Successful Conservative Management in Iatrogenic Tracheobronchial Injury

[Tracheobronchial Injuries]

Tracheobronchial injury is a rare, but potentially life-threatening condition. These injuries are associated with high morbidity and mortality, which is ascribed to underlying diseases and additional injuries. Lacerations of the airway are differentiated into iatrogenic and non-iatrogenic injuries, while the group of non-iatrogenic lesions are grouped into blunt and penetrating traumas.The exact incidence of tracheobronchial injury is unknown, because many iatrogenic injuries occur without symptoms and most patients after traumatic laceration die before inpatient treatment. All patients with suspicion of airway injury require fast and accurate management.Common signs and symptoms are dyspnoea, haemoptysis, stridor and subcutaneous emphysema.Bronchoscopy is the most important tool for diagnosis and in several cases also for initial treatment.Further management depends on the patient's clinical condition and findings of bronchoscopy and computed tomography. Surgery has been the cornerstone of therapy, but in selected patients bronchoscopic stent implantation or conservative management must be discussed.

Iatrogenic tracheal laceration due to rigid bronchoscopy treated by endoscopic stent placement: a case report

Although rigid bronchoscopy may lead to tracheal injury, the incidence is unknown. A 59-year-old woman diagnosed with clinical stage IV esophageal cancer was scheduled to undergo placement of a silicon Y-stent by rigid bronchoscopy to address tracheal stenosis. When the tumor was cored out by rigid bronchoscopy, perforation of the lower trachea occurred, and a silicon Y-stent was inserted to cover the tracheal fistula. Chest X-ray revealed right pneumothorax, and chest drainage was performed. When spontaneous ventilation was confirmed, the patient was weaned from the ventilator in the operating room. Chest computed tomography immediately after surgery showed an air space on the right side of the stent. The space gradually disappeared over time, and no air leakage was observed. The chest drain was removed on postoperative Day 12. Conservative treatment using a silicon Y-stent for iatrogenic tracheal injury due to rigid bronchoscopy is safe.

Post-intubation iatrogenic tracheobronchial injuries: The state of art

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

Post-intubation tracheal lacerations: Risk-stratification and treatment protocol according to morphological classification

Background

Post-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients.

Methods

This retrospective analysis is based on a prospectively collected series (2003-2020) of 62 patients with PITL, staged and treated according to our revised morphological classification.

Results

Fifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity.

Conclusions

Our previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.

Terapia de presión negativa para pacientes con enfisema subcutáneo y neumomediastino masivo

Se han descrito diversas técnicas para el tratamiento del enfisema subcutáneo y del neumomediastino. Algunos pacientes con pequeñas perforaciones traqueales pueden ser manejados de forma expectante, salvo que requieran ventilación mecánica. Se presentan las imágenes de un paciente con enfisema subcutáneo y neumomediastino no candidato a cirugía y quien fue tratado exitosamente con terapia de presión negativa.

Conservative Treatment in Tracheobronchial Injuries—An Institutional Report

Tracheobronchial injuries are rare but potentially high-impact events with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma, often combined with various complex injuries, while iatrogenic injury usually occurs during operation, intubation, or bronchoscopy. An early and accurate diagnosis and a multidisciplinary approach in a center experienced in treating airway lesions are essential to obtain favorable results. For a long time, surgery has been considered the treatment of choice for post-traumatic airway lesions. However, recent reports have shown a paradigm shift in the management of tracheal injury towards a conservative approach, especially in treating iatrogenic lesions. In our experience of 11 consecutive patients, although there are still definitive indications for surgery, we demonstrated the effectiveness of conservative treatment in patients with mixed varieties of tracheal injury by etiology, extension, and complications.

