Case Report
Obstructive Inflammatory Tracheal Pseudomembrane
Tabique traqueal inflamatorio
Astrid Crespo-Lessmann
, Alfons Torrego-Fernández
Corresponding author
Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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The interest of this case lies in the unusual presentation of a post-intubation tracheal inflammatory reaction, as well as its subsequent evolution.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Observation</span><p id="par0010" class="elsevierStylePara elsevierViewall">This is the case of a 74-year-old woman, smoker with a cumulative dose of 60 packs/year, with a history of chronic obstructive pulmonary disease (COPD) and kyphoscoliosis. Her most recent functional tests revealed moderate airflow limitation, predominantly obstructive (FVC 1.0<span class="elsevierStyleHsp" style=""></span>l (58% of ref.), FEV<span class="elsevierStyleInf">1</span>: 0.630<span class="elsevierStyleHsp" style=""></span>l (54% of ref.), FEV<span class="elsevierStyleInf">1</span>/FVC ratio: 63%).</p><p id="par0015" class="elsevierStylePara elsevierViewall">She arrived at the emergency department after being intubated at home due to severe respiratory failure with a decreased level of consciousness. Her family members reported that the patient had presented coughing with rusty sputum, progressive drowsiness and dyspnoea on minimal exertion over the previous 72<span class="elsevierStyleHsp" style=""></span>h. Once in the intensive care unit (ICU), empirical treatment was initiated with broad spectrum antibiotics, glucocorticoids (intravenous methylprednisolone 60<span class="elsevierStyleHsp" style=""></span>mg/day) and bronchodilators. She initially progressed well and was extubated 48<span class="elsevierStyleHsp" style=""></span>h later. However, the patient deteriorated again within a few hours, presenting respiratory failure and hypercapnic acidosis that was not corrected with non-invasive mechanical ventilation, and which required reintubation. Two days later, she accidentally removed the tube, before being reintubated as the severe respiratory failure persisted. In the following days, she again progressed well, and was extubated definitively about 10 days after the first intubation and then transferred to a conventional hospital ward.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Once on the Respiratory Medicine ward, a chest radiograph was performed, which showed volume loss in the left lung. Videobronchoscopy was therefore indicated, in which the presence of a tracheal pseudomembrane of inflamed tissue that formed a septum of around 2<span class="elsevierStyleHsp" style=""></span>cm in length, dividing the middle third of the endotracheal lumen, was observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). It also revealed the presence of mucous secretions retained in the bronchial tree, especially in the left side, interpreted as atelectasia of the left lung secondary to mucous retention due to the presence of the tracheal pseudomembrane described. A chest computed axial tomography (CT) scan was performed, showing an inflammatory infiltrate in the lingula, probably in resolution, and also confirming the presence of an intratracheal septum that raised the differential diagnosis of tracheal duplication, traumatic sequelae and reaction to a foreign body (due to repeated intubations) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the following hours, treatment was intensified with respiratory physiotherapy and she remained on antibiotic and glucocorticoid therapy. The possibility of performing a therapeutic endotracheal procedure was raised in the following days, but was never carried out due to the patient's gradual improvement. The endoscopic check-up a few days later confirmed that the intratracheal septum had completely disappeared (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Curiously, the patient reported that the day before this test, she had expelled a dense material with coughing. The patient received the following glucocorticoid treatment in total: intravenous methylprenisolone 60<span class="elsevierStyleHsp" style=""></span>mg/day for 8 days, followed by 40<span class="elsevierStyleHsp" style=""></span>mg/day for 2 days; she was then changed to oral prednisone 30<span class="elsevierStyleHsp" style=""></span>mg/day, in a tapered regimen until discontinuation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was discharged and sent home with the following diagnoses:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0030" class="elsevierStylePara elsevierViewall">Hypercapnic respiratory failure secondary to exacerbation of chronic lung disease (COPD+kyphoscoliosis).</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Mechanical ventilation (with repeated intubations).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Lingular pneumonia.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Left pulmonary atelectasia and retention of secretions secondary to an obstructive tracheal pseudomembrane resolved with conservative treatment.