Extracorporeal membrane oxygenation in traumatic tracheal injuries: a bold life-saving option

Perioperative strategies and management of giant anterior mediastinal tumors: a narrative review

Background and Objective

Giant anterior mediastinal tumors sometimes may cause circulatory collapse and respiratory failure, known as mediastinal mass syndrome (MMS). The prediction and prevention of MMS is challenging. The aim of this study is to summarize the evaluation methods for MMS and formulate treatment strategies for giant anterior mediastinal tumors.

Methods

We performed a thorough analysis of recent international literature on giant anterior mediastinal tumors (>10 cm in diameter) and MMS published in the PubMed database. The search spanned the duration of the preceding 10 years from August 19, 2023, and only studies published in English were included.

Key Content and Findings

Mature teratomas and liposarcomas are the most common giant anterior mediastinal tumors and MMS develops most frequently in case of malignant lymphomas. Here, we propose a new treatment strategy for giant anterior mediastinal tumors. Based on imaging findings, giant anterior mediastinal tumors can be classified as cystic or solid and further blood investigation data are useful for a definitive diagnosis. When malignant lymphoma or malignant germ cell tumor is highly suspected, the first choice of treatment is not surgery but chemotherapy and radiotherapy. Moreover, image-guided drainage may be effective if giant cystic anterior tumors develop into MMS. The risk classification of MMS is important for treating giant anterior mediastinal tumors. If the MMS risk classification is 'unsafe' or 'uncertain', the intraoperative management deserves special attention. The surgical approach should however be based on tumor localization and invasion of surrounding tissues. Multidisciplinary team coordination is indispensable in the treatment of giant anterior mediastinal tumors.

Conclusions

When giant anterior mediastinal tumors are encountered, it is important to follow the appropriate treatment strategy, focusing on the development of MMS based on imaging findings and symptoms.

Traumatic main airway rupture successfully rescued by extracorporeal membrane oxygenation: A case report

The chest is a common site for traumatic injury; however, rupture of the main airway after chest trauma is a rare and potentially fatal condition. The present study demonstrated that extracorporeal membrane oxygenation (ECMO) may serve a crucial role in the effective conventional treatment of patients with severe chest trauma, ECMO was used before tracheal repair surgery to prevent hypoxia during surgery. When effective ventilation of the patient cannot occur without assistance, ECMO support is considered to be essential in ensuring effective gas exchange. This rescue procedure can provide guidance for the treatment of patients suffering from traumatic tracheal rupture and respiratory failure. To summarize, ECMO may be able to improve the treatment experience of patients with traumatic tracheal rupture and increase the treatment success rate of such patients.

Dogmalysis

Air medical and critical care providers encounter the extremes of being both in-hospital and out-of-hospital clinicians, work in unpredictable environments, and treat patients with the most significant injury patterns and diagnoses. These demands highlight the need to recognize unique mental challenges for those who work in the air medical environment and the process by which providers make decisions. Patients who present with a high-acuity/low-volume pathology generate particularly difficult situations with abundant opportunity for both celebrations of performance and learning from mistakes. There are times when the desired option of therapy is not available, the most appropriate destination is not feasible, or the crew is unable to address every aspect of patient care with resources that are immediately available. Although it is logical to make decisions based on anatomic and physiological knowledge, the absence of an actual answer does not necessitate the acceptance of consensus. Dogmalysis refers to the dissolution of authoritative tenets held as established opinion without adequate grounds. This article highlights the importance of dogmalysis, the value of honest scientific reflection, and the aggressive seeking of evidence-based answers as it pertains to the air medical environment.

Traumatic Pediatric Tracheal Rupture After Blunt Force Sporting Injury: Case Report and Review of the Literature

OBJECTIVE

This paper presents the case of a traumatic tracheal rupture in a pediatric patient. The body of literature of the clinical features, evaluation, and management of this uncommon presentation is discussed.

CASE

A 13-year-old boy sustained an intrathoracic tracheal rupture whilst playing Australian Rules football. He developed hallmark clinical features of air extravasation and was intubated prior to transfer to a tertiary pediatric center for further management. After a short trial of conservative management, his respiratory status deteriorated and he was taken to the operating theater for open surgical repair of the defect.

CONCLUSION

Traumatic rupture of the trachea is a rare injury in children. This case demonstrates the dynamic nature of this serious injury and the need for multidisciplinary care in achieving the optimal outcome.

Utility of extracorporeal membrane oxygenation (ECMO) in the management of traumatic tracheobronchial injuries: case series

Tracheobronchial injury is a rare, but potentially life-threatening condition, and in most cases requires urgent treatment to restore normal respiratory physiology. Over the past decades, extracorporeal membrane oxygenation (ECMO) has evolved as an important adjunct in airway surgery. We presented three cases of traumatic tracheobronchial injury managed with ECMO support at a level-1 trauma center and emphasized the benefits of anticipation and early institution of ECMO support perioperatively, in these high-risk cases. The management of traumatic tracheobronchial injuries requires early measures to guarantee adequate ventilation. Anticipation and early institution of ECMO in these patients may support respiratory physiology, facilitate repair and improve survival. The time factor and multidisciplinary communication and plan prior to intervention should be considered. ECMO support, whenever available, plays important role in the management of complicated tracheobronchial surgical procedure and thereby reduces risk of mortality.

Extracorporeal Membrane Oxygenation Support During Repair of a Non-Iatrogenic Tracheal Injury

Tracheal trauma is uncommon but carries major morbidity and mortality. A 26-year-old male sustained a near-transection of the cervical trachea due to penetrating trauma. Veno-venous extracorporeal membrane oxygenation (ECMO) support allowed for a controlled primary repair with muscular buttress and facilitated airway management. Facial injuries prevented oral intubation and retrograde intubation through the transection established an airway. On the tenth post-operative day, a percutaneous tracheostomy was performed through the surgical site. This case discusses the management, technical details, and adjuncts to successfully repair complex tracheal injuries.

Silicone Y-stent insertion under extracorporeal membrane oxygenation (ECMO) in a patient with tracheal tear

Tracheal tear after endotracheal intubation is extremely rare. The role of silicone Y-stent in the management of tracheal injury has been documented in the previous studies. However, none of the studies have mentioned the deployment of silicone Y-stent via rigid bronchoscope with the patient solely supported by extracorporeal membrane oxygenation (ECMO) without general anaesthesia delivered via the side port of the rigid bronchoscope. We report a patient who had a tracheal tear due to endotracheal tube migration following a routine video-assisted thoracoscopic surgery sympathectomy, which was successfully managed with silicone Y-stent insertion. Procedure was done while she was undergoing ECMO; hence, no ventilator connection to the side port of the rigid scope was required. This was our first experience in performing Y-stent insertion fully under ECMO, and the patient had a successful recovery.