Young woman with recurrent paroxysmal stridor after extubation

Dong Eun Lee; Jong Kun Kim; Sin-Youl Park

doi:10.15441/ceem.24.311

A 21-year-old woman presented to the emergency department unconscious after an overdose of antidepressants. Her vital signs were blood pressure 90/60 mmHg, heart rate 71 beats per minute, and oxygen saturation 98%. Physical examination was unremarkable. Endotracheal intubation was performed to maintain airway patency. A first-year resident performed successful initial intubation without difficulty. Endotracheal tube cuff pressure was measured with a cuff pressure gauge and was maintained at 20 to 25 cmH₂O. Ventilator weaning was initiated on day 1, and extubation was performed 25 hours after admission. Dexamethasone was administered before extubation, and nebulized epinephrine was given after extubation.

Six hours after extubation, she developed sudden stridor with oxygen saturation of 88%, which improved with high-flow oxygen therapy but recurred 18 hours later. Chest computed tomography (CT) revealed intraluminal tracheal soft tissue, and bronchoscopy revealed desquamated tracheal mucosa causing airway obstruction (Fig. 1).

Postextubation stridor is a common complication of intubation, typically due to laryngeal edema [1]. Prophylactic steroids and nebulized epinephrine are effective preventative strategies. Persistent or recurrent stridor requires evaluation for alternative causes. Intubation-induced tracheal injury, although rare, may result in airway obstruction due to desquamated mucosa [2].

Chest CT is useful in identifying tracheal injuries and associated complications [3]. Bronchoscopy provides definitive evaluation, and bronchoscopic forceps removal is considered the first-line treatment for airway obstruction [4]. In cases where forceps are ineffective, bronchoscopic cryoextraction is a viable alternative [5].

In this case of partial airway obstruction due to intubation-induced mucosal desquamation, cryoextraction resolved airway obstruction by removing the desquamated mucosa without significant bleeding (Fig. 2). The patient was discharged the next day, and no respiratory distress or bleeding was reported at the 7-day follow-up.

NOTES

Ethics statement

Written informed consent for publication of clinical details and images was obtained from the patient.

Author contributions

Conceptualization: SYP; Investigation: all authors; Project administration: all authors; Supervision: SYP; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

REFERENCES

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2. Cardillo G, Carbone L, Carleo F, et al. Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment. Eur J Cardiothorac Surg 2010; 37:581-7.

3. Chen JD, Shanmuganathan K, Mirvis SE, Killeen KL, Dutton RP. Using CT to diagnose tracheal rupture. AJR Am J Roentgenol 2001; 176:1273-80.

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5. DiBardino DM, Lanfranco AR, Haas AR. Bronchoscopic cryotherapy: clinical applications of the cryoprobe, cryospray, and cryoadhesion. Ann Am Thorac Soc 2016; 13:1405-15.

Fig. 1.

Chest radiography and computed tomography (CT) findings in a patient with stridor after extubation. (A) Chest radiography revealed nonspecific findings. (B) Coronal chest CT demonstrated two thin membranous structures within the trachea and extending diagonally across it, approximately 28 mm below the vocal cords. Each membranous structure measured approximately 34 mm in length, causing partial airway obstruction. (C, D) Axial chest CT showed a rounded membranous structure attached to the posterior tracheal wall. This membranous structure extended from the posterior aspect of the trachea to the 5 o’clock position and measures approximately 34 mm in total length.

Fig. 2.

Bronchoscopic findings and cryoextraction procedure. (A) Initial bronchoscopy showed a thin, scaly mucosal membrane obstructing the trachea, 28 mm below the vocal cords. Attempts to remove the membrane with bronchoscopic forceps were unsuccessful due to poor grasping, and the procedure was halted to prevent bleeding. (B) The following day, bronchoscopy prior to cryoextraction revealed persistent obstruction by the desquamated mucosa. Good adhesion was achieved between the cryoprobe and the desquamated tissue. (C) Post-cryoextraction bronchoscopy confirmed resolution of airway obstruction, with no significant or persistent bleeding. (D) The extracted desquamated mucosa measured approximately 34 mm in length and had a semicylindrical shape, likely resulting from tracheal mucosal injury during endotracheal tube insertion.