Successful silicon stent for life-threatening tracheal wall laceration

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.

Conservative management of posterior tracheal wall injury by endoscopic stent placement in children: Preliminary data of three cases

The management of tracheal wall lacerations is debated. Current treatments are mainly derived by the experience on adults and include conservative or surgical treatments depending on the clinical condition of the patient. We report our preliminary data with removable tracheal stents in 3 children with tracheal tears and respiratory failure. If performed in specialized centers with appropriate endoscopic and clinical follow-up, airway stents can be considered a valid and safe conservative treatment for tracheal tears and an alternative to intubation or tracheostomy. Further studies are needed to compare different therapeutic options and better define the management and duration of stent treatment.

Management of tracheobronchial injuries

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.

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.

Traumatic Airway Injuries: Role of Imaging

Airway Injuries are rare but often immediately life threatening. Incidence ranges from 0.5-2 % in blunt and 1-6 % in penetrating trauma. Upper airway injuries (UAI) are often clinically apparent and get shunted during the primary survey in the emergency department. Few UAI and majority of lower airway injuries (LAI) are occult on primary survey and need a high suspicion index. Clinically, the diagnosis of tracheobronchial injury is delayed in many patients because the airway column is maintained by the peribronchial tissue. Imaging in the form of MDCT, in conjunction with endoscopy, plays a role in delineating the exact site and extent of injury and ruling out associated vascular and esophageal injuries for definitive management of UAI. Chest radiographs and ultrasonography help raise suspicion of LAI by detection of pneumomediastinum, persistent pneumothorax and/or subcutaneous emphysema and should be followed up with multidetector computed tomography (MDCT) which is the mainstay of diagnosis. However, it requires careful evaluation of the airway tract and a thorough knowledge about the mechanism of trauma for detection of subtle injuries. Reconstructions in multiple planes and use of various post-processing techniques including minimum intensity projection (MinIP) images enhance the detection rate. The specific signs of LAI on CT include discontinuity in the tracheobronchial tree, focal intimal flap projecting in the lumen, focal soft tissue attached to the tracheal/bronchial wall, complete cut off of the bronchus/trachea and the fallen lung sign. We, hereby, illustrate the imaging spectrum of traumatic airway injuries in detail and discuss their management implications.

Use of veno-arterial extracorporeal membrane oxygenation in a case of tracheal injury repair in a patient with severe relapsing polychondritis

Tracheobronchial malacia occurs in 50% of patients with relapsing polychondritis (RP), and is often managed with stent insertion. While severe complications have been described after silicone tracheal stent insertion, there are few reports describing tracheal injury in patients with RP. We present a case of tracheal perforation secondary to Dumon^® stent manipulation in a patient with RP. The tracheal injury was successfully repaired with a silicone Y-stent inserted via right thoracotomy using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for ventilatory support. It is safe and feasible to introduce a silicone Y-stent through a thoracotomy for a tracheal trauma in combination with VA-ECMO support.

Bronchoscopic management of iatrogenic tracheal laceration using polyurethane-covered nitinol tracheal stents

Iatrogenic tracheal laceration is a known complication of emergent endotracheal intubation. Patients with tracheal laceration present a therapeutic challenge. There is no established standard treatment approach in this patient population. Interventions reported include conservative management, stent placement, or surgery. We present our experience of tracheal tears in patients with respiratory failure successfully managed with polyurethane-covered nitinol stent, including three cases of postintubation and one case of postsurgical tracheostomy tracheal injury.

Tracheal rupture related to endotracheal intubation after thyroid surgery: a case report and systematic review

Tracheobronchial rupture is an uncommon but potentially serious complication of endotracheal intubation. The most likely cause of tracheal injury is massive overinflation of the endotracheal tube cuff and pre-existing tracheal wall weakness. We review the relevant literature and predisposing factors contributing to this complication. Only articles that reported at least the demographic data (age and sex), the treatment performed and the outcome were included. Papers that did not detail these variables were excluded. We also focus on a case of tracheal laceration after tracheal intubation in a patient with severe thyroid carcinoma. This patient received surgical repair and recovered uneventfully. Two hundred and eight studies that reported cases or case series were selected for analysis. Most of the reported cases (57·2%) showed an uneventful recovery after surgical therapy. The overall mortality was 19·2% (40 patients). Our patient too recovered without any serious complication. Careful prevention, early detection and proper treatment of the problem are necessary when tracheal rupture occurs. The morbidity and mortality associated with tracheal injury mandate a high level of suspicion and expedient management.

Repair of tracheobronchial injuries

Tracheobronchial injuries (TBIs) are caused by blunt, penetrating injury or by iatrogenic damage. Most injuries are life threatening and need early and skillful airway management. Bronchoscopy remains the gold standard of diagnosis. Penetrating TBI always needs blunt trauma, and iatrogenic TBI sometimes needs surgical exploration and reconstruction, which is performed after sparing debridement with primary repair and wound closure. Prognosis mainly depends on associated injuries and comorbidities in terms of tracheal membrane laceration.