1
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Herrmann D, Hecker E. [Tracheobronchial Injuries]. Zentralbl Chir 2024; 149:275-285. [PMID: 37884026 DOI: 10.1055/a-2182-7126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
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.
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Affiliation(s)
- Dominik Herrmann
- Klinik für Thoraxchirurgie, Thoraxzentrum Ruhrgebiet - EVK Herne, Herne, Deutschland
| | - Erich Hecker
- Klinik für Thoraxchirurgie, Thoraxzentrum Ruhrgebiet - EVK Herne, Herne, Deutschland
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2
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Buschulte K, Kahn N, Schmidt W, Reinhardt L. Severe tracheal tear - an alternative extracorporeal membrane oxygenation indication. Perfusion 2023:2676591231175983. [PMID: 37160714 DOI: 10.1177/02676591231175983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Conservative management is usually preferred for iatrogenic tracheal injuries. Venovenous extracorporeal membrane oxygenation (V-V ECMO) is mostly used in acute refractory hypoxemia, airway lesions are an alternative indication. CASE REPORT A 51-year-old female was transferred with a large tracheal tear after plastic tracheotomy. Due to a critical ventilation situation with hypercapnia, conservative management was set and V-V ECMO was installed. With optimized tube positioning, minimal ventilation and gas transfer via V-V ECMO, a complete healing of the injury could be achieved. DISCUSSION Fast diagnosis of tracheal injuries is essential; transfer to a specialized centre should be considered. In our case, organ support via ECMO was necessary due to a difficult ventilation situation with persisting hypercapnia. Thus, reduction in ventilation pressures with reduction of possible leakage and healing of the tracheal tear could be achieved. CONCLUSION Management of tracheal tears is complex; in severe cases special therapy concepts such as the use of V-V ECMO may become necessary.
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Affiliation(s)
- Katharina Buschulte
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
- Centre for ARDS and Weaning, Heidelberg University Hospital, Heidelberg, Germany
| | - Nicolas Kahn
- Department of Pneumology and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Centre for Lung Research (DZL), Heidelberg, Germany
| | - Werner Schmidt
- Centre for ARDS and Weaning, Heidelberg University Hospital, Heidelberg, Germany
- Department of Anaesthesiology, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - Lars Reinhardt
- Centre for ARDS and Weaning, Heidelberg University Hospital, Heidelberg, Germany
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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3
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Fuentes-Martín Á, Disdier Vicente C, Cilleruelo-Ramos Á. Complete bronchial rupture due to blunt chest trauma. Pulmonology 2023; 29:176-177. [PMID: 36655594 DOI: 10.1016/j.pulmoe.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/30/2022] [Accepted: 07/31/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Á Fuentes-Martín
- Thoracic Surgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
| | - C Disdier Vicente
- Pulmonology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Á Cilleruelo-Ramos
- Thoracic Surgery Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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4
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Tombelli S, Viggiano D, Gatteschi L, Voltolini L, Gonfiotti A. Video-assisted transcervical-transtracheal repair of posterior wall laceration of thoracic trachea: A new approach. Case Report. Front Surg 2023; 10:1120404. [PMID: 36843996 PMCID: PMC9945533 DOI: 10.3389/fsurg.2023.1120404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
Iatrogenic tracheal lacerations are a rare but potentially fatal event. In selected acute cases, surgery plays a key role. Treatment can be conservative, for lacerations of less than 3 cm; surgical or endoscopic, depending on the size and location of the lesion and fan efficiency. There is no clear indication of the use of any of these approaches and the decision is therefore linked to local expertise. We present an emblematic clinical case of a 79 years old female patient undergoing polytrauma as a result of a road accident, without neurological damage, which required intubation and subsequent tracheotomy due to a significant limitation to ventilation. Imaging has shown the tracheal laceration involving the anterior wall and the pars membranacea up to the origin of the right main bronchus.A percutaneous tracheotomy was permormed without any improvement of the respiratory dynamic. Therefore, the patient underwent a surgical repair of the tracheal laceration with a hybrid mini-cervicotomic/endoscopic approach. This less invasive approach successfully repaired the extensive loss of substance.
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Affiliation(s)
| | - Domenico Viggiano
- Division of Thoracic Surgery, Careggi University Hospital, Florence, Italy
| | - Lavinia Gatteschi
- Division of Thoracic Surgery, Careggi University Hospital, Florence, Italy
| | - Luca Voltolini
- Division of Thoracic Surgery, Careggi University Hospital, Florence, Italy
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5
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Kalverkamp S, Störmann P, Graeff P, Raab S. [Traumatic Tracheobronchial Injuries - Recommendation of the Interdisciplinary Working Group of the DGT and DGU to Establish a Uniform Classification for Diagnostics and Therapy]. Zentralbl Chir 2023; 148:85-92. [PMID: 36822184 DOI: 10.1055/a-1970-3555] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Traumatic tracheobronchial injuries are extremely rare. In comparison, iatrogenic injuries are somewhat more common. A literature search revealed that there is a large number of case reports and small case series for this clinical entity. There are hardly any reviews and they usually have a low level of evidence. One reason for this is the lack of a classification to allow comparison of the individual cases with each other. There is only one classification for iatrogenic injuries of the posterior tracheal wall, which the authors modified and expanded with regard to traumatic tracheobronchial injuries. This classification was extended by the authors to also include traumatic injuries. A three-digit classification is presented here. The grading of the injury covers the entire spectrum of injury patterns, from peribronchial emphysema to wall injuries of different depths to subtotal and complete rupture of the bronchus. In addition, the anatomical location and the cause of the injury were added to the classification. The levels of injury in the tracheobronchial tree are distinguished anatomically. The third digit distinguishes traumatic, iatrogenic and spontaneous injuries. On the basis of the three-digit classification resulting from these parameters, it is possible to group individual cases together and to develop recommendations for diagnostics and therapy.
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Affiliation(s)
| | - Philipp Störmann
- Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - Pascal Graeff
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Stephan Raab
- Herz- und Thoraxchirurgie, Universitätsklinikum Augsburg, Augsburg, Deutschland
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6
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Tahir I, Alizai Q, Ullah F, Haseeb A, Ijaz N. Successful Repair of a Complete Tracheobronchial Tear Two Months After the Injury. Cureus 2022; 14:e31628. [DOI: 10.7759/cureus.31628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 11/19/2022] Open
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7
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Fu B, Hu J, Chen T, Fu X. Tracheal Membrane Rupture as the Cause of Pneumomediastinum in a Patient with COVID-19. Korean J Radiol 2022; 23:488-490. [PMID: 35345063 PMCID: PMC8961011 DOI: 10.3348/kjr.2021.0947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/28/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bao Fu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jie Hu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Tao Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xiaoyun Fu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, China.
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Evermann M, Roesner I, Denk-Linnert DM, Taghavi S, Klepetko W, Hoetzenecker K, Schweiger T. Cervical Repair of Iatrogenic Tracheobronchial Injury by Tracheal T-Incision. Ann Thorac Surg 2022; 114:1863-1870. [PMID: 35346636 DOI: 10.1016/j.athoracsur.2022.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/06/2022] [Accepted: 03/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tracheobronchial injury is a rare but potentially life-threatening condition. Various surgical treatment options have been described for symptomatic patients with full-thickness injury. However, studies comprising a meaningful number of patients are sparse. METHODS We retrospectively analyzed all patients who received surgical repair of tracheobronchial injury between January 1999 and May 2021 at the Department of Thoracic Surgery, Medical University of Vienna. Patient characteristics, surgical variables, postoperative morbidity, and mortality were retrieved and analyzed. RESULTS Fifty patients with a median age of 68 years (range, 17-88) were included in the analysis. The etiologies of the iatrogenic tracheobronchial injuries were emergency intubation (48%), elective percutaneous dilatation tracheostomy (38%), or elective intubation (14%). The most common location of tracheobronchial injuries was distal third (28%) with a median length of 50 mm (range, 20-100 mm). The surgical approach was cervicotomy in 52%, thoracotomy in 38%, sternotomy in 2%, and combined approaches in 8% of cases. Moreover, intraoperative venovenous (n = 4) or venoarterial (n = 2) extracorporeal membrane oxygenation support was required in 12% of cases. Procedure-related mortality was 0%. However, as patients with tracheobronchial injury usually have severe comorbidities, the rate of patients discharged alive from the intensive care unit was only 66%. The median follow-up period of discharged patients was 5.5 months (range, 0.7-209). Airway stenosis or dehiscence was not observed in any patient. CONCLUSIONS Surgical repair of tracheobronchial injuries can be performed safely with a low procedure-related morbidity. If possible, the less-invasive cervical access should be preferred for patients with tracheobronchial injury, even for injuries extending to the main bronchi.
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Affiliation(s)
- Matthias Evermann
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Imme Roesner
- Division of Phoniatrics and Logopedics, Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | - Doris-Maria Denk-Linnert
- Division of Phoniatrics and Logopedics, Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | - Shahrokh Taghavi
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Thomas Schweiger
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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9
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Salami MA, Beeman A, Ramaswamy M, Muthialu N. Complex airway reconstruction in children with tracheobronchial injuries: a case series. J Int Med Res 2022; 50:3000605221081726. [PMID: 35259976 PMCID: PMC8918970 DOI: 10.1177/03000605221081726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Paediatric airway surgery in the setting of complex tracheobronchial defects is challenging. This report describes the surgical management and outcomes of pericardial flap repair in three children. The first patient was a 4-month-old boy with a history of tracheoesophageal fistula repair who presented after out-of-hospital cardiac arrest. He was treated by re-do tracheobronchial reconstruction of the carina using a pedicled pericardial flap. The second patient was an 11-month-old boy who presented following aspiration of a button battery. Bronchoscopy showed erosion of the battery through both main bronchi and the oesophagus. The patient underwent emergency reconstruction of the extensive tracheobronchial defect with pedicled right and left pericardial patches. The third patient was a 5-year-old girl who fell from a swing, resulting in avulsion of the right main bronchus. Pedicled pericardium was used to reconstruct the damaged posterior tracheal wall and the right and left main bronchi. All three patients underwent successful repair of complex tracheobronchial defects with good outcomes in terms of survival and quality of life during 6 to 21 months of follow-up. Pedicled pericardial flap repair may be a viable option for achieving improved results in children with severe tracheobronchial defects.
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Affiliation(s)
- Mudasiru A Salami
- Tracheal Team, Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom.,Cardiovascular and Thoracic Surgery Division, University College Hospital, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Arun Beeman
- Tracheal Team, Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Madhavan Ramaswamy
- Tracheal Team, Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Nagarajan Muthialu
- Tracheal Team, Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom
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10
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Rieth A, Varga E, Kovács T, Ottlakán A, Németh T, Furák J. Contemporary management strategies of blunt tracheobronchial injuries. Injury 2021; 52 Suppl 1:S7-S14. [PMID: 32674886 DOI: 10.1016/j.injury.2020.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/09/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tracheobronchial injuries are rare but feasibly life-threatening conditions. A prompt diagnosis and early management can be lifesaving. Due to the unspecific symptoms and indirect radiological signs the diagnosis often delays. OBJECTIVES We present a short series of patients suffering from tracheobronchial airway laceration. All the three patients had blunt thoracic or neck trauma and showed early signs of tracheobronchial injury. In the first case a 44-year-old woman was crushed by a bus. Subcutaneous emphysema, pneumothorax on chest computed tomography and hypoxaemia despite of chest tube suggested the presence of an airway injury. During operation a 4-cm-long tear of the trachea and a complete transection of the right main bronchus were found. In the second case a 12-year-old girl was crossed by a truck trailer. Early signs were respiratory failure, extended subcutaneous emphysema, blood clot in the larynx, pneumothorax on both sides. Chest CT showed pneumomediastinum. During the operation a longitudinal laceration was found separating the two main bronchi at the bifurcation. In the third case a 9-year-old boy was injured in a car accident, when the seat-belt crossed his neck. Spreading subcutaneous emphysema, pneumomediastinum and an overinflated endotracheal tube's cuff were found on CT. A completely transected trachea between the first and second tracheal rings was found. All three patients required fast intubation and bronchoscopic examination to confirm the diagnosis, and to identify the site of lacerations. All the patients underwent primary reconstruction and recovered successfully. CONCLUSIONS In case of suspected tracheobronchial injury, a high index of suspicion is required for early diagnosis. Most commonly respiratory distress, subcutaneous emphysema and pneumothorax are found on physical examination. Prompt intubation below the site of the injury and early laryngo- or bronchoscopic examination have priority, as we did in our cases. A primary anastomosis is required with minimal resection during urgent operation. A better outcome is to be expected when extubation is done early after surgery. We offer ordinal steps that should be taken to lead to a prompt management and good long-term outcome based on the literature and our experiences.
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Affiliation(s)
- Anna Rieth
- Division of Pediatric Surgery, Department of Pediatrics, University of Szeged, Szeged, Hungary.
| | - Endre Varga
- Department of Traumatology, University of Szeged, Szeged, Hungary.
| | - Tamás Kovács
- Division of Pediatric Surgery, Department of Pediatrics, University of Szeged, Szeged, Hungary.
| | - Aurél Ottlakán
- Division of Thoracic Surgery, Department of Surgery, University of Szeged, Szeged, Hungary.
| | - Tibor Németh
- Division of Thoracic Surgery, Department of Surgery, University of Szeged, Szeged, Hungary.
| | - József Furák
- Division of Thoracic Surgery, Department of Surgery, University of Szeged, Szeged, Hungary.
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11
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Abstract
Tracheobronchial injuries (TBI) are a heterogenous group of sometimes life-threatening traumas with different management approaches. Symptoms are mediastinal and subcutaneous emphysema, bloody secretions from the airway or haemoptysis in alert patients, and high air leakage along the cuff or increased ventilatory resistance may be signs for TBI in intubated patients. The necessity of immediate clinical evaluation, CT-scan and bronchoscopic evaluation are essential for prompt diagnosis and classification as well as experienced air way management and treatment, these patients are best managed from interdisciplinary teams including thoracic surgeons. While iatrogenic tracheal membrane laceration from intubation can be treated by lesion bridging with ventilation tube, stent application, open operative repair or endoluminal repair, intraoperative accidental cuts should be repaired by direct suture or with vital tissue coverage in case of local ischemia. The management of blunt or penetrating injury is sequential and needs immediate establishment and maintenance of a secure patent airway to provide adequate oxygenation. The next step is the treatment of life-threatening collateral injuries like major hemorrhage, cranial trauma or major organ damage arranged in the trauma team. The treatment of penetrating injuries to the airway need operative exploration in almost every case with minimal local dissection and debridement followed by direct repair. Muscle flap coverage is useful in case of combined esophageal injury. Damage of the tracheobronchial tree after blunt trauma must be repaired by direct suture or local tissue sparing resection and anastomosis. These lesions can be missed in the initial phase and may become prominent with scar tissue formation, stenosis and atelectasis in the later phases.
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Affiliation(s)
- Stefan Welter
- Department of thoracic surgery, Lung Clinic Hemer, Hemer, Germany
| | - Weam Essaleh
- Department of thoracic surgery, Lung Clinic Hemer, Hemer, Germany
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12
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Dogrul BN, Kiliccalan I, Asci ES, Peker SC. Blunt trauma related chest wall and pulmonary injuries: An overview. Chin J Traumatol 2020; 23:125-138. [PMID: 32417043 PMCID: PMC7296362 DOI: 10.1016/j.cjtee.2020.04.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 03/15/2020] [Accepted: 04/08/2020] [Indexed: 02/04/2023] Open
Abstract
Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the third most common cause of death in all age groups, one out of four trauma patients die due to thoracic injury or its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importance of chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.
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13
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Herrmann D, Volmerig J, Al-Turki A, Braun M, Herrmann A, Ewig S, Hecker E. Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration? J Thorac Dis 2019; 11:4772-4781. [PMID: 31903267 DOI: 10.21037/jtd.2019.10.22] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Dominik Herrmann
- Thoraxzentrum Ruhrgebiet, Department of Thoracic Surgery, Evangelisches Krankenhaus, Herne, Germany
| | - Jan Volmerig
- Thoraxzentrum Ruhrgebiet, Department of Thoracic Surgery, Evangelisches Krankenhaus, Herne, Germany
| | - Ahmad Al-Turki
- Thoraxzentrum Ruhrgebiet, Department of Thoracic Surgery, Evangelisches Krankenhaus, Herne, Germany
| | - Monique Braun
- Thoraxzentrum Ruhrgebiet, Department of Thoracic Surgery, Evangelisches Krankenhaus, Herne, Germany
| | - Anke Herrmann
- Institute of Virology, University of Duisburg-Essen, Essen, Germany
| | - Santiago Ewig
- Thoraxzentrum Ruhrgebiet, Department of Respiratory and Infectious Diseases, Evangelisches Krankenhaus, Herne, Germany
| | - Erich Hecker
- Thoraxzentrum Ruhrgebiet, Department of Thoracic Surgery, Evangelisches Krankenhaus, Herne, Germany
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14
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Struck MF, Hempel G, Pietsch UC, Broschewitz J, Eichfeld U, Werdehausen R, Krämer S. Thoracotomy for emergency repair of iatrogenic tracheal rupture: single center analysis of perioperative management and outcomes. BMC Anesthesiol 2019; 19:194. [PMID: 31656172 PMCID: PMC6816164 DOI: 10.1186/s12871-019-0869-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/17/2019] [Indexed: 12/25/2022] Open
Abstract
Background Iatrogenic tracheal ruptures are rare but life-threatening airway complications that often require surgical repair. Data on perioperative vital functions and anesthetic regimes are scarce. The goal of this study was to explore comorbidity, perioperative management, complications and outcomes of patients undergoing thoracotomy for surgical repair. Methods We retrospectively evaluated adult patients who required right thoracotomy for emergency surgical repair of iatrogenic posterior tracheal ruptures and were admitted to a university hospital over a 15-year period (2004–2018). The analyses included demographic, diagnostic, management and outcome data on preinjury morbidity and perioperative complications. Results Thirty-five patients who met the inclusion criteria were analyzed. All but two patients (96%) presented with critical underlying diseases and/or emergency tracheal intubations. The median time (interquartile range) from diagnosis to surgery was 0.3 (0.2–1.0) days. The durations of anesthesia, surgery and one-lung ventilation (OLV) were 172 (128–261) min, 100 (68–162) min, and 52 (40–99) min, respectively. The primary airway management approach to OLV was successful in only 12 patients (34%). Major complications during surgery were observed in 10 patients (29%). Four patients (11%) required cardiopulmonary resuscitation, one of whom received extracorporeal membrane oxygenation, and another one of these patients died during surgery. Major complications were associated with significantly higher all-cause 30-day mortality (p = 0.002) and adjusted mortality (p = 0.001) compared to patients with minor or no complications. Conclusions Surgical repair of iatrogenic tracheal ruptures requires advanced perioperative care in a specialized center due to high morbidity and potential complications. Airway management should include early anticipation of alternative OLV approaches to provide acceptable conditions for surgery.
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Affiliation(s)
- Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany.
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Uta C Pietsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Johannes Broschewitz
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Uwe Eichfeld
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Robert Werdehausen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Sebastian Krämer
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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15
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Henley MD, Kumar PA. Tracheal Injury Prior to Sternotomy: A Cautionary Tale. Semin Cardiothorac Vasc Anesth 2019; 23:319-323. [DOI: 10.1177/1089253218825443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Tracheal laceration during cardiac surgery is a rarely reported form of iatrogenic tracheal injury. During dissection prior to sternotomy, the interclavicular ligament must be divided. This structure overlies the proximal trachea, predisposing the trachea to injury at this location. Challenges related to tracheal laceration in cardiac surgery include patients with already tenuous cardiopulmonary status, surgical positioning that increases the risk of injury, obscured traditional clinical findings causing delayed recognition, increased risk of mediastinitis, and a heightened risk of airway fire. The incidence, mechanism, and ideal management of sternotomy-related tracheal injury, though a life-threatening complication, is rarely described in the literature. Consensus is lacking regarding the necessity and timing of tracheal repair versus conservative management, whether to proceed with the initially planned procedure, and the optimal timing of airway exchange in the event of endotracheal tube cuff rupture. In this article, we present the management of a full-thickness thermal tracheal injury due to electrocautery, resulting in a large air leak treated with delayed endotracheal tube exchange and tracheal repair after cardiopulmonary bypass.
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Affiliation(s)
| | - Priya A. Kumar
- University of North Carolina at Chapel Hill, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Abstract
Blunt airway trauma is rare but life threatening. Injuries to other vital organs accompany this type of injury in most cases; therefore, conservative treatment may be considered first. In cases of delayed fibrotic airway stenosis after conservative treatment, surgical treatment or bronchoscopic intervention are therapeutic options. We herein report a case of delayed airway stenosis after a blunt traumatic airway injury that was successfully managed by silicone stenting.
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Affiliation(s)
- Ji Yeon Roh
- Department of Intermal Medicine, Pusan National University School of Medicine, Korea
| | - Insu Kim
- Department of Intermal Medicine, Pusan National University School of Medicine, Korea
| | - Jung Seop Eom
- Department of Intermal Medicine, Pusan National University School of Medicine, Korea
| | - Geewon Lee
- Department of Radiology, Pusan National University School of Medicine, Korea
| | - Hyo Yeong Ahn
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Korea
| | - Min Ki Lee
- Department of Intermal Medicine, Pusan National University School of Medicine, Korea
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Singh P, Wojnar M, Malhotra A. Iatrogenic tracheal laceration in the setting of chronic steroids. J Clin Anesth 2016; 37:38-42. [PMID: 28235525 DOI: 10.1016/j.jclinane.2016.10.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 10/01/2016] [Accepted: 10/28/2016] [Indexed: 02/06/2023]
Abstract
We report the case of a 71-year-old woman with end-stage chronic obstructive pulmonary disease who presented with a 10-cm tracheal laceration from a presumed traumatic intubation in the setting of respiratory distress and chronic obstructive pulmonary disease exacerbation and subsequently developed significant subcutaneous emphysema along her neck and mediastinum in addition to her peritoneum and mesentery. We were successfully able to treat this patient conservatively up until the time that tracheostomy was warranted. We discuss and review tracheobronchial injuries with respect to etiology, risk factors, and management and hope to benefit health care providers managing airways in patients at risk for tracheal injury.