Airway Rupture Caused by Double-Lumen Tubes: A Review of 187 Cases

The double-lumen tubes (DLTs) are the most widely used devices to provide perioperative lung isolation. Airway rupture is a rare but life-threatening complication of DLTs. The primary aim of this review was to collect all cases reported in the literature about airway rupture caused by DLTs and to describe the reported possible contributors, diagnosis, treatment, and outcomes of this complication. Another aim of this review was to assess the possible factors associated with mortality after airway rupture by DLTs. A comprehensive literature search for all cases of airway rupture caused by DLTs was performed in the PubMed, EMBASE, Ovid, Wanfang Database, and CNKI. The extracted data included age, sex, height, weight, type of operation, type and size of DLT, site of airway rupture, possible contributors, clinical presentation, diagnosis timing, treatment, and outcome. We included 105 single case reports and 22 case series with a total number of 187 patients. Most of the ruptures were in the trachea (n = 98, 52.4%) and left main bronchus (n = 70, 37.4%). The common possible contributors include use of a stylet, cuff overdistention, multiple attempts to adjust the position of a DLT, difficult intubation, and use of an oversized DLT. Most of the airway ruptures were diagnosed intraoperatively (n = 138, 82.7%). Pneumomediastinum, air leakage, hypoxemia, and subcutaneous emphysema were the common clinical manifestations. Most patients were treated with surgical repair (n = 147, 78.6%). The mortality of the patients with airway rupture by DLTs was 8.8%. Age, sex, site of rupture, diagnosis timing, and method of treatment were not found to be associated with mortality.

Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration?

Background

Iatrogenic tracheobronchial injury is a rare, but severe complication of endotracheal intubation. Risk factors are emergency intubation, percutaneous dilatational tracheostomy and intubation with double lumen tube. Regarding these procedures, underlying patients often suffer from severe comorbidities. The aim of this study was to evaluate the results of a standardized treatment algorithm in a referral center with focus on the surgical approach.

Methods

Sixty-four patients with iatrogenic tracheal lesion were treated in our department by standardized management adopted to clinical findings between 2003 and 2019. Patients with superficial laceration were treated conservatively. In the case of transmural injury of the tracheal wall and necessity of mechanical ventilation, patients underwent surgery. We decided on a cervical surgical approach for lesions limited to the trachea. In case of involvement of a main bronchus we performed thoracotomy. Data were evaluated retrospectively.

Results

In 19 patients the tracheal lesion occurred in elective intubation and in 17 patients during emergency intubation. In 23 cases a tracheal tear occurred during percutaneous dilatational tracheostomy and in three patients at replacement of a tracheostomy tube. Two patients received laceration during bronchoscopy. Twenty-nine patients underwent surgery with cervical approach and 14 underwent thoracotomy. There was no difference in the mortality of these groups. Treatment of tracheal tear was successful in 62 individuals. Nine patients died of multi organ dysfunction syndrome (MODS), two of them during surgery.

Conclusions

Iatrogenic tracheal laceration is a life-threatening complication and the mortality after tracheal injury is high, even in a specialized thoracic unit. Conservative management in patients with superficial tracheal lesion is a feasible procedure. In case of complete laceration of tracheal wall, surgical therapy is recommendable, whereby several approaches of surgical management seem to be equivalent.

Diagnosis, management and treatment of neck trauma

Trauma injuries to the neck account for 5-10% of all trauma injuries and carry a high rate of morbidity and mortality, as several vital structures can be damaged. Currently, there are several treatment approaches based on initial management by zones, initial management not based on zones and conservative management of selected patients. The objective of this systematic review is to describe the management of neck trauma.

Treatment of Tracheobronchial Injuries: A Contemporary Review

Tracheobronchial injury is a rare but a potentially high-impact event with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma and iatrogenic injury that might occur during surgery, endotracheal intubation, or bronchoscopy. Early recognition of clinical signs and symptoms can help risk-stratify patients and guide management. In recent years, there has been a paradigm shift in the management of tracheal injury towards minimally invasive modalities, such as endobronchial stent placement. Although there are still some definitive indications for surgery, selected patients who meet traditional surgical criteria as well as those patients who were deemed to be poor surgical candidates can now be managed successfully using minimally invasive techniques. This paradigm shift from surgical to nonsurgical management is promising and should be considered prior to making final management decisions.

Successful Treatment of an Iatrogenic Tracheal Laceration With a Temporary Polyurethane-Coated Nitinol Stent

We report the case of a 63-year-old woman who required emergent intubation after a choking episode at home. It resulted in a 5-cm tear in the membranous trachea. She was treated by placement of a temporary tracheal stent, which was successfully removed 3 months later.

Conservative versus Surgical Management of Iatrogenic Tracheal Rupture

Iatrogenic tracheal rupture (ITR) represents a life-threatening condition requiring prompt diagnosis, management, and treatment. The management of ITR is challenging, and treatment options depend on tear location, size, injury extent, and the patient's respiratory status. Although this complication has been extensively reported in published literature, the best evidence practice, for the management, requires clarification. In this review, the authors focused on the establishment of a differential diagnosis and the potential mechanism of the injury, the decision-making process, and the therapeutic approaches. It is suggested that for small lacerations or stable patients, conservative management could be considered sufficient, whereas invasive surgical therapy would be more appropriate in cases of large defects with significant air leak and patient instability.

Does Surgical Repair Still have a Role for Iatrogenic Tracheobronchial Rupture? Clinical Analysis of a Thoracic Surgeon's Opinion

PURPOSE

The choice of surgical repair or conservative treatment for iatrogenic tracheobronchial rupture (ITBR) remains controversial. However, thoracic surgeons consider that surgical repair is an important treatment modality. The purpose of this study was to evaluate the clinical results from the perspective of the surgery-preferred group.

METHODS

We treated 11 patients (8 women and 3 men; age: 52.6 ± 22.9 years) with ITBR from January 2011 to January 2016. A posterolateral thoracotomy or a trans-tracheal approach was performed according to the mechanism of injury.

RESULTS

Nine patients underwent surgery, and all patients received primary repair. Five patients received a right posterolateral thoracotomy, whereas one patient received a left posterolateral thoracotomy. No mortality or morbidity related to the surgery was observed. The mechanical ventilation time was 65.9 ± 99.2 hours. The intensive care unit duration was 19.7 ± 33.3 days. Two patients received conservative treatment, and all patients died of another disease that was not related to the conservative treatment.

CONCLUSION

Our mortality or morbidity due to surgery was not higher than world literature results of conservative treatment. We thought surgery is the primary treatment choice for ITBR in the absence of a good indication for conservative treatment.

Successful Conservative Management of Tracheal Injury After Forceful Coughing During Extubation: A Case Report

A-56-year-old woman underwent carpal tunnel release surgery under general anesthesia. Thirty minutes after extubation, the patient complained of chest discomfort with dyspnea. Swelling of the neck and upper anterior chest was observed. Computed tomography of the chest showed tracheal rupture at the brachiocephalic trunk level, and bronchoscopy demonstrated a 5 cm linear tracheal defect in the posterior membranous wall, 6 cm proximal to the carina. Surgical repair of the tracheal injury was impossible due to its location. The patient was managed with intubation, mechanical ventilator care, and antibiotics. She made a full and uncomplicated recovery and was discharged 18 days after the original injury. When suspicious symptoms appear in patients receiving mechanical ventilation support, an immediate and accurate diagnostic process should be undertaken to rule out endotracheal tube-related tracheal injuries and to avoid potentially lethal complications.

Airway stenting in the management of iatrogenic tracheal injuries: 10-Year experience

BACKGROUND AND OBJECTIVE

Iatrogenic tracheal injury (ITI) is a rare yet severe complication of endotracheal tube (ETT) placement or tracheostomy. ITI is suspected in patients with clinical and/or radiographic signs or inefficient mechanical ventilation (MV) following these procedures. Bronchoscopy is used to establish a definitive diagnosis.

METHODS

We conducted a retrospective, single-centre chart review of 35 patients between 2004 and 2014. Depending on the nature and location of ITI and need for MV, patients were triaged to surgical repair, endoscopic management with airway stents or conservative treatment consisting of ETT or tracheotomy cannula (TC) placement distal to the wound and bronchoscopic surveillance.

RESULTS

Three of the four patients (11.43%) presenting with tracheoesophageal fistula (TEF) underwent surgery. Seven patients (20%) who did not require MV underwent endoscopic surveillance. Of the 24 ventilated patients (68.57%), 7 with ITI in the lower trachea were treated with silicone Y-stent (ETT or TC was placed inside the stent) and 17 patients with ITI in the upper trachea were managed by placing ETT or TC cuff distal to the injury. Overall management success, defined as complete healing of the ITI, was seen in 88.57% of patients. Four patients (11.43%) died of non-ITI-related comorbidities.

CONCLUSION

Conservative management should be considered in non-ventilated patients with ITI and when ITI is located in the upper trachea of ventilated patients where ETT or TC bypasses the injury. Airway stenting should be considered in ventilated patients with ITI located in the lower trachea. Surgery should be reserved for TEF and conservative and endoscopic management failure.

Iatrogenic injuries to the trachea and main bronchi

Introduction

Iatrogenic tracheobronchial injuries are rare.

Aim

To analyse the mechanism of injury, symptoms and treatment of these patients.

Material and methods

Retrospective analysis of hospital records of all patients treated for main airway injuries between 1990 and 2012 was performed.

Results

There were 24 patients, including 21 women and 3 men. Mean time between injury and initiation of treatment was 12 hours (range: 2-48). In 16 patients the injury occurred during tracheal intubation, in 1 during rigid bronchoscopy, in 1 during rigid oesophagoscopy, in 1 during mediastinoscopy and in 5 during open surgery. Mean length of airway tear was 3.8 cm (range: 1.5-8). In 1 patient there was an injury to the cervical trachea and in the remaining 23 in the thoracic part of the airway. The treatment included repair of the membranous part of the trachea performed via right thoracotomy in 10 patients (in 1 patient additionally coverage with a pedicled intercostal muscle flap was used), a self-expanding metallic stent in 1 patient, suture of the right main bronchus and the oesophagus in 1, left upper sleeve lobectomy in 1, right upper lobectomy in 1, implantation of a silicone Y stent in 3, mini-tracheostomy in 1, and conservative treatment in 5 patients.

Conclusions

Intubation is the most frequent cause of iatrogenic main airway injuries. Patients with these life-threatening complications require an individualised approach and treatment in a reference centre.

Anesthetic Implications for Tracheal Injury During Bronchoscopy-Guided Percutaneous Dilational Tracheostomy

Bronchoscopic-guided percutaneous dilational tracheostomy has become one of the most common elective tracheostomy methods for patients requiring prolonged ventilatory support. The safety profile, patient selection, and risks as well as complication management, when compared with an open surgical technique, remain somewhat controversial with no clear recommendations. We present a case of a critically ill patient undergoing percutaneous dilation tracheostomy complicated by tracheal wall injury and airway loss. The airway was successfully conservatively managed as well as the tracheal injury. Anesthetic implications, safety, and management options as well as recommendations are reviewed.

Non-intubated video-assisted thoracic surgery in patients aged 80 years and older

BACKGROUND

Video-assisted thoracic surgery (VATS) is routinely performed with general anesthesia and double-lumen endotracheal intubation, but this technique may stress an elderly patient's functional reserve. We chose to study the safety and efficacy of non-intubated VATS, utilizing local anesthesia, sedation, and spontaneous ventilation in the elderly.

METHODS

The medical records of all patients aged 80 years and older who underwent VATS under local anesthesia and sedation during the time period 6/1/2002 to 6/1/2010 at Geisinger Health System (Pennsylvania, USA) and 10/1/2011 to 12/31/2014 at Sinai Hospital (Maryland, USA) were retrospectively reviewed. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on comorbidity.

RESULTS

A total of 96 patients ranging in age from 80 to 104 years underwent 102 non-intubated VATS procedures: pleural biopsy/effusion drainage with or without talc 73, drainage of empyema 17, evacuate hemothorax 4, pericardial window 3, lung biopsy 2, treat chylothorax 2, treat pneumothorax 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent procedure or biopsy. Complications occurred in three patients (3.1% morbidity): cerebrovascular accident, pulmonary embolism, prolonged air leak. One 94-year-old patient died from overanticoagulation and two 84-year-old patients died of their advanced lung cancers (3.1% morbidity).

CONCLUSIONS

Non-intubated VATS utilizing local anesthesia and sedation in the elderly is well tolerated and safe for a number of indications.

Nonintubated thoracoscopic pulmonary nodule resection under spontaneous breathing anesthesia with laryngeal mask

OBJECTIVE

During the past 20 years, the use of video-assisted thoracoscopic surgery has increased as an important minimally invasive tool. To further reduce its invasiveness, after a preliminary experience, we decided to use a nonintubated spontaneous breathing general anesthesia, for video-assisted thoracoscopic surgery resection of lung nodule, using a laryngeal mask (LMA). This study aimed to verify the safety and the feasibility of this technique.

METHODS

Twenty consecutive patients who underwent thoracoscopic wedge of lung nodule under spontaneous breathing general anesthesia with LMA are the subjects of this study. Clinical data, American Society of Anesthesiologists status, Adult Comorbidity Evaluation-27 score, and Revised Cardiac Risk Index score were recorded for each patient. General inhalatory anesthesia (sevoflurane) was given in all cases through an LMA, without muscle relaxants, thus allowing spontaneous breathing. All procedures were performed in the lateral decubitus position. The maximum and minimum values of end-tidal carbon dioxide tension and oxygen saturation were recorded during the procedure. The level of technical feasibility was stratified by the operating surgeon according to four levels: excellent, good, satisfactory, and unsatisfactory.

