Management of Postintubation Tracheobronchial Ruptures*

Centre Hospitalier Régional Universitaire de Lille, Lille, Nord-Pas-de-Calais, France
Chest (Impact Factor: 7.48). 09/2006; 130(2):412-8. DOI: 10.1378/chest.130.2.412
Source: PubMed

ABSTRACT To determine whether nonoperative management can be applied to iatrogenic postintubation tracheobronchial rupture (TBR).
Prospective cohort study.
Thirty consecutive patients with TBR complicating intubation between June 1993 and December 2005 entered the study. Patients not receiving mechanical ventilation at time of diagnosis were treated nonsurgically. Patients receiving mechanical ventilation who were judged operable underwent surgical repair, while nonoperable candidates had their TBR bridged by endotracheal tubes.
Fifteen patients not requiring mechanical ventilation underwent simple conservative management. TBR length measured 3.85 +/- 1.46 cm (mean +/- SD). Eight TBRs showed full-thickness rupture with frank anterior intraluminal protrusion of the esophagus. In three patients, transient noninvasive positive pressure ventilatory support (NIV) was necessary. All lesions healed without sequelae. Two patients receiving mechanical ventilation underwent surgical repair and died. Thirteen patients receiving mechanical ventilation were considered at high surgical risk, and TBR bridging was attempted as salvage therapy. Complete bridging was achieved in five patients by simply advancing the endotracheal tube distal to the injury. Separate bilateral mainstem endobronchial intubation was necessary in six patients whose TBRs were too close to the carina. Nine of 13 patients (69%) treated with nonoperative therapy completely recovered.
We conclude that conservative nonoperative therapy should be considered in patients with postintubation TBR who are breathing spontaneously, or when extubation is scheduled within 24 h from the time of diagnosis, or when continued ventilation is required to treat an underlying respiratory status. Surgical repair should be reserved for cases in which NIV or bridging the lesion is technically not feasible.

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Available from: Massimo Conti, Sep 28, 2015
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    • "Although Kiser et al. [12] showed that no treatment or conservative management is associated with higher rates of death, several studied have commented on the possibility for non-operative management in patients with postintubation tracheal lacerations [43,66-68]. The prerequisites for such management include: small lacerations (<2 cm), a tube’s cuff inflated distally to the site of the injury, adequate ventilation with PEEP and low tidal volumes, evacuation of the air form the pleural cavity once a chest tube is placed, not increasing subcutaneous emphysema and absence of signs of an ongoing infection. "
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    ABSTRACT: 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.
    Journal of Cardiothoracic Surgery 06/2014; 9(1):117. DOI:10.1186/1749-8090-9-117 · 1.03 Impact Factor
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    • "Several complications could occur after severe tracheal ischemic lesions, such as tracheal stenosis [40], tracheal rupture [41], tracheobronchiomalacia [42], tracheoinnominate artery fistula [43], and tracheoesophageal fistula [44]. However, few data are available on the transition from ischemic tracheal lesions to these complications. "
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    ABSTRACT: Despite the increasing use of non-invasive ventilation and high-flow nasal-oxygen therapy, intubation is still performed in a large proportion of critically ill patients. The aim of this narrative review is to discuss recent data on long-term intubation-related complications, such as microaspiration, and tracheal ischemic lesions. These complications are common in critically ill patients, and are associated with substantial morbidity and mortality. Recent data suggest beneficial effects of tapered cuffed tracheal tubes in reducing aspiration. However, clinical data are needed in critically ill patients to confirm this hypothesis. Polyurethane-cuffed tracheal tubes and continuous control of cuff pressure could be beneficial in preventing microaspiration and ventilator-associated pneumonia (VAP). However, large multicenter studies are needed before recommending their routine use. Cuff pressure should be maintained between 20 and 30 cmH2O to prevent intubation-related complications. Tracheal ischemia could be prevented by manual or continuous control of cuff pressure.
    Annals of Intensive Care 02/2014; 4(1):7. DOI:10.1186/2110-5820-4-7 · 3.31 Impact Factor
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    • "The management of PiTR is guided by whether the patient is self or mechanically ventilated, and whether an operative approach is required. Determinants include location and, length of defect, time to diagnosis and sequela (e.g., mediastinitis, bleeding or progressive respiratory failure).[5910] Surgery is suggested when bridging of the TR is not feasible.[11] "
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    ABSTRACT: 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.
    Indian Journal of Critical Care Medicine 03/2013; 17(2):99-103. DOI:10.4103/0972-5229.114826
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