Article

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.

Full-text

Available from: Massimo Conti
Management of Postintubation
Tracheobronchial Ruptures*
Massimo Conti, MD; Marie Pougeoise, MD; Alain Wurtz, MD;
Henri Porte, MD, PhD; Franc¸ois Fourrier, MD, FCCP; Philippe Ramon, MD;
and Charles-Hugo Marquette, MD, PhD
Study objectives: To determine whether nonoperative management can be applied to iatrogenic
postintubation tracheobronchial rupture (TBR).
Design: Prospective cohort study.
Patients and interventions: 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.
Results: 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.
Conclusion: 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. (CHEST 2006; 130:412–418)
Key words: injury; intubation; mechanical ventilation; rupture; surgery; trachea
Abbreviations: NIV noninvasive positive pressure ventilatory support; TBR tracheobronchial rupture
T
racheobronchial rupture (TBR) is an uncommon
but potentially serious complication of endotra-
cheal intubation. Iatrogenic TBR should be differenti-
ated from tracheobronchial injuries of traumatic origin
since it has different mechanisms leading to different
morphologic appearance and therapeutic options.
1
Traumatic TBR is usually the result of blunt chest
trauma and appears as horizontal or irregularly shaped
disruptions involving the main carina and often extend-
ing into the main bronchi. Iatrogenic TBR, in contrast,
usually presents as longitudinal lacerations of the pos-
*From the Clinique de Chirurgie Thoracique (Drs. Conti, Wurtz,
and Porte), Clinique d’Anesthe´sie Cardio-Thoracique (Dr. Pou-
geoise), Service de Re´animation Polyvalente (Dr. Fourrier), and
Clinique des Maladies Respiratoires (Drs. Marquette and
Ramon), CHRU Lille, Lille, France.
The authors report that they have no conflicts of interest related
to this paper.
Manuscript received November 19, 2005; revision accepted
January 30, 2006.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Charles-Hugo Marquette, Clinique des Mal-
adies Respiratoires, Hoˆpital Albert Calmette, CHRU de Lille,
59037 Lille cedex, France; e-mail: c-marquette@chru-lille.fr
DOI: 10.1378/chest.130.2.412
Original Research
CRITICAL CARE MEDICINE
412 Original Research
Page 1
terior tracheal wall either centrally located, or laterally
such that the membranous wall is avulsed from its
cartilaginous insertion. Extension into either mainstem
bronchi is rare. Predominance in women has been
documented.
1–3
Iatrogenic TBR may occur in the
absence of difficult intubation, use of a stylet, or cuff
overinflation. The exact mechanism remains uncertain,
but the most probable explanation is a direct laceration
from an endotracheal tube tip caught in a fold of a
flaccid posterior tracheal membrane, while advancing
the tube.
Management of iatrogenic TBR is controversial.
Early surgical repair has traditionally been considered
as the cornerstone of therapy.
2–9
There is, however, a
growing body of evidence showing that iatrogenic TBR
can be dealt with conservatively in selected cases.
10–21
Selection criteria for nonoperative management are
still debated. While most authors
1,12,14,16,19
agree on the
fact that there should be no evidence of respiratory or
hemodynamic instability, esophageal injury, mediasti-
nitis, or progressive pneumomediastinum, others
2,4
9,18,21
also consider the size and the depth of the defect
as important criteria, advocating surgery whenever
full-thickness or lengthy lacerations are present. Criti-
cally ill patients, especially those in whom TBR results
from emergency intubation, may fulfill all the criteria
for surgical repair. Surgery in these patients involves a
high risk, with a reported mortality as high as 71.4%.
7
Such a high mortality for the repair of TBR in critically
ill patients receiving mechanical ventilation demands
that alternatives to high-risk surgery be considered.
Based on the data available in the literature and on
our previous experience,
17
we designed a multidisci-
plinary management protocol integrating both oper-
ative and nonoperative strategies. We report herein
the results of this approach in a consecutive series of
patients with iatrogenic TBR.
Materials and Methods
Setting
This study took place in the emergency and critical care
department and the department of thoracic surgery and respira-
tory diseases of a university-affiliated hospital that serves as a
referral trauma center for a region of 4 million inhabitants.
Study Population and Inclusion Criteria
All patients with TBR complicating endotracheal intubation
between June 1993 and July 2005 entered the study. Excluded
were tracheobronchial injuries complicating blunt chest trauma,
tracheostomy, rigid bronchoscopy, or thoracic surgery.
Procedures and Protocol
All patients underwent fiberoptic bronchoscopy and chest CT.
The length and location of the TBR was determined by bronchos-
copy with a special attention paid to the lower limit of the rupture.
Chest CT was used to detect direct or indirect signs of TBR
(pneumomediastinum, pneumothorax, pneumoperitoneum) as well
as associated lesions (mediastinitis). Each case was discussed by a
multidisciplinary staff including thoracic surgeons, anesthetists, pul-
monologists, and intensivists. Our approach to treatment was based
on two key factors: first, the need for mechanical ventilation; and
second, the ability of the patient to tolerate a surgical intervention
related to their underlying medical condition.
Two clinical scenarios were identified. In the first scenario, the
diagnosis was made in a patient breathing spontaneously, or who
could be weaned immediately, with no need for further mechanical
ventilation expected in the upcoming days. In these patients,
nonoperative management was considered regardless of the size and
location of the TBR or the time interval from extubation to
diagnosis. Patients were carefully followed up clinically and via
bronchoscopy (every other day during the first 10 days and weekly
until cure thereafter). Oral intake of food was withheld for the first
2 to 5 days until esophageal injury was eliminated and the patient’s
status had stabilized. Antibiotics were prophylactically administered
for the first 3 days to prevent mediastinitis. Oxygen was administered
when necessary. Noninvasive positive pressure ventilatory support
(NIV) was provided in case of mild respiratory distress.
In the second scenario, the patient still required mechanical
ventilation at time of diagnosis because of respiratory failure or
for other reasons (ie, coma, multiorgan failure). In these patients,
the decision to surgically repair the TBR depended on the
severity of the underlying illness. If the multidisciplinary staff
deemed the patient to be operable, surgical repair of the TBR
was immediately undertaken in order to restore effective venti-
lation. In patients with an unacceptably high operative risk,
conservative management was followed. In these cases, surgery
was reserved as a salvage option in case of TBR-related uncon-
trolled air leaks or mediastinitis.
In operable patients, the first step was to determine an
appropriate intraoperative anesthetic management in order to
maintain oxygenation and ventilation without compromising sur-
gical repair. Intraoperative selective lung intubation with tubes
placed bronchoscopically was used in order to bypass the lesion.
Extension of TBR determined the surgical approach (posterolat-
eral thoracotomy for lesions extending to the distal third of the
trachea, and cervical approach otherwise).
When surgery was considered to be high risk, the aim was to
prevent widening of the injury during inspiration. To do so, the
lesion was bridged in order to keep the lesion under zero pressure
(under mechanical ventilation, positive pressure is distal to the
endotracheal cuff). The bridging technique depended on the loca-
tion of the TBR. If the lesion was proximal to the distal third of the
trachea, a low-pressure, cuffed endotracheal tube was advanced as
distal to the rupture as possible, nearing the main carina (simple
bridging). The cuff was minimally inflated. Small air leaks were
tolerated in order not to enlarge the TBR with an overinflated cuff.
When the lesion involved the distal third of the trachea, or even the
first centimeter of one mainstem bronchus, selective bilateral main-
stem bronchus intubation with high-volume/low-pressure cuffed
6-mm endotracheