The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
How I Do It
Acquired Tracheal Dilatation After Prolonged Ventilation: An Unusual Treatment Option Marco Giudice, MD; Stefania Gallo, MD; Marco P. Maffioli, MD; Giulio Minoja, MD; Giuseppe Mazzi, MD; Surendra Narne, MD; Paolo Castelnuovo, MD
INTRODUCTION Tracheal dilatation is an infrequently recognized late-onset complication of cuffed endotracheal intubation. The reported rate of incidence is 2% to 5% among patients requiring prolonged ventilatory support. Although the use of high-compliance, low-pressure soft cuffs introduced in the early 1980s could significantly reduce the morbidity of prolonged intubation,1 international literature still does not provide sufficient data for the management or outcomes of this rare but severe condition in patients with long-term use tracheal devices. We present a case of an unusual management technique for tracheal dilatation secondary to prolonged intubation.
TECHNICAL NOTE A 30-year-old female was admitted to the intensive care unit (ICU) of our institution for recurrent episodes of respiratory distress. The patient, affected by tetraplegia, had a tracheotomy 13 years earlier for chronic respiratory failure, which required prolonged all-day mechanical ventilation as a consequence of cervical spine trauma after a car accident. The respiratory distress appeared as acute hypoxemia with multiple episodes of oxygen desaturation down to 60% to 70%. The cause of these episodes was attributed to a dilated trachea, mainly at the level of the cervical tracheal stoma, which concurred to frequent displacement of the tracheal cannula with air escape around the tube, an increased need
From the Airway Endoscopic Surgery Department (S.N.), University of Padua, Azienda Ospedaliera di Padova, Padua, is now ENT– Specialist; the Department of Otorhinolaryngology (M.G., S.G., M.P.M., P.C.); and the Department of Anaesthesiology and Intensive Care (GIULIO M., GIUSEPPE M.), University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy Editor’s Note: This Manuscript was accepted for publication February 11, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Marco Giudice, MD, Department of Otolaryngology, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy. E-mail: [email protected] DOI: 10.1002/lary.24645
Laryngoscope 124: October 2014
of air volume for an adequate cuff seal, and trouble in preserving the airways’ ventilation. The tracheal damage extended from the skin of the anterior neck around the previous tracheotomy to the deeper soft tissues around the tracheal pipe and posteriorly up to the anterior vertebral wall. A chronic local inflammation was evident, with granulations and purulent secretions around the tracheal cannula. The microbiological examination was positive for an infection sustained by Pseudomonas aeruginosa, treated with intravenous antibiotic (meropenem, MERREM). A computed tomography (CT) scan confirmed the dilatation of the trachea beginning from the skin of the tracheal stoma down for about 5.4 cm (from the carina, 5 tracheal rings appeared to be undamaged with normal caliber). The anterior wall of the cranial tract of the trachea was absent, probably due to infection and subsequent necrosis of the tracheal rings with initial exposure of the major epiaortic vessels. In addition, an anterior erosion of the cervical vertebral bones was detected. The residual “crater,” extending from the anterior wall (soft retrosternal tissues) to the posterior one (vertebral eroded bones), measured about 3.5 cm (Fig. 1). No tracheo-esophageal fistulas were found during the endoscopic examination. The management options were discussed with a multidisciplinary team (anesthesiologist, ENT, and thoracic surgeons). The use of an extra-long tracheal tube again resulted in frequent displacement due to the enlarged tracheal opening. Surgical procedures such as tracheoplasty and reconstruction of the damaged tissues around the tracheal wall were discarded as a first approach due to the high risk of surgical intraoperative and perioperative complications and the patient’s clinical status. A tracheal reconstruction with prefabricated free flaps was taken into account, but the phlogosis around the defect and the urgency for a proper mechanical ventilation leaned toward an immediate conservative treatment. The controversy was resolved by an innovative technique based on a “home-made trick” (conceived of by one of the present author (S.N.)). The procedure was performed in the ICU with the patient under sedation with repeated boluses of Diprivan (propofol). We employed a tailored T-tube n. 18, 12
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
2309