RESULTS

There were 13 men and 7 women (mean age, 57 years). The mean induction anesthesia time was 6 minutes, whereas the mean operative time was 38 minutes. The values of oxygen saturation as well as minimum and maximum end-tidal carbon dioxide tension were 99.1%, 33.6 mm Hg, and 39.1 mm Hg, respectively. No mask displacement occurred. The mean operative time was 38 minutes (range, 25-90 minutes). The level of technical feasibility was defined as excellent in 19 cases and good in 1 case. No mortality occurred. Morbidity consisted of pleural effusion (one case), which was medically resolved. The mean postoperative stay was 3.5 days. Histopathologic results were one squamous cell lung cancer (lung primary), one adenocarcinoma (lung primary), five metastasis from colon cancer, four metastasis from breast cancer, three metastasis from renal cancer, three sarcoidosis, two amartocondroma, and one tuberculosis.

CONCLUSIONS

Our experience suggests that thoracoscopic wedge resection of lung nodule is safe and feasible under spontaneous breathing anesthesia with LMA. This technique permits a confident manipulation of lung parenchyma and a safe stapler positioning, without cough, pain, or panic attack described for awake epidural anesthesia, avoiding the risks related to tracheal intubation and mechanical ventilation.

Conservative extracorporeal membrane oxygenation treatment in a tracheal injury: a case report

In patients with tracheal injuries, conservative treatment is an alternative approach when surgical treatment is difficult. However, the success rate of conservative treatment is low when a ventilator is used constantly because of underlying lung disease, and successful conservative treatment requires the maintenance of as much self-respiration as possible without a ventilator. Here, we report a case of lower tracheal injury in which both surgical and conservative treatments were difficult, but conservative treatment with extracorporeal membrane oxygenation was successful while maintaining self-respiration without a ventilator.

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

Traumatic intrathoracic tracheobronchial injuries: a study of 78 cases

BACKGROUND

Tracheobronchial injuries are encountered with increasing frequency because of improvements in pre-hospital care. We reviewed our experience of these injuries to determine how to better recognize them and facilitate their correct management.

METHODS

Patients with traumatic non-iatrogenic intrathoracic tracheobronchial injuries managed in 2 tertiary centers in Saudi Arabia between 2000 and 2012, were studied. Clinical presentation, diagnostic evaluation, management, and outcome were reviewed.

RESULTS

78 patients with tracheobronchial injuries were included in this study. They were divided into 2 groups according to the management strategy. Forty-seven patients who were managed conservatively, and 31 underwent surgery. Surgery allowed shorter intensive care unit and hospital stays; otherwise, the results were comparable between the two groups.

CONCLUSIONS

Early recognition and expedient appropriate management are essential in these potentially lethal injuries. Operative management can be achieved with acceptable mortality, and conservative treatment should be considered as a valuable alternative to the well-established surgical treatment.

Bilateral pneumothorax following a blunt trachea trauma

A-13 year old boy had an accident with his bike with a blunt thorax trauma and presented shortly after with facial swelling. Due to respiratory insufficiency, intubation was done during the transport to the clinic. First, a chest radiograph was performed, which showed a unilateral pneumothorax. Later a CT scan revealed bilateral pneumothorax and pneumomediastinum. Bilateral chest tube insertions improved the respiratory situation. Bronchoscopy showed a tracheal lesion two cm posterior to the main carina. After good wound healing, the patient was dismissed after 21 days in good health. Conservative treatment can be recommended in selected patients with a tracheal lesion when having a stable respiratory situation. If the patient does not improve after 48 h or if the clinical condition worsens, surgical management should be considered.

Management of post-intubation tracheal membrane ruptures: A practical approach

Tracheal rupture is an infrequent, severe complication of endotracheal intubation, which can be difficult to diagnose. Post-intubation tracheal rupture (PiTR) is distinct from non-iatrogenic causes of tracheobronchial trauma and often requires different treatment. The increasing adoption of pre-hospital emergency services increases the likelihood of such complications from emergency intubations. Effective management strategies for PiTR outside specialist cardiothoracic units are possible. Two cases of severe PiTR, successfully managed non-operatively on a general medical-surgical intensive care unit, illustrate a modified approach to current standards. The evidence base for PiTR is reviewed and a pragmatic management algorithm presented.

