CHESTGuidelines & Topic CollectionsPostintubation Tracheal Stenosis (PITS)

Postintubation Tracheal Stenosis (PITS)

Postintubation tracheal stenosis (PITS) is increasingly recognized in survivors of severe COVID-19, often weeks to months after discharge. It may be misdiagnosed as asthma or a COPD exacerbation.

Compiled by the CHEST Bronchoscopy Domain Task Force

Last updated June 06, 2022

DOWNLOAD THIS INFORMATION AS A PDF 

Features

  • Prevalence: 15% to 19% in previously intubated patients; of these, 1% to 5% are symptomatic
  • Etiology: Mucosal damage from pressure or infection
  • Morphology: Cicatricial stenosis, with or without malacia, granulation tissue
  • Location: Cervical, midtrachea, subglottis
  • Extent: Usually 1 to 4 cm

Image: Multilevel complex PITS (arrow) seen on virtual bronchography (A). Fixed upper airway obstruction pattern on flow volume loop (arrow) seen with fibrotic PITS (B).

Risk factors

  • Prolonged mechanical ventilation, typically >14 days
  • High cuff pressures (>30 cm H2O)
  • Microbial inflammation with bacteria and viral tracheitis
  • Acid reflux, diabetes, obesity, glucocorticoid use
  • Prone positioning

Identification

  • Symptoms: Dyspnea, initially with exertion and later at rest; stridor; dysphagia; cough; difficulty raising secretions; respiratory distress
  • Studies: Bronchoscopy, neck and chest CT imaging, pulmonary function testing

Image: Critical PITS before (A) and after (B) laser-assisted rigid bronchoscopic dilation.

Prevention

  • Maintain tracheal cuff pressure 20 to 30 cm H2O and monitor every shift
  • Elevate head of bed >30 degrees
  • Treatment of superimposed tracheitis
  • Consider avoiding large (>8) endotracheal tube (ETT)
  • Verify appropriate ETT placement (3 to 5 cm above the carina), especially after repositioning or transport