Abstract Introduction Obstructive fibrinous tracheal pseudomembrane (OFTP) is a rare, potentially life-threatening complication following endotracheal intubation, characterized by the formation of a thick, adherent fibrinous membrane in the trachea that can cause significant airway obstruction. Often under-recognized due to nonspecific symptoms like stridor and dyspnea, OFTP is thought to arise from ischemic mucosal injury induced by endotracheal tube cuffs, exacerbated by factors such as hypotension, critical illness, or pooling of caustic gastric contents around the cuff. While tracheal stenosis typically manifests weeks post-extubation, OFTP can present acutely, even after brief intubation periods. Literature is limited to case reports and small series. 1-3. Case A 74-year-old male with hypertension, hyperlipidemia, and recent transient ischemic attack (TIA) presented with facial droop and was hospitalized for TIA. He was discharged without residual neurological deficits, but returned days later with dizziness, altered mental status, syncope, and hypotension, requiring intubation for airway protection. The patient was extubated after 24 hours. Following extubation, he developed stridor, prompting CT imaging revealing 70% tracheal narrowing. Upon assessment, he was alert on 2L nasal cannula with mild inspiratory stridor and increased work of breathing. Pulmonary consultation led to bronchoscopy, confirming 75% upper tracheal narrowing of the lumen, with a concentric, necrotic appearing pseudo-membrane that was 2 cm in length, sloughing off the tracheal wall. This was extracted with a cryoprobe, revealing underlying erythema, mild oozing, but no residual stenosis. Pathology of the membrane revealed necrotic tissue with degenerated acute inflammatory cells and bacteria. Cultures from the membrane grew Serratia marcescens and methicillin-sensitive Staphylococcus aureus (MSSA), with negative fungal and AFB cultures. Post-procedure, low-volume hemoptysis occurred, managed with nebulized tranexamic acid (TXA). Repeat CT confirmed resolution of obstruction. The patient was discharged with no issues. Discussion We present a case of OFTP after one day of intubation in an elderly patient without prior pulmonary comorbidities, contrasting with typical reports involving prolonged ventilation or difficult intubations. The rapid onset of symptoms post-extubation (within days) and bacterial colonization (Serratia and MSSA) without systemic infection add unique insights, potentially linking microbial factors to pseudomembrane formation despite negative cultures in many prior cases. Early recognition prevents progression to respiratory arrest, as seen in up to 87% of reported cases with stridor. 3 In an era of increasing short-term intubations in critically ill patients, this underscores the need for routine post-extubation airway evaluation. Favorable prognosis without recurrence emphasizes bronchoscopy’s efficacy, for both diagnostic and therapeutic purposes. This abstract is funded by: None
Halawa et al. (Fri,) studied this question.