Tracheal stenosis is an often underdiagnosed disease that can have numerous causes, including trauma, infection, autoimmune disease, and injury related to intubation. Severe tracheal stenosis is an emergent situation, and early recognition is important. We present a case of tracheal stenosis that was evaluated and managed in the outpatient setting, highlighting key clinical findings that help with diagnosis.

The patient is a 38 yo male with hypertension, OSA, morbid obesity, heart failure, and chronic hypercapnic/hypoxic respiratory failure. He was admitted to the hospital for dyspnea due to volume overload and required intubation for severe hypoxemia. After adequate diuresis, he was extubated but found to have post-extubation stridor that improved with racemic epinephrine and IV decadron. He was discharged after 8 days. Over the next month, he continued to have dyspnea and complained about new “loud breathing.” He was seen by a few providers and noted to have wheezing but no actions were taken. He was eventually seen by pulmonology, where he was again noted to have loud inspiratory wheezing without expiratory wheezing over the lower lung fields. Due to concerns for stridor, a chest x-ray was obtained that showed tracheal narrowing at the level of the clavicles. Pulmonary function tests were performed for further evaluation and demonstrated flattening of both the inspiratory and expiratory limbs of the flow-volume loop, suggestive of a fixed obstruction often seen with tracheal stenosis. The patient was sent for high-resolution CT that same day, confirming significant tracheal stenosis at the thoracic inlet. He was set up for bronchoscopy within 48 hours, and had definitive treatment with balloon dilation.

Tracheal stenosis has been reported in up to 19% of intubated patients(1), and this seems to be more common in women and patients with obesity, hypertension, cardiovascular disease, and cigarette use(2). Our case of intubation-induced tracheal stenosis was left untreated for nearly 5 weeks and highlights how difficult it can be to recognize this diagnosis in the outpatient setting in a patient not in respiratory distress. It is important to have a low threshold for additional work-up for this life-threatening disease in the right clinical context.

References and Resources

1. Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1981;70(1):65-76. doi:10.1016/0002-9343(81)90413-7
2. Zias N, Chroneou A, Tabba MK, et al. Post tracheostomy and post intubation tracheal stenosis: report of 31 cases and review of the literature. BMC Pulm Med. 2008;8:18. Published 2008 Sep 21. doi:10.1186/1471-2466-8-18