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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 3  |  Page : 211-217

Management of post-intubation subglottic stenosis with individualised homoeopathic therapy: A case report


1 Department of Homeopathy, Janardan Rai Nagar, Rajasthan Vidyapeeth, Udaipur, Rajasthan, India
2 School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia
3 Postgraduate Doctors Training Institute, Health Care Ministry of the Chuvash Republic, Cheboksary, Russian Federation, Russia

Date of Submission19-Nov-2019
Date of Acceptance14-Aug-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Seema Mahesh
School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijrh.ijrh_80_19

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  Abstract 


Introduction: Subglottic stenosis is a narrowing of the airway just below the vocal cords. This narrowing can cause serious breathing difficulties. Subglottic stenosis can be congenital or acquired. Frequent or long-term intubation is the most common cause of acquired subglottic stenosis. Case Summary: In this case report, adjuvant homoeopathic treatment helped prevent tracheal stent implantation surgery, otherwise deemed necessary in such a state and improved the overall general state. This case report gives ground to further investigate the extent to which individualised Homoeopathy may be applied in postintubation subglottic stenosis.

Keywords: Antimonium tartaricum, Coronary artery bypass grafting, Homoeopathy, Paralytic ileus, Postintubation stenosis, Postoperative pulmonary dysfunction, Tracheal stent


How to cite this article:
Sharma SS, Mahesh S, Vithoulkas G. Management of post-intubation subglottic stenosis with individualised homoeopathic therapy: A case report. Indian J Res Homoeopathy 2020;14:211-7

How to cite this URL:
Sharma SS, Mahesh S, Vithoulkas G. Management of post-intubation subglottic stenosis with individualised homoeopathic therapy: A case report. Indian J Res Homoeopathy [serial online] 2020 [cited 2020 Oct 24];14:211-7. Available from: https://www.ijrh.org/text.asp?2020/14/3/211/296246




  Introduction Top


Postoperative pulmonary dysfunction (PPD) is a frequent and significant [1] complication after coronary artery bypass grafting (CABG) with over 40% of patients readmitted into intensive care units (ICUs) with this state, presenting with respiratory failure.[2] Treatment of acute respiratory failure frequently requires intubation of the trachea with either an endotracheal or tracheostomy tube. As the subglottic space is the narrowest part of the airway at the cricoid level, translaryngeal intubation may result in damage involving both the glottis and the subglottis. Subglottic stenosis is graded according to the Cotton–Myer classification system [3] from Grade 1 to 4 based on the severity of blockage: Grade I up to 50% obstruction, Grade II from 51% to 70% obstruction, Grade III from 71% to 99% obstruction and Grade IV no detectable lumen.

Subglottic stenosis is a common complication in these cases due to injury during tracheal intubation. This usually follows periods of prolonged intubation in ICUs due to need for mechanical ventilatory support.[4] The most common symptom is gradually worsening breathlessness, which in severe cases can be identified as stridor. Stabilisation of the patient's airway, evaluation with bronchoscopy and use of a temporising airway appliance are the important components of the management of airway complications.[4] A subglottic stenosis is potentially life-threatening condition, and if not corrected in time, it may portend limited life expectancy and cause considerable suffering from debilitating complications.[5] The general line of treatment depending on the diagnosis is tracheal dilation using rigid bronchoscope, laser surgery and endoluminal stenting, tracheal resection and laryngotracheal reconstruction.[6] Tracheal stent is the common treatment modality, but it leads to complications such as granulation tissue formation (27%), restenosis (19%), migration (10%), fracture (8%), erosion (4%) and bleeding (1%). Granulation tissue formation may be mild enough to remain asymptomatic, moderate to produce stridor or severe enough to present as life-threatening respiratory distress.[7]

Classical homoeopathy has been reported [8] in the treatment of hospitalised critical illness [9],[10] before; there are published cases such as postoperative coma,[11] severe sepsis [12] and typically surgical cases [13] which have documented remarkable effects of Homoeopathy. However, there have not been any other reports on PPD or subglottic stenosis treated with Homoeopathy, to the best of the authors' knowledge.


  Case Report Top


A 47-year-old Indian male patient's relative brought the patient's report on November 20, 2014, at Cura Homeopathic Clinic, Vasai, Maharashtra. The patient was admitted in the ICU for severe breathlessness, tachypnoea, tachycardia and severe stridor with sudden lung collapse.

Before the patient was introduced to the homoeopathic treatment, the pulmonologist examining the patient found a 50% subglottic stenosis narrowing of tracheal lumen. He was advised to have a tracheal stent. However, due to the collapsed lung, as mentioned in the inpatient department's case paper of the patient, the patient was not in a state to undergo the procedure. He had also developed paralytic ileus and antibiotic resistance. Resistance to penicillins, beta-lactamase inhibitors, cephalosporins, aminoglycosides, fluoroquinolones, carbapenams and co-trimoxazole was reported. The patient was sensitive to Colistin and intermediate to tigecycline. The patient's left ventricular ejaculation was reported as 25%.

Clinical History

The patient had undergone CABG two months earlier. During that period, the patient had a history of dyspnoea with recurrent cough and was intubated twice to provide ventilator support.

The patient, at present, was in no state to give the symptoms in his collapsed state, and at the time of first consultation, the totality for homoeopathic prescription was drawn from information gathered from his attendants, on bedside observations made by the prescribing physician and from the clinical diagnosis. On 20th November 2014, the, medicine prescribed was Antimonium tartaricum 200C, single dose.