Fig. 1. Computed tomography scan in sagittal and axial plane showing the tracheal dilatation with damage of the skin and soft tissues of the neck. yellow line: size of the tracheal stoma (3.4 cm); blue line: cranio–caudal size of the tracheal dilatation (5.4 cm); orange line: size of the undamaged trachea (2.7 cm); red line: antero–posterior diameter of the tracheal dilatation (3.6 cm). [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
cm in length. The tube was manually altered into a clarinet mouthpiece-like shape (Fig. 2). A tracheal cuffed cannula (Portex, Norwell, MA) with flange n. 8 was placed inside the external arm of the T-tube, with the cuff protruding beyond the distal arm of the tube by about 4 cm (Fig. 3). The tracheal cannula “snap-fitted” into the T-tube, closed the proximal arm of the tube from the airflow, firmly fixing the whole system. The device was then placed inside the tracheotomy, fixed with a textile collar, inserting the proximal arm of the Ttube into the subglottic region of the larynx. At last, the distal portion of the cannula was located 1 cm from the carina, guaranteeing an adequate clearing of the dilated tract. This kind of T-tube prosthesis combined with the cuff of the tracheal tube was able to fix the “modified device” to the tracheal and laryngeal pipe, preserving the ventilation without direct pressure of the cuff onto the damaged tissues. A videoendoscopy and CT scan performed at the end of the procedure confirmed the correct setting of the system, which was maintained for the following 2 months and then regularly changed every 2 months under sedation in the ICU. Home Care consisted of a daily cleaning with normal saline solution of the outer portion of the whole system (external arm of the Ttube and tracheal cannula) and the surrounding skin, and catheter suction of the tracheal cannula. The patient is still in mechanical ventilation through the described system, without evidence of further ventilatory complications at 1-year follow-up. The damage of tisLaryngoscope 124: October 2014
2310
sues decreased with resolution of the local infection and gradual reduction of the initial dilatation (Fig. 4).
DISCUSSION Persistent tracheal dilatation was first recognized by Lloyd in 19642 as a complication of tracheotomy or
Fig. 2. T-tube n. 18, manually altered into a clarinet mouthpiecelike shape. A 5 proximal arm; B 5 external arm; C 5 distal arm. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
Fig. 3. Image of the employed system, consisting of a tracheal cuffed cannula (Portex; flange n. 8) set inside the external arm of the T-tube, with the cuff protruding beyond the tube for about 4 cm. A 5 proximal arm; B 5 external arm; C 5 distal arm. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
prolonged mechanical ventilation. It is known that capillary perfusion pressure of the tracheal mucosa is 25 mmHg to 30 mmHg; a lower cuff pressure is required to prevent ischemic necrosis of the mucosal surface, which leads to lumen stenosis.3 In addition, the ischemic injury followed by chondritis, destruction, and necrosis of the supporting tracheal cartilage leads to a tracheal dilatation.4 The most frequent site of tracheal weakening is reported to be at the level of the tracheal stoma, followed by the site of the inflatable cuff (1.5 cm or more
below the stoma) and occasionally the point of impingement of the tip of the tracheostomy tube.5 Before the introduction of high-volume, low pressure cuffs, the incidence of this complication was described to be as high as 24%6; however, in recent years the percentage decreased. The management of tracheal dilatation and reconstruction is difficult and still debated.7 All authors agree on the need for a safe and long-term solution that can provide an autologous well-vascularized tissue, structurally supported, in order to prevent stenosis and scarring. Different surgical options are suggested in the literature, involving the employment of composite pedicled and free flaps (i.e., pectoral, deltopectoral, or forearm flaps) with or without costal cartilage graft, and also mucosal grafts in selected cases.8,9 Autologous mesenchymal stem cell-derived chondrocytes, autologous cultured epithelial cell, and matrix derived from tracheal grafts are also well reported.10 Preliminary studies on animals11 showed good results from the use of autologous cervical skin flaps scaffolded with costal cartilages to replace long-segment tracheal defects. These often are multi-staged surgical procedures that have potential intraoperative and postoperative complications (i.e., suture-line dehiscence with infection and mediastinitis or granulation and subsequent stenosis) . Different endotracheal tubes are proposed as a treatment option, especially when a multi-staged procedure is not indicated or advisable, as in this case. The idea is to achieve a good balance between the need for a positive pressure ventilation and the protection of
