricoid.
-requires surgery
Subglottic Stenosis
-due to trauma to endolaryngeal structures distal to vocal cords.
-often caused by improperly placed cricothyroidotomy tube or oversized ETT.
MC Question:
All of the following are classic signs of tracheoesophageal fistulas except?A) Hemoptysis
B) increased tracheal secretions
C) presence of gastric secretions in airway
D) recurrent pneumonia
E) gastric dilation
Free Response Questions:
Name several ways to prevent tracheoinnominate fistula formation.
Quick Facts:
Tracheomalacia
-Weakness of the trachea leading to collapse of airway.
-Commonly acquired via trach or ETT intubation.
-Dx w/ endoscopic visualization and cross sectional CT.
Treatment
-Control bronchospasms
-Bipap may be effective.
-Multiple surgical options
-Mesh tracheoplasty appears to be operation of choice currently.
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