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Bronchoscopic topical steroid instillation in prevention of tracheal stenosis.

Agarwal A, Singh DK - J Anaesthesiol Clin Pharmacol (2014)

Bottom Line: Corrosive acid poisoning commonly results in chemical injuries to respiratory and upper gastrointestinal tract.Corrosive mucosal erosion of the larynx and trachea may occur if the patient aspirates acid.We successfully used local anti-inflammatory action of dexamethasone instilled through a fiber-optic bronchoscope for regression of mucosal edema and prevention of subsequent development of stricture in a young female.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Critical Care, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India.

ABSTRACT
Corrosive acid poisoning commonly results in chemical injuries to respiratory and upper gastrointestinal tract. Corrosive mucosal erosion of the larynx and trachea may occur if the patient aspirates acid. We successfully used local anti-inflammatory action of dexamethasone instilled through a fiber-optic bronchoscope for regression of mucosal edema and prevention of subsequent development of stricture in a young female.

No MeSH data available.


Related in: MedlinePlus

Initial bronchoscopic view with marked edema and airway narrowing
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Figure 1: Initial bronchoscopic view with marked edema and airway narrowing

Mentions: We received a 22 year girl, a known schizophrenic, with alleged history of acid ingestion followed by multiple episodes of vomiting and abdominal pain. She presented in altered sensorium (Glasgow Coma Sacle (GCS)-E2V2M3) with rapid shallow breathing. In view of her low GCS (<8), trachea was intubated with a size 7.0 mm cuffed endotracheal tube in the emergency department and she was subsequently shifted to the critical care unit for further management. She was initially put on synchronized intermittent mandatory ventilation mode with tidal volume 450 ml, respiratory rate 12/min and a pressure support of 14 cm H2O. Gradually her respiratory effort improved, and she could be weaned to continuous positive airway pressure mode with a pressure support of 10 cm H2O. Eventually, she was weaned off to T-piece within 24 h of admission to ICU and was extubated on day 2 of admission. Post-extubation arterial blood gas analysis on FiO2 0.21 was pH-7.443, PaCO2-36.0 mm Hg, and PaO2-243 mm Hg. After around 6 h of extubation patient started developing respiratory distress with inspiratory stridor and a respiratory rate of 40-42 breaths/min. Hence reintubation was performed with difficulty using a snugly fitting 6.0 mm endotracheal tube. A USG neck was planned to diagnose the cause and site of airway obstruction, and it revealed supraglottic tracheal narrowing and edema. As she could be intubated with a maximum tube size of 6.0 mm only, which offered resistance to breathing, a percutaneous tracheostomy was planned below the level of tracheal narrowing so as to bypass the pathology as confirmed by USG. She was tracheostomized with 7.5 mm cuffed tracheostomy tube. Fiber-optic bronchoscopy was carried out to observe the mucosal changes. Tracheal mucosa showed intense inflammation. These inflammatory changes prompted us towards initiation of steroid therapy. We explored the option of nebulized steroids but owing to tracheostomy site being below the inflammation site, nebulized steroids would bypass the pathology and proven futile. We therefore planned topical instillation of dexamethasone right at the site of inflammation through a fiber-optic bronchoscope. We used a dilute solution of dexamethasone. A total of 8 mg dexamethasone was diluted to a volume of 5 ml. The tip of the bronchoscope was positioned in the trachea so as to focus the lesion. The steroid solution was loaded in a syringe, which was attached to the oxygen insufflation port of the bronchoscope. The solution was then pushed down through the bronchoscope along with simultaneous fine rotation of the fiber-optic tip so that the steroid solution topically covered the lesion. The bronchoscope was then withdrawn. This method of steroid instillation was performed once in 8 h. With progressive instillation of dexamethasone for 5 days, we noticed progressive resolution of edema and near normalization of tracheal mucosal epithelium [Figures 1-4]. Eventually, patient was decannulated on the 7th day of admission.