[Delayed iatrogenic tracheal post-intubation rupture. A short review of the aetiopathology and treatment]

Iatrogenic tracheal rupture is a rare complication with a high morbidity and mortality. Tracheal intubation is the main cause and its origin is multifactorial. The diagnosis is based on non-specific but highly suggestive signs and symptoms, such as subcutaneous emphysema, pneumothorax, respiratory distress, or haemoptysis. Confirmation of the diagnosis requires an examination by bronchoscopy. Surgical repair has traditionally been the treatment of choice although the current trend is conservative management.

Iatrogenic tracheal rupture: bovine pericardial patch repair without flap reinforcement

We describe a case of an extensive post-intubation membranous tracheal rupture in a 67-year old patient after emergency intubation. This was managed surgically by bovine pericardial patch repair. Other cases of autologous and bovine patch repair of tracheal lacerations exist in the literature, and we believe this is the first report of successful bovine patch repair without accessory autologous tissue reinforcement. This technique may be used in surgically managed cases of membranous tracheal rupture where primary repair is unsuitable, thereby reducing procedural complexity.

[Successful surgical treatment of tracheal rupture caused by endotracheal intubation]

Rupture of the trachea is a rare complication of endotracheal intubation. The most common cause of the injury is the overinflation of the cuff. The authors present the case of a 45-year-old male in whom a 6 cm long trachea lesion was perceived during the operation due to a meso-hypopharyngeal tumor. Primary intervention resulted in successful reconstruction and full recovery. The case demonstrates the importance of prompt diagnosis and adequate therapy that helped in preventing an assumingly life-long complication or even death.

Tracheobronchial injury

Tracheobronchial injuries (TBI) can be challenging to diagnose, manage, and definitively treat. They encompass a heterogeneous group of injuries that are often associated with other injuries. Although relatively rare, diagnosis and treatment of TBI often requires skillful and creative airway management, careful diagnostic evaluation, and operative repairs that are often resourceful and necessarily unique to the given injury. An experienced surgeon with a high level of suspicion and the liberal use of bronchoscopy constitute the major tools necessary for diagnosing and treating these injuries. Most TBI can be repaired primarily using a tailored surgical approach and techniques specific to the injury. Associated injuries are common, and surgeons must be knowledgeable in treating a wide variety of physiologic abnormalities, especially those involving the chest wall and lung parenchyma, if a successful outcome is to be achieved in the management of these often challenging patients.

Management of Iatrogenic Tracheobronchial Injuries: A Retrospective Analysis of 29 Cases

BACKGROUND

Tracheobronchial injuries are rare but potentially life-threatening complications of endotracheal intubations or endobronchial interventions. This retrospective analysis discusses the criteria for the operative and nonoperative management of tracheal lacerations.

METHODS

From July 1996 to June 2006, 29 patients with iatrogenic tracheobronchial injuries were diagnosed at our institution. The injury occurred during single-lumen tube intubation in 14 patients and during double-lumen tube intubation in 2 patients. Two ruptures were diagnosed after surgical tracheostomy, eight after dilational percutaneous tracheostomy, and three after interventional bronchoscopy.

RESULTS

The lacerations in 11 patients were superficial or were sufficiently covered by the esophagus, and they underwent conservative management. Bronchoscopy revealed healing per primam in every case. Surgical repair was done in 18 patients (62%). The transtracheal approach was used for repair in 7 patients; a right-sided posterolateral thoracotomy was performed in 11 patients with lacerations affecting the lower third of the trachea. Three surgical patients died from causes unrelated to the tracheal injury. No clinically evident mediastinitis or postoperative tracheobronchial stenosis was observed.

CONCLUSIONS

The decision for operative or nonoperative treatment of iatrogenic tracheobronchial lacerations is determined by the ventilating situation and the local extent of the injury. Nonoperative management of iatrogenic tracheobronchial injuries may be a save option in patients with uncomplicated ventilation, superficial or sufficiently covered tears, and moderate and nonprogressive emphysema. Immediate surgical repair remains warranted in those patients who require mechanical ventilation that cannot be delivered past the laceration.