Bedside observations

  • The patient could not bring up expectoration, but was relieved when he brought it up
  • Cough forced him to sit erect
  • Anguished look
  • Delusions of ghosts at night
  • Wants to hold hand of attendant at night
  • Fear of being alone
  • Anger on contradiction
  • Sunken look of the face and eyes
  • Strong offensive odour from the body of the patient
  • Nostrils flapping motion
  • The patient seems in lot of pain
  • Coldness of breath
  • Angered if his wife asked him anything.


Physical generals

  • Temperature: 99.6°F
  • Blood pressure: 160/94 mm Hg
  • Pulse rate: 82 per minute
  • SpaO2 with O2 insufflation: 88%.


Acute dispositional and characteristic symptoms of the patient were selected for constructing the totality and for repertorisation.

The details of prescription and the follow-up are given in [Table 1].
Table 1: Follow Up

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The follow-up lasted for over 18 months, during which the patient showed remarkable improvement in respiratory complaints with no severe relapse. His quality of life improved.

Modified Medical Research Council Dyspnoea scale was used to assess the prognosis of the patient at each follow-up which is represented graphically in [Figure 1]. (X-axis is follow-up and Y-axis is the score. The scoring was performed by a homeopathic doctor.
Figure 1: Modified medical research council dyspnea scale

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  Discussion Top


Tracheal injuries, independent of their origin, may be life-threatening. Surgical repair is regarded as the treatment of choice, but has not been compared with other approaches.[14] There are well documented case reports which show the possibility of homoeopathy to treat severe pathologies.[15],[16],[17],[18] Homoeopathic prescription is based on the signs and symptoms of the patient and not on the diagnosis or pathology alone.[19] This way, the entire immunological events and reactions in a person's life are considered to arrive at a solution that is integrative.[20],[21]

Therefore, it is able to address the multifactorial nature of the autoimmune diseases and other conditions that involve the whole organism. In this case also, we see that there is a systemic inflammatory response prior to the lung collapse and this itself might have triggered the later events.

We could observe that on the second day, after administration of Antimonium tartaricum, the frequency of suction was reduced to 3–4 times a day from 1-2 hourly, followed by improvement in breathlessness and decrease in expectoration. Furthermore, the patient passed stools on the second day which he was previously unable to, due to paralytic ileus. The remedy Antimonium tartaricum 200C [22] not only helped the patient to recover from his pulmonary dysfunction, but brought about an overall well-being. Although prognosis is bad in postoperative pulmonary complications,[23] this patient improved with homoeopathy given along with the conventional medication to control hypertension and elevated blood lipid levels, as well as anticoagulation medication and anti-allergic remedies. Of these, the anti-allergics, bronchodilators, steroids and mucolytic agents could further be tapered down. Although it may be difficult to achieve good response in all cases with such a poor prognosis, this case demonstrates the potential and scope of homoeopathy. When the patient was admitted in a state of acute respiratory distress, he was examined by the pulmonologist and was advised for tracheal stenting. The patient's left ventricle ejection fraction was 25%. The relatives did not give the consent for the tracheal stenting because the patients respiratory, cardiac and general condition was poor and non responsive. Then, homoeopathic medicine Antimonium tartaricum 200C was prescribed. The patient was advised for bronchoscopy and Computed Tomography scan. As the the patient did not undergo the procedure, so the investigators are not in a position to describe the post interventional state of the respiratory tract. This case can also have a selection bias as the patient and attendants chose to take homoeopathic treatment. As case reports are the first line of evidence and the scientific documentation of a single clinical observation, a good case report should be clear about the importance of the observation being reported. If multiple case reports show something similar, the next step might be a case–control study to determine if there is a relationship between the relevant variables. Hence, conducting controlled studies could clear this bias.


  Conclusions Top


This case of PPD with subglottic stenosis after CABG surgery, was treated with individualised homoeopathic therapy along with conventional medicine, preventing the tracheal stenting, which was otherwise indicated. Further, the patient's general condition and quality of life improved greatly, as shown by a long follow-up after the crisis. Although, a case report would not lead to a conclusion to arrive upon the role of homoeopathy in tracheal injuries, it gives a scope and potential to study more tracheal injury cases with homoeopathy which are not responding to conventional medicines. Clinical practice, and further randomized controlled trials are needed to arrive to definitive conclusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Ethical approval

Not obtained as the patient volunteered for homoeopathic treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

None declared.



 
  References Top

1.
Piotto RF, Ferreira FB, Colósimo FC, Silva GS, Sousa AG, Braile DM. Independent predictors of prolonged mechanical ventilation after coronary artery bypass surgery. Rev Bras Cir Cardiovasc 2012;27:520-8.  Back to cited text no. 1
    
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Kogan A, Cohen J, Raanani E, Sahar G, Orlov B, Singer P, et al. Readmission to the intensive care unit after “fast-track” cardiac surgery: Risk factors and outcomes. Ann Thorac Surg 2003;76:503-7.  Back to cited text no. 2
    
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Myer CM, O'Connor DM, Cotton RT. Proposed grading system for subglottic stenosis based on endotracheal tube sizes; 1994. Journals.sagepub.com; 2018. Available from: http://journals.sagepub.com/doi/10.1177/000348949410300410. [Last accessed on 2018 Dec 01].  Back to cited text no. 3
    
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[PUBMED]  [Full text]  
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21.
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