To the Editor,
Post-intubation laryngotracheal stenosis is the fibrotic narrowing of the larynx or trachea that follows translaryngeal intubation. Reported in 0.3 per cent to more than 11 per cent of intubated patients, it arises from mucosal ischaemia at the tube–mucosa interface, which initiates a dysregulated, transforming growth factor-beta-driven healing response rather than simple scarring.Reference Dorris, Russell and Murphy1 Patients typically present weeks to months after discharge with exertional dyspnoea or stridor, long after the intubation itself has been forgotten. Treatment is rarely definitive: recurrence follows endoscopic dilation in 28.0 per cent of patients, compared with 12.4 per cent after endoscopic resection with adjuvant medical therapy and 1.2 per cent after cricotracheal resection.Reference Cho, Huh, Cho, Chang, Park and Lee2 It is, in short, an iatrogenic condition in which prevention matters more than any treatment currently available.
Established prevention centres on the tube. Oversized tubes and excessive cuff pressure are recognised risk factors, and current guidance recommends low-pressure cuffs, cuff pressures near 25 cm H2O, and limiting the duration of intubation.Reference Dorris, Russell and Murphy1, Reference Cho, Huh, Cho, Chang, Park and Lee2 More recent data complicate this emphasis. In a multicentre cross-sectional study of 8167 mechanically ventilated adults, laryngotracheal stenosis occurred in 6.4 per cent of coronavirus disease 2019 (Covid-19)-negative and 12.7 per cent of Covid-19-positive patients, a difference attributable to exposure rather than to Covid-19 status itself, and was most often diagnosed within 60 days of intubation. On multivariable analysis, each additional reintubation carried a hazard ratio of 1.52 (95 per cent confidence interval = 1.36–1.71), substantially exceeding the incremental risk of each ventilator day (hazard ratio = 1.03) or intensive care unit day (hazard ratio = 1.02).Reference Gray, Pradhan, Hoffmeister, Misono, Cho and Tignanelli3 Clinician understanding has not kept pace: in a survey of 103 anaesthesiologists, intensivists and emergency physicians, only 41.8 per cent considered themselves adequately informed about the risk factors for posterior glottic stenosis, and 62.1 per cent incorrectly identified cuff pressure as one of them.Reference Chwa, Shuman and O’Dell4 Preventive attention is concentrated where the marginal risk appears smallest.
Three changes follow. Firstly, reintubation should be framed explicitly as an airway-injury event. Trials of post-extubation respiratory support enrol exactly the high-risk patients in whom reintubation occurs in 15 per cent to 19 per cent of cases, yet they report reintubation and mortality without ever capturing laryngotracheal injury.Reference Qin, Liao, Liao, Wang and Han5 Adding this outcome would cost little. Secondly, post-extubation laryngeal surveillance should be stratified by the number of intubation episodes rather than by duration alone; existing guidance addresses bronchoscopy follow up only after stenosis has been treated or once stridor has already appeared.Reference Cho, Huh, Cho, Chang, Park and Lee2 Thirdly, airway-injury teaching must reach the clinicians who intubate, who seldom see the sequelae. A defined otolaryngology review pathway for patients with multiple intubations is a low-cost step towards earlier diagnosis.
• Post-intubation laryngotracheal stenosis follows trans-laryngeal intubation in 0.3 per cent to more than 11 per cent of intubated patients, arising from mucosal ischaemia that initiates a dysregulated healing response
• Established preventive guidance centres on endotracheal tube size, cuff pressure and limiting the duration of intubation, but treatment is rarely definitive, with recurrence in 28.0 per cent of patients after endoscopic dilation compared with 1.2 per cent after cricotracheal resection
• Recent multicentre data indicate that each additional reintubation carries a hazard ratio of 1.52, substantially exceeding the incremental risk of each additional ventilator day (hazard ratio = 1.03) or intensive care day (hazard ratio = 1.02)
• Survey evidence indicates that clinicians performing intubation frequently misattribute this risk to cuff pressure, and fewer than half consider themselves adequately informed about the risk factors for posterior glottic stenosis
• This paper argues that reintubation should be framed explicitly as an airway-injury event, and that post-extubation laryngeal surveillance should be stratified by the number of intubation episodes rather than by duration alone
• It further proposes that trials of post-extubation respiratory support, which enrol precisely the population at risk, should report laryngotracheal injury alongside their existing outcomes
Acknowledgements
During the preparation of this work, the author used Claude (Anthropic) to assist with drafting and language editing. The author conducted the literature search, selected and verified all cited sources, and takes full responsibility for the content of the publication.
Competing interests
None declared.
