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Critical Airway Stenosis in the Parturient
Abstract Number: T-67
Abstract Type: Case Report/Case Series
An 18 year old G1P0 parturient was admitted to our facility at 32 WGA with complaint of dyspnea. The patient had a history of pharyngeal web, nasopharyngeal stenosis, glottic and tracheal stenosis, and severe asthma. A tracheostomy had been performed at an outside facility four months prior to this admission due to worsening glottic stenosis, however a tracheostomy tube was not left in place and the site had subsequently closed. Upon arrival, the patient was evaluated by ENT. Flexible laryngoscopy revealed nasopharyngeal stenosis and a narrow glottic opening. A repeat tracheostomy was then performed under local anesthesia and IV sedation followed immediately by tracheal dilation under general inhalational anesthesia. The patient noted improvement of her symptoms and was discharged on POD #6 with a stoma stent. Five days after discharge the patient returned with worsening dyspnea which was attributed to bilateral mainstem bronchial stenosis. Balloon dilation of her mainstem bronchi was then performed under general anesthesia via her pre-existing tracheostomy. At 36 WGA, she presented in labor. The tracheal stoma stent had been removed by the patient against medical direction and her tracheostomy site had significantly narrowed. Due to concern regarding the ability to secure the patient’s airway, a #4 Shiley tracheostomy tube was prophylactically placed in the stoma by ENT prior to labor augmentation. An epidural catheter was then placed for labor analgesia. The patient delivered vaginally without airway compromise or complication and was discharged on POD #2.
Complications from securing an airway in parturients is a major cause of morbidity.1 Tracheal stenosis is often idiopathic or a result of prior trauma. The airway engorgement seen in pregnancy may worsen pre-existing tracheal stenosis. In nonpregnant adults, signs of upper airway obstruction do not manifest until 75% narrowing has occurred2. The increased ventilatory demands of labor can have detrimental effects on parturients with uncorrected tracheal stenosis. Post-partum death from airway obstruction has been reported in a patient with uncorrected tracheal stenosis after delivery by c-section under regional anesthesia3. In this patient, a functioning tracheostomy provided a near ideal means to deal with potential airway emergencies. In patients with known airway pathology and with a high suspicion of potential airway difficulties, antepartum placement of a tracheostomy may be the best course of action.
1. Obstetric anesthesia. Clinical anesthesiology ed Morgan, G et al. McGraw Hill 2006.
2. Kuczkowski KM & Benumof JL. Subglottic tracheal stenosis in pregnancy: anesthetic implications. Anaesth Intensive Care 2003; 31:576-7.
3. Sutcliffe N, Remington SA, Ramsay TM, & Mason C. Severe tracheal stenosis & operative delivery. Anaesthesia 1995;50:26-9.