Tracheobronchial Stenosis Medical Slides

Present the decision framework: Benign stenosis — silicone stent preferred (removable, repositionable, but requires rigid bronchoscopy for placement, can migrate in 10-20%). Avoid uncovered metallic SEMS in benign disease — granulation tissue ingrowth makes removal nearly impossible. Malignant stenosis — covered SEMS acceptable (self-expanding, can be placed via flexible bronchoscopy, immediate airway patency); uncovered SEMS for external compression (allows mucosal incorporation). Hybrid stents (covered metallic) offer intermediate properties. AQuIRE registry data shows stent-related complications in ~30% at 1 year.

Present the pathogenesis: cuff pressure exceeding mucosal perfusion pressure (>30 cmH2O) causes ischemic injury at the cuff site within 48-72 hours, progressing through inflammation, granulation, and cicatricial stenosis over 3-8 weeks post-extubation. Prevention: maintain cuff pressure 20-30 cmH2O (continuous monitoring preferred), minimize intubation duration, avoid oversized tubes, early tracheostomy in anticipated prolonged ventilation (>14 days per TracMan trial). Symptomatic stenosis develops when lumen narrows >50% — symptoms lag weeks to months after extubation.

Present iSGS as a distinct entity: predominantly affects women (95%) aged 20-60, located within 1-2 cm below vocal cords, circumferential cicatricial narrowing, no prior intubation history. Etiology likely involves estrogen and progesterone receptor-mediated fibroblast activation (ER/PR positive in surgical specimens). Management: serial endoscopic dilation ± local steroid injection (triamcinolone 40 mg/mL) — may require 1-3 dilations per year. Cricotracheal resection is definitive but reserved for refractory cases. Distinguish from GPA (check ANCA), sarcoidosis, and relapsing polychondritis.