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">The presence of pseudomembranes and tracheal inflammatory reactions due to various causes is a well-known finding. The interest of the case presented lies partly in the clinical presentation, in the form of a longitudinal tracheal septum of a significant size that compromised the lumen and movement of secretions, as well as its complete resolution within a few days of using conservative treatment based on respiratory physiotherapy and anti-inflammatory drugs (glucocorticoids). In our case, extraction or mechanical treatment of the lesion using more complex therapeutic bronchoscopic procedures were unnecessary. Unfortunately, and as a limitation, the histological analysis of the lesion described, which could have provided useful information on its tissue characteristics, is not available.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Among the conditions acquired after the introduction of an artificial airway (intubation or tracheostomy), post-intubation stenosis is the most common in adults,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and is due to extensive scarring in an area of the airways in which a transmural lesion was produced on intubation. Most of these stenoses are circumferential (tranverse membrane, in the form of a bottleneck or granuloma) and surround the tracheal wall, although it can rarely present in the form of a septum, as occurred in this clinical case. The appearance of tracheal pseudomembranes is not an uncommon finding for bronchoscopists in patients with long periods of intubation. However, when we review the literature on this condition, there are few cases reported and/or articles that explain its incidence, physiopathology and treatments used.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is known that among the factors that could contribute to increasing the risk of the aforementioned disorders are: traumatic or prolonged intubation, repeated intubations (as happened in our case), an excessively large tube, tube movements and local infection. Added to these causes are possible predisposing factors, such as autoimmune mechanisms,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> administration of glucocorticoids and the effect of gastro-oesophageal reflux.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Other authors suggest that the presence of intratracheal septa or pseudomembranes represents an early stage of ischaemic lesion in the tracheal wall related with the high pressure of the cuff on intubation. This endotracheal pressure exerted by the tube produces inflammation, infarction and finally, necrosis of the tracheal mucosa with the secondary development of tracheal stenosis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> These inflammatory lesions sometimes resolve spontaneously or aided by glucocorticoid treatment (although there are no formal guidelines in this respect). However, most cases require the application of interventionist endoscopic techniques (rigid bronchoscopy, laser resection or electrocauterization, etc.).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> In other cases, this complication has a fatal outcome, despite a history of short-duration intubation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore clinicians, especially those who work with the airways, must be alerted to this little known complication within endotracheal intubation.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres272953" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec254938" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres272954" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec254937" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Observation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec254938" "palabras" => array:3 [ 0 => "Tracheal pseudomembrane" 1 => "Intubation" 2 => "Bronchoscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec254937" "palabras" => array:3 [ 0 => "Pseudomembrana traqueal" 1 => "Intubación" 2 => "Broncoscopia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pathologies acquired after the establishment of an artificial airway include stenosis, granulomas and the formation of pseudomembranes, to name a few. The most common form of presentation in adults is circumferential stenosis, which often requires therapeutic endoscopic measures to achieve resolution.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This Case Report describes the case of an obstructive inflammatory tracheal pseudomembrane secondary to repeated intubations that was resolved with conservative treatment.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The clinical presentation of this entity generally includes the appearance of respiratory infection and/or atelectasis after the withdrawal of the orotracheal tube as a consequence of the accumulation of secretions between the tracheal wall and the pseudomembrane. Inflammatory pseudomembranes can resolve spontaneously with the help of glucocorticoids, although on occasion they require an invasive endotracheal procedure depending on the evolution.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Dentro de las patologías adquiridas tras la instauración de una vía aérea artificial tenemos: las estenosis, los granulomas, la presencia de pseudomembranas y la formación de tabiques traqueales, entre otros. La forma más habitual de presentación en el adulto es la estenosis circunferencial y muchas veces requiere para su resolución medidas endoscópicas terapéuticas.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En esta Nota clínica se describe el caso de una pseudomembrana traqueal inflamatoria obstructiva secundaria a intubaciones repetidas y que se resolvió con tratamiento conservador.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La presentación clínica de esta entidad generalmente incluye la aparición de infección respiratoria y/o atelectasia tras la retirada del tubo orotraqueal, siendo consecuencia del acúmulo de secreciones entre la pared traqueal y el tabique formado. Los tabiques traqueales inflamatorios se pueden resolver espontáneamente con ayuda de glucocorticoides, otras veces requieren de un procedimiento endotraqueal invasivo en función de la evolución.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Crespo-Lessmann A, Torrego-Fernández A. Tabique traqueal inflamatorio. Arch Bronconeumol. 2013;49:402–4.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 1741 "Tamanyo" => 133495 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Evolution of the tracheal pseudomembrane. (A and B) Tracheal pseudomembrane in the form of a longitudinal septum, connected to the anterior and posterior wall of the trachea, 2–3<span class="elsevierStyleHsp" style=""></span>cm long and located in the middle third of the trachea. (C) Resolution of the pseudomembrane with the presence of some remaining mucus.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 534 "Ancho" => 1749 "Tamanyo" => 227763 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Radiological images of the tracheal pseudomembrane in the form of a septum in the transverse and sagittal slices.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Postintubation tracheal stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 4 | 7 |
| 2024 October | 109 | 34 | 143 |
| 2024 September | 62 | 34 | 96 |
| 2024 August | 84 | 55 | 139 |
| 2024 July | 74 | 38 | 112 |
| 2024 June | 88 | 48 | 136 |
| 2024 May | 123 | 42 | 165 |
| 2024 April | 80 | 34 | 114 |
| 2024 March | 58 | 29 | 87 |
| 2024 February | 57 | 32 | 89 |
| 2023 September | 1 | 0 | 1 |
| 2023 June | 1 | 0 | 1 |
| 2023 March | 11 | 8 | 19 |
| 2023 February | 82 | 38 | 120 |
| 2023 January | 59 | 65 | 124 |
| 2022 December | 60 | 65 | 125 |
| 2022 November | 96 | 62 | 158 |
| 2022 October | 75 | 61 | 136 |
| 2022 September | 82 | 37 | 119 |
| 2022 August | 84 | 42 | 126 |
| 2022 July | 69 | 65 | 134 |
| 2022 June | 56 | 64 | 120 |
| 2022 May | 77 | 40 | 117 |
| 2022 April | 80 | 47 | 127 |
| 2022 March | 96 | 48 | 144 |
| 2022 February | 108 | 53 | 161 |
| 2022 January | 135 | 52 | 187 |
| 2021 December | 122 | 38 | 160 |
| 2021 November | 96 | 56 | 152 |
| 2021 October | 129 | 63 | 192 |
| 2021 September | 90 | 62 | 152 |
| 2021 August | 80 | 41 | 121 |
| 2021 July | 87 | 49 | 136 |
| 2021 June | 70 | 42 | 112 |
| 2021 May | 77 | 51 | 128 |
| 2021 April | 216 | 120 | 336 |
| 2021 March | 93 | 47 | 140 |
| 2021 February | 58 | 34 | 92 |
| 2021 January | 54 | 32 | 86 |
| 2020 December | 37 | 31 | 68 |
| 2020 November | 74 | 30 | 104 |
| 2020 October | 81 | 29 | 110 |
| 2020 September | 61 | 31 | 92 |
| 2020 August | 66 | 36 | 102 |
| 2020 July | 87 | 40 | 127 |
| 2020 June | 116 | 23 | 139 |
| 2020 May | 76 | 35 | 111 |
| 2020 April | 82 | 32 | 114 |
| 2020 March | 60 | 25 | 85 |
| 2020 February | 84 | 36 | 120 |
| 2020 January | 94 | 34 | 128 |
| 2019 December | 85 | 28 | 113 |
| 2019 November | 85 | 37 | 122 |
| 2019 October | 61 | 27 | 88 |
| 2019 September | 76 | 30 | 106 |
| 2019 August | 57 | 34 | 91 |
| 2019 July | 64 | 37 | 101 |
| 2019 June | 54 | 34 | 88 |
| 2019 May | 66 | 49 | 115 |
| 2019 April | 93 | 55 | 148 |
| 2019 March | 66 | 56 | 122 |
| 2019 February | 59 | 37 | 96 |
| 2019 January | 64 | 46 | 110 |
| 2018 December | 82 | 41 | 123 |
| 2018 November | 64 | 47 | 111 |
| 2018 October | 84 | 35 | 119 |
| 2018 September | 73 | 21 | 94 |
| 2018 May | 33 | 0 | 33 |
| 2018 April | 71 | 12 | 83 |
| 2018 March | 48 | 9 | 57 |
| 2018 February | 57 | 14 | 71 |
| 2018 January | 60 | 15 | 75 |
| 2017 December | 74 | 17 | 91 |
| 2017 November | 54 | 15 | 69 |
| 2017 October | 46 | 11 | 57 |
| 2017 September | 56 | 15 | 71 |
| 2017 August | 73 | 30 | 103 |
| 2017 July | 50 | 26 | 76 |
| 2017 June | 82 | 48 | 130 |
| 2017 May | 68 | 37 | 105 |
| 2017 April | 62 | 33 | 95 |
| 2017 March | 58 | 37 | 95 |
| 2017 February | 56 | 27 | 83 |
| 2017 January | 60 | 21 | 81 |
| 2016 December | 58 | 16 | 74 |
| 2016 November | 103 | 18 | 121 |
| 2016 October | 111 | 29 | 140 |
| 2016 September | 198 | 18 | 216 |
| 2016 August | 171 | 20 | 191 |
| 2016 July | 72 | 25 | 97 |
| 2016 June | 2 | 0 | 2 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 88 | 3 | 91 |
| 2015 September | 93 | 21 | 114 |
| 2015 August | 72 | 26 | 98 |
| 2015 July | 137 | 18 | 155 |
| 2015 June | 57 | 25 | 82 |
| 2015 May | 63 | 34 | 97 |
| 2015 April | 64 | 17 | 81 |
| 2015 March | 72 | 10 | 82 |
| 2015 February | 86 | 6 | 92 |
| 2015 January | 60 | 11 | 71 |
| 2014 December | 79 | 9 | 88 |
| 2014 November | 56 | 11 | 67 |
| 2014 October | 68 | 22 | 90 |
| 2014 September | 53 | 13 | 66 |
| 2014 August | 72 | 16 | 88 |
| 2014 July | 64 | 15 | 79 |
| 2014 June | 77 | 18 | 95 |
| 2014 May | 63 | 25 | 88 |
| 2014 April | 79 | 20 | 99 |
| 2014 March | 92 | 15 | 107 |
| 2014 February | 72 | 14 | 86 |
| 2014 January | 55 | 16 | 71 |
| 2013 December | 39 | 10 | 49 |
| 2013 October | 0 | 1 | 1 |
| 2013 September | 1 | 1 | 2 |
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