Fig. 4. Computed tomography scan in sagittal and axial plane performed after 1 year follow- up, which confirmed the correct setting of the system. orange line 5 distance between the tip of the device and the tracheal carina (1.5 cm); red line 5 antero–posterior diameter of the device (1.7 cm), with evident reduction of the tracheal dilatation, progressively replaced by scarring tissue. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 124: October 2014
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
2311
airways from the aspiration of secretions and gastric contents, without exceeding the tracheal mucosal pressure, while paying attention to the volume and cuff pressure and monitoring them routinely (cuff pressure should be restricted to less than 25 mmHg).12 In the present case, the main problems were: the complexity of maintaining adequate mechanical ventilation with a standard cuffed tracheal tube; the risk that a high pressure cuff could worsen the tracheal damage; and the instability of the cannula inside the dilated trachea, which caused frequent displacement. The technical artifice consisted of placing the tracheal tube cuff underneath the damaged portion of the trachea, with a controlled cuff pressure protecting the residual normal tracheal rings. This was achieved with the combined system of a T-tube and a cuffed Portex in order to overcome the dilated tracheal tract and maintain the all-day mechanical ventilation. This method, at first easy to build up, and probably not impeccable but safe and with low morbidity, did not immediately decrease the tracheal diameter. Our goal was to reduce the risk of further dilatation. Furthermore, at 1 year follow-up, not only was the ventilation maintained but the tracheal diameter and tissue inflammation were reduced. Given the safety and the efficacy of the system to date, and the ease of its periodical replacement, it is reasonable to think that it can be maintained life-long, unless complications arise.
CONCLUSION In conclusion, despite these encouraging technical advances, complications must always be taken into account for the prevention and early recognition of tra-
Laryngoscope 124: October 2014
2312
cheal dilatation—especially after prolonged cuffed intubation . A uniform and standard treatment method has not yet been defined, but any procedure should be considered effective if it can avoid the progression and worsening of this condition. Because it demonstrated positive outcomes, for complex cases of tracheal dilatation we suggest considering the system described here, along with previously published treatment options.
BIBLIOGRAPHY 1. Honig EG, Francis PB. Persistent tracheal dilatation: onset after brief mechanical ventilation with a “soft-cuff” endotracheal tube. South Med J 1979 Apr; 72: 487–490. 2. Lloyd JW, McClelland RMA. Tracheal dilatation: an unusual complication of tracheostomy. Lancet 1964;1:83–84. 3. Wood DE, Mathisen DJ. Late complications of tracheostomy. Clin Chest Med 1991;12:597–609. 4. Epstein SK. Late complications of tracheostomy. Respir Care 2005;50:542– 549. 5. Feist JH, Johnson TH, Wilson RJ. Chest 1975;68:340–345. 6. Jacobsen E, Jensen J. Tracheal dilatation: a complication of tracheostomy. Acta Anaesthesiol Scand 1968;12:95–102. 7. Papakostas K, Morar P, Fenton JE. Ballooned trachea caused by cuffed tracheostomy tube. J Laryngol Otol 2000;114:724–726. 8. Shinohara H, Yuzuriha S, Matsuo K, Kushima H, Kondoh S. Tracheal reconstruction with a prefabricated deltopectoral flap combined with costal cartilage graft and palatal mucosal graft. Ann Plast Surg 2004;53: 278–281. 9. Teng MS, Malkin BD, Urken ML. Prefabricated composite free flaps for tracheal reconstruction: a new technique. Ann Otol Rhinol Laryngol 2005;114:822–826. 10. Schultz P, Vautier D, Dupret-Bories A, Debry C, Charpiot A. Replacement of the trachea using surgical reconstruction: current state of research. Ann Otolaryngol Chir Cervicofac 2009;126:272–277. 11. Fabre D, Singhal S, De Montpreville V, Decante B, Mussot S, Chataigner O, et al. Composite cervical skin and cartilage flap provides a novel large airway substitute after long-segment tracheal resection. J Thorac Cardiovasc Surg 2009;138:32–39. 12. Rhodes A, Lamb FJ, Grounds RM, Bennett ED. Tracheal dilatation complicating prolonged tracheal intubation. Anaesthesia 1997;52: 70–72.
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
Rhinological and Otological Society, Inc.
How I Do It
Acquired Tracheal Dilatation After Prolonged Ventilation: An Unusual Treatment Option Marco Giudice, MD; Stefania Gallo, MD; Marco P. Maffioli, MD; Giulio Minoja, MD; Giuseppe Mazzi, MD; Surendra Narne, MD; Paolo Castelnuovo, MD
INTRODUCTION Tracheal dilatation is an infrequently recognized late-onset complication of cuffed endotracheal intubation. The reported rate of incidence is 2% to 5% among patients requiring prolonged ventilatory support. Although the use of high-compliance, low-pressure soft cuffs introduced in the early 1980s could significantly reduce the morbidity of prolonged intubation,1 international literature still does not provide sufficient data for the management or outcomes of this rare but severe condition in patients with long-term use tracheal devices. We present a case of an unusual management technique for tracheal dilatation secondary to prolonged intubation.
TECHNICAL NOTE A 30-year-old female was admitted to the intensive care unit (ICU) of our institution for recurrent episodes of respiratory distress. The patient, affected by tetraplegia, had a tracheotomy 13 years earlier for chronic respiratory failure, which required prolonged all-day mechanical ventilation as a consequence of cervical spine trauma after a car accident. The respiratory distress appeared as acute hypoxemia with multiple episodes of oxygen desaturation down to 60% to 70%. The cause of these episodes was attributed to a dilated trachea, mainly at the level of the cervical tracheal stoma, which concurred to frequent displacement of the tracheal cannula with air escape around the tube, an increased need
From the Airway Endoscopic Surgery Department (S.N.), University of Padua, Azienda Ospedaliera di Padova, Padua, is now ENT– Specialist; the Department of Otorhinolaryngology (M.G., S.G., M.P.M., P.C.); and the Department of Anaesthesiology and Intensive Care (GIULIO M., GIUSEPPE M.), University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy Editor’s Note: This Manuscript was accepted for publication February 11, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Marco Giudice, MD, Department of Otolaryngology, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy. E-mail: [email protected] DOI: 10.1002/lary.24645
Laryngoscope 124: October 2014
of air volume for an adequate cuff seal, and trouble in preserving the airways’ ventilation. The tracheal damage extended from the skin of the anterior neck around the previous tracheotomy to the deeper soft tissues around the tracheal pipe and posteriorly up to the anterior vertebral wall. A chronic local inflammation was evident, with granulations and purulent secretions around the tracheal cannula. The microbiological examination was positive for an infection sustained by Pseudomonas aeruginosa, treated with intravenous antibiotic (meropenem, MERREM). A computed tomography (CT) scan confirmed the dilatation of the trachea beginning from the skin of the tracheal stoma down for about 5.4 cm (from the carina, 5 tracheal rings appeared to be undamaged with normal caliber). The anterior wall of the cranial tract of the trachea was absent, probably due to infection and subsequent necrosis of the tracheal rings with initial exposure of the major epiaortic vessels. In addition, an anterior erosion of the cervical vertebral bones was detected. The residual “crater,” extending from the anterior wall (soft retrosternal tissues) to the posterior one (vertebral eroded bones), measured about 3.5 cm (Fig. 1). No tracheo-esophageal fistulas were found during the endoscopic examination. The management options were discussed with a multidisciplinary team (anesthesiologist, ENT, and thoracic surgeons). The use of an extra-long tracheal tube again resulted in frequent displacement due to the enlarged tracheal opening. Surgical procedures such as tracheoplasty and reconstruction of the damaged tissues around the tracheal wall were discarded as a first approach due to the high risk of surgical intraoperative and perioperative complications and the patient’s clinical status. A tracheal reconstruction with prefabricated free flaps was taken into account, but the phlogosis around the defect and the urgency for a proper mechanical ventilation leaned toward an immediate conservative treatment. The controversy was resolved by an innovative technique based on a “home-made trick” (conceived of by one of the present author (S.N.)). The procedure was performed in the ICU with the patient under sedation with repeated boluses of Diprivan (propofol). We employed a tailored T-tube n. 18, 12
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
2309
Fig. 1. Computed tomography scan in sagittal and axial plane showing the tracheal dilatation with damage of the skin and soft tissues of the neck. yellow line: size of the tracheal stoma (3.4 cm); blue line: cranio–caudal size of the tracheal dilatation (5.4 cm); orange line: size of the undamaged trachea (2.7 cm); red line: antero–posterior diameter of the tracheal dilatation (3.6 cm). [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
cm in length. The tube was manually altered into a clarinet mouthpiece-like shape (Fig. 2). A tracheal cuffed cannula (Portex, Norwell, MA) with flange n. 8 was placed inside the external arm of the T-tube, with the cuff protruding beyond the distal arm of the tube by about 4 cm (Fig. 3). The tracheal cannula “snap-fitted” into the T-tube, closed the proximal arm of the tube from the airflow, firmly fixing the whole system. The device was then placed inside the tracheotomy, fixed with a textile collar, inserting the proximal arm of the Ttube into the subglottic region of the larynx. At last, the distal portion of the cannula was located 1 cm from the carina, guaranteeing an adequate clearing of the dilated tract. This kind of T-tube prosthesis combined with the cuff of the tracheal tube was able to fix the “modified device” to the tracheal and laryngeal pipe, preserving the ventilation without direct pressure of the cuff onto the damaged tissues. A videoendoscopy and CT scan performed at the end of the procedure confirmed the correct setting of the system, which was maintained for the following 2 months and then regularly changed every 2 months under sedation in the ICU. Home Care consisted of a daily cleaning with normal saline solution of the outer portion of the whole system (external arm of the Ttube and tracheal cannula) and the surrounding skin, and catheter suction of the tracheal cannula. The patient is still in mechanical ventilation through the described system, without evidence of further ventilatory complications at 1-year follow-up. The damage of tisLaryngoscope 124: October 2014
2310
sues decreased with resolution of the local infection and gradual reduction of the initial dilatation (Fig. 4).
DISCUSSION Persistent tracheal dilatation was first recognized by Lloyd in 19642 as a complication of tracheotomy or
Fig. 2. T-tube n. 18, manually altered into a clarinet mouthpiecelike shape. A 5 proximal arm; B 5 external arm; C 5 distal arm. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
Fig. 3. Image of the employed system, consisting of a tracheal cuffed cannula (Portex; flange n. 8) set inside the external arm of the T-tube, with the cuff protruding beyond the tube for about 4 cm. A 5 proximal arm; B 5 external arm; C 5 distal arm. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
prolonged mechanical ventilation. It is known that capillary perfusion pressure of the tracheal mucosa is 25 mmHg to 30 mmHg; a lower cuff pressure is required to prevent ischemic necrosis of the mucosal surface, which leads to lumen stenosis.3 In addition, the ischemic injury followed by chondritis, destruction, and necrosis of the supporting tracheal cartilage leads to a tracheal dilatation.4 The most frequent site of tracheal weakening is reported to be at the level of the tracheal stoma, followed by the site of the inflatable cuff (1.5 cm or more
below the stoma) and occasionally the point of impingement of the tip of the tracheostomy tube.5 Before the introduction of high-volume, low pressure cuffs, the incidence of this complication was described to be as high as 24%6; however, in recent years the percentage decreased. The management of tracheal dilatation and reconstruction is difficult and still debated.7 All authors agree on the need for a safe and long-term solution that can provide an autologous well-vascularized tissue, structurally supported, in order to prevent stenosis and scarring. Different surgical options are suggested in the literature, involving the employment of composite pedicled and free flaps (i.e., pectoral, deltopectoral, or forearm flaps) with or without costal cartilage graft, and also mucosal grafts in selected cases.8,9 Autologous mesenchymal stem cell-derived chondrocytes, autologous cultured epithelial cell, and matrix derived from tracheal grafts are also well reported.10 Preliminary studies on animals11 showed good results from the use of autologous cervical skin flaps scaffolded with costal cartilages to replace long-segment tracheal defects. These often are multi-staged surgical procedures that have potential intraoperative and postoperative complications (i.e., suture-line dehiscence with infection and mediastinitis or granulation and subsequent stenosis) . Different endotracheal tubes are proposed as a treatment option, especially when a multi-staged procedure is not indicated or advisable, as in this case. The idea is to achieve a good balance between the need for a positive pressure ventilation and the protection of
Fig. 4. Computed tomography scan in sagittal and axial plane performed after 1 year follow- up, which confirmed the correct setting of the system. orange line 5 distance between the tip of the device and the tracheal carina (1.5 cm); red line 5 antero–posterior diameter of the device (1.7 cm), with evident reduction of the tracheal dilatation, progressively replaced by scarring tissue. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 124: October 2014
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
2311
airways from the aspiration of secretions and gastric contents, without exceeding the tracheal mucosal pressure, while paying attention to the volume and cuff pressure and monitoring them routinely (cuff pressure should be restricted to less than 25 mmHg).12 In the present case, the main problems were: the complexity of maintaining adequate mechanical ventilation with a standard cuffed tracheal tube; the risk that a high pressure cuff could worsen the tracheal damage; and the instability of the cannula inside the dilated trachea, which caused frequent displacement. The technical artifice consisted of placing the tracheal tube cuff underneath the damaged portion of the trachea, with a controlled cuff pressure protecting the residual normal tracheal rings. This was achieved with the combined system of a T-tube and a cuffed Portex in order to overcome the dilated tracheal tract and maintain the all-day mechanical ventilation. This method, at first easy to build up, and probably not impeccable but safe and with low morbidity, did not immediately decrease the tracheal diameter. Our goal was to reduce the risk of further dilatation. Furthermore, at 1 year follow-up, not only was the ventilation maintained but the tracheal diameter and tissue inflammation were reduced. Given the safety and the efficacy of the system to date, and the ease of its periodical replacement, it is reasonable to think that it can be maintained life-long, unless complications arise.
CONCLUSION In conclusion, despite these encouraging technical advances, complications must always be taken into account for the prevention and early recognition of tra-
Laryngoscope 124: October 2014
2312
cheal dilatation—especially after prolonged cuffed intubation . A uniform and standard treatment method has not yet been defined, but any procedure should be considered effective if it can avoid the progression and worsening of this condition. Because it demonstrated positive outcomes, for complex cases of tracheal dilatation we suggest considering the system described here, along with previously published treatment options.
BIBLIOGRAPHY 1. Honig EG, Francis PB. Persistent tracheal dilatation: onset after brief mechanical ventilation with a “soft-cuff” endotracheal tube. South Med J 1979 Apr; 72: 487–490. 2. Lloyd JW, McClelland RMA. Tracheal dilatation: an unusual complication of tracheostomy. Lancet 1964;1:83–84. 3. Wood DE, Mathisen DJ. Late complications of tracheostomy. Clin Chest Med 1991;12:597–609. 4. Epstein SK. Late complications of tracheostomy. Respir Care 2005;50:542– 549. 5. Feist JH, Johnson TH, Wilson RJ. Chest 1975;68:340–345. 6. Jacobsen E, Jensen J. Tracheal dilatation: a complication of tracheostomy. Acta Anaesthesiol Scand 1968;12:95–102. 7. Papakostas K, Morar P, Fenton JE. Ballooned trachea caused by cuffed tracheostomy tube. J Laryngol Otol 2000;114:724–726. 8. Shinohara H, Yuzuriha S, Matsuo K, Kushima H, Kondoh S. Tracheal reconstruction with a prefabricated deltopectoral flap combined with costal cartilage graft and palatal mucosal graft. Ann Plast Surg 2004;53: 278–281. 9. Teng MS, Malkin BD, Urken ML. Prefabricated composite free flaps for tracheal reconstruction: a new technique. Ann Otol Rhinol Laryngol 2005;114:822–826. 10. Schultz P, Vautier D, Dupret-Bories A, Debry C, Charpiot A. Replacement of the trachea using surgical reconstruction: current state of research. Ann Otolaryngol Chir Cervicofac 2009;126:272–277. 11. Fabre D, Singhal S, De Montpreville V, Decante B, Mussot S, Chataigner O, et al. Composite cervical skin and cartilage flap provides a novel large airway substitute after long-segment tracheal resection. J Thorac Cardiovasc Surg 2009;138:32–39. 12. Rhodes A, Lamb FJ, Grounds RM, Bennett ED. Tracheal dilatation complicating prolonged tracheal intubation. Anaesthesia 1997;52: 70–72.
Giudice et al.: Acquired Tracheal Dilatation After Prolonged Ventilation
