Multidisciplinary approach to management of postintubation tracheal stenoses

The optimal management of postintubation tracheal stenosis is not well defi ned, A therapeutic algorithm was designed by thoracic surgeons, ear, nose and th roat (ENT) surgeons, anaesthetists and pulmonologists, Rigid bronchoscopy w ith neodymium-yttrium aluminium garnet (Nd-YAG) laser resection or stent im plantation (removable stent) was proposed as first-line treatment, dependin g on the type of stenosis (web-like versus complex stenosis), In patients w ith web-Like stenoses, sleeve resection was proposed when laser treatment ( up to three sessions) failed. In patients with complex stenoses, operabilit y was assessed 6 months after stent implantation. If the patient was judged operable, the stent was removed and the patient underwent surgery if the s tenosis recurred. This algorithm was validated prospectively in a series of 32 consecutive pa tients. Three patients died from severe coexistent illness shortly after th e first bronchoscopy. Of the 15 patients with web-like stenosis, laser rese ction was curative in 10 (66%). Among the 17 patients with complex stenoses , three remained symptom-free after stent removal. Bronchoscopy alone was t hus curative in more than one-third of the patients. Six patients underwent surgery, two after failure of laser resection and four after failure of te mporary stenting, Surgery was always performed with the patient in good ope rative condition. Palliative stenting was the definitive treatment in nine cases. Tracheostomy was the definitive solution in two cases. This approach, including an initial conservative treatment, depending on th e type of the stenosis, appears to be applicable to almost all patients and allows secondary surgery to be performed with the patient in good conditio n.