What is the management for obstructive fibrinous tracheal pseudomembrane?

Management of Obstructive Fibrinous Tracheal Pseudomembrane

Bronchoscopic removal is the definitive treatment for obstructive fibrinous tracheal pseudomembrane (OFTP), with rigid bronchoscopy being the preferred approach for complete removal of the pseudomembrane. 1

Clinical Presentation and Diagnosis

• OFTP is a rare but potentially life-threatening complication of endotracheal intubation characterized by formation of a tubular pseudomembrane that obstructs the trachea after extubation 1
• Symptoms typically occur within 24-72 hours after extubation (average 3 ± 3 days) and present as stridor, respiratory distress, or acute respiratory failure 1
• Diagnosis is frequently delayed (average 26 hours from symptom onset to correct identification), which can significantly increase morbidity and mortality 2
• Flexible bronchoscopy is the recommended diagnostic tool to confirm OFTP, revealing a circumferential membrane partially or completely obstructing the tracheal lumen 1, 2

Initial Management

• Immediate airway assessment and management is critical when OFTP is suspected, as tracheal obstruction ≥70% is common (observed in 14 of 18 documented cases) 1
• Supplemental oxygen should be provided to maintain SpO₂ >92% while preparing for definitive management 3
• Avoid sedating medications before securing the airway, as they may compromise the patient's compensatory mechanisms and worsen respiratory distress 3
• Emergency tracheostomy may be required in cases of severe obstruction to maintain airway patency before definitive treatment 4

Definitive Treatment

• Bronchoscopic removal of the pseudomembrane is the treatment of choice with a high success rate and no recurrence reported after complete removal 1
• Rigid bronchoscopy is preferred for removal of the pseudomembrane in 46.3% of cases due to better control of the airway and superior ability to remove the entire membrane 2
• Flexible bronchoscopy can be used for removal in less severe cases or when rigid bronchoscopy is not available 2
• Microscopic direct laryngoscopy is an alternative approach for removal of the obstructive pseudomembrane when bronchoscopy is not immediately available 4

Post-Procedure Management

• After removal of the pseudomembrane, close monitoring for respiratory status is essential as residual airway edema may persist 5
• Humidification and regular tracheal suction should be employed to reduce avoidable tube blockage if the patient requires reintubation 5
• Intravenous corticosteroids for at least 12 hours may be beneficial to reduce airway edema and post-extubation stridor 5
• Maintain 35° head-up positioning to help reduce airway swelling 5
• Antibiotics may be indicated if upper airway infection is suspected 5

Prevention and Special Considerations

• Proper endotracheal tube size selection and cuff pressure management (20-30 cm H₂O) during intubation can help prevent OFTP 5
• Documentation of tracheal tube insertion depth and regular checks are important to prevent tube movement that may cause mucosal injury 5
• In patients with known difficult airways or those who have experienced OFTP, consider using an airway exchange catheter during extubation to facilitate reintubation if needed 5
• Patients with a history of OFTP should have this documented prominently in their medical records to alert future providers about this airway complication 5

Prognosis

• With prompt recognition and appropriate bronchoscopic intervention, most patients recover completely with no recurrence 1
• Mortality is rare but has been reported in both adult and pediatric populations (2 deaths in 53 documented cases) 2
• Long-term follow-up with repeat bronchoscopy at 1-3 months may be considered to ensure complete resolution and absence of tracheal stenosis 6