Bronchoscopic topical steroid instillation in prevention of tracheal stenosis.

Agarwal A, Singh DK - J Anaesthesiol Clin Pharmacol (2014)

Initial bronchoscopic view with marked edema and airway narrowing
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3927302&req=5

Figure 1: Initial bronchoscopic view with marked edema and airway narrowing
Mentions: We received a 22 year girl, a known schizophrenic, with alleged history of acid ingestion followed by multiple episodes of vomiting and abdominal pain. She presented in altered sensorium (Glasgow Coma Sacle (GCS)-E2V2M3) with rapid shallow breathing. In view of her low GCS (<8), trachea was intubated with a size 7.0 mm cuffed endotracheal tube in the emergency department and she was subsequently shifted to the critical care unit for further management. She was initially put on synchronized intermittent mandatory ventilation mode with tidal volume 450 ml, respiratory rate 12/min and a pressure support of 14 cm H2O. Gradually her respiratory effort improved, and she could be weaned to continuous positive airway pressure mode with a pressure support of 10 cm H2O. Eventually, she was weaned off to T-piece within 24 h of admission to ICU and was extubated on day 2 of admission. Post-extubation arterial blood gas analysis on FiO2 0.21 was pH-7.443, PaCO2-36.0 mm Hg, and PaO2-243 mm Hg. After around 6 h of extubation patient started developing respiratory distress with inspiratory stridor and a respiratory rate of 40-42 breaths/min. Hence reintubation was performed with difficulty using a snugly fitting 6.0 mm endotracheal tube. A USG neck was planned to diagnose the cause and site of airway obstruction, and it revealed supraglottic tracheal narrowing and edema. As she could be intubated with a maximum tube size of 6.0 mm only, which offered resistance to breathing, a percutaneous tracheostomy was planned below the level of tracheal narrowing so as to bypass the pathology as confirmed by USG. She was tracheostomized with 7.5 mm cuffed tracheostomy tube. Fiber-optic bronchoscopy was carried out to observe the mucosal changes. Tracheal mucosa showed intense inflammation. These inflammatory changes prompted us towards initiation of steroid therapy. We explored the option of nebulized steroids but owing to tracheostomy site being below the inflammation site, nebulized steroids would bypass the pathology and proven futile. We therefore planned topical instillation of dexamethasone right at the site of inflammation through a fiber-optic bronchoscope. We used a dilute solution of dexamethasone. A total of 8 mg dexamethasone was diluted to a volume of 5 ml. The tip of the bronchoscope was positioned in the trachea so as to focus the lesion. The steroid solution was loaded in a syringe, which was attached to the oxygen insufflation port of the bronchoscope. The solution was then pushed down through the bronchoscope along with simultaneous fine rotation of the fiber-optic tip so that the steroid solution topically covered the lesion. The bronchoscope was then withdrawn. This method of steroid instillation was performed once in 8 h. With progressive instillation of dexamethasone for 5 days, we noticed progressive resolution of edema and near normalization of tracheal mucosal epithelium [Figures 1-4]. Eventually, patient was decannulated on the 7th day of admission.

Bottom Line: Corrosive acid poisoning commonly results in chemical injuries to respiratory and upper gastrointestinal tract.Corrosive mucosal erosion of the larynx and trachea may occur if the patient aspirates acid.We successfully used local anti-inflammatory action of dexamethasone instilled through a fiber-optic bronchoscope for regression of mucosal edema and prevention of subsequent development of stricture in a young female.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology and Critical Care, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India.

ABSTRACT
Corrosive acid poisoning commonly results in chemical injuries to respiratory and upper gastrointestinal tract. Corrosive mucosal erosion of the larynx and trachea may occur if the patient aspirates acid. We successfully used local anti-inflammatory action of dexamethasone instilled through a fiber-optic bronchoscope for regression of mucosal edema and prevention of subsequent development of stricture in a young female.

No MeSH data available.


Related in: MedlinePlus