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Affiliation(s)
- Punit Singh
- Department of Anesthesiology, Penn State College of Medicine, Penn State Hershey, Medical Center, Hershey, PA 17033, USA.
| | - Margaret Wojnar
- Department of Critical Care Medicine, Penn State College of Medicine, Penn State, Hershey Medical Center, Hershey, PA 17033, USA
| | - Anita Malhotra
- Department of Anesthesiology, Penn State College of Medicine, Penn State Hershey, Medical Center, Hershey, PA 17033, USA
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Endobronchial Cartilage Rupture: A Rare Cause of Lobar Collapse. Case Rep Pulmonol 2016; 2016:8178129. [PMID: 27525149 PMCID: PMC4976168 DOI: 10.1155/2016/8178129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/10/2016] [Indexed: 02/08/2023] Open
Abstract
Endobronchial cartilage rupture is a rare clinical condition, which can present in patients with severe emphysema with sudden onset shortness of breath. We present a case of a 62-year-old male who presented to our emergency department with sudden onset shortness of breath. Chest X-ray showed lung hyperinflation and a right lung field vague small density. Chest Computed Tomography confirmed the presence of right middle lobe collapse. Bronchoscopy revealed partial right middle lobe atelectasis and an endobronchial cartilage rupture. Endobronchial cartilage rupture is a rare condition that can present as sudden onset shortness of breath due to lobar collapse in patients with emphysema and can be triggered by cough. Bronchoscopic findings include finding a collapsed lung lobe and a visible ruptured endobronchial cartilage. A high index of suspicion, chest imaging, and early bronchoscopy can aid in the diagnosis and help prevent complications.
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Shroff GS, Ocazionez D, Vargas D, Carter BW, Wu CC, Nachiappan AC, Gupta P, Restrepo CS. Pathology of the Trachea and Central Bronchi. Semin Ultrasound CT MR 2016; 37:177-89. [DOI: 10.1053/j.sult.2015.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Eroglu A, Aydin Y, Altuntas B, Ahiskalioglu A. Primary Endoscopic Repair of a Large Tracheal Rupture Through Tracheal Stoma. Ann Thorac Surg 2016; 100:e71-3. [PMID: 26434482 DOI: 10.1016/j.athoracsur.2015.05.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 04/27/2015] [Accepted: 05/26/2015] [Indexed: 02/08/2023]
Abstract
We describe the case of an 83-year-old man who presented with a large trauma to the membranous wall of the trachea and was treated with endoscopic primary repair of the tracheal wall through a preexisting tracheal stoma. Assessment with an optical telescope through the tracheal stoma revealed a 5-cm laceration in the membranous wall of the trachea starting immediately above the carina. The laceration was closed using continuous 4-0 monofilament polydioxanone sutures with direct visualization of tissues through a fiberoptic telescope. This approach is particularly effective in cases of traumatic rupture of the membranous trachea.
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Affiliation(s)
- Atilla Eroglu
- Department of Thoracic Surgery, Ataturk University, Medical Faculty, Erzurum, Turkey.
| | - Yener Aydin
- Department of Thoracic Surgery, Ataturk University, Medical Faculty, Erzurum, Turkey
| | - Bayram Altuntas
- Department of Thoracic Surgery, Ataturk University, Medical Faculty, Erzurum, Turkey
| | - Ali Ahiskalioglu
- Department of Anesthesia and Reanimation, Ataturk University, Medical Faculty, Erzurum, Turkey
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Oguzhan S, Schirren M, Sponholz S, Kudelin N, Mese M, Schirren J. Strategien beim Thoraxtrauma. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-015-0040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Blackney KA, Alfille PH. Anesthetic Management of a Delayed Carinal Resection Following Traumatic Disruption. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojanes.2014.410034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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