Tracheobronchomalacia Post-Pneumonectomy: A Late Complication
An 83-year-old male presented with barking cough with greenish expectoration, shortness of breath (grade III MMRC) and wheezing for 3 days. For last 3 years he has been under treatment for recurrent exacerbations of bronchial asthma, required multiple admissions at various hospitals and was suspected to have brittle asthma. He was a diabetic and hypertensive and a lifelong non-smoker. He had undergone left pneumonectomy 40 years ago for pulmonary tuberculosis. On general examination he was conscious, alert, afebrile, pulse was regular, 120 per minute, BP was 130/80 mm Hg. He had tachypnoea with respiratory rate of 28/min and had hypoxia with SpO2 of 89% on room air. Examination of respiratory system revealed shift of trachea to left, audible stridor which increased on lying down, absent air entry on the left side and conducted sounds on the right side. Arterial Blood Gas analysis showed; pH–7.28, pCO2–53 mm Hg, pO2–75.1 mm Hg, HCO3–22.1.\n2D Echocardiography showed normal LV function, Mild RV dysfunction, dilated RA/RV (TAPSE: 1.24 cm), mild TR and plethoric IVC. CBP, Serum sodium, potassium, and magnesium, were normal. Serum calcium-6.8 mg/dl, phosphate-2.7 mg/dl, parathyroid hormone-179.4 pg/ml, Vit D-3.58, and serum albumin-2.7 mg/dl.\nPatient was given intravenous hydrocortisone, calcium gluconate infusion, and NIV-BiPAP support. CT scan of Neck and Chest were done which showed left post-pneumonectomy status, thickening and calcification of left pleura, tortuous trachea with acute angulation at the thoracic inlet, gross shift of mediastinum to the left, multiple spiculated lesions with surrounding fibrosis (granulomas) in anterior and posterior segments of RUL, multiple calcified pretracheal lymph nodes and compensatory hyperinflation of right lung []. In view of worsening of arterial blood gas values and respiratory failure, he was intubated and mechanically ventilated. Fibreoptic bronchoscopy showed severe narrowing of trachea during inspiration and near total closure during expiration suggestive of tracheomalacia []. Similar dynamic airflow obstruction was visualized up to segmental bronchi, though of progressively lesser severity. Patient was considered unsuitable for invasive surgical procedures in view of poor general condition, high risk for anesthetic complications, and generalized debility. He was unsuitable for placement of stent due to long segment tracheobronchial involvement. He refused further invasive procedures. Long length tracheostomy tube (Portex 8.0) was placed with tip of tracheostomy tube 2 - 3 cm from the level of carina as checked with FOB post-placement. Patency of lower trachea was maintained and chest radiography showed well-aerated right lung. He was discharged with tracheostomy used as interface for BiPAP ventilator with no requirement of supplemental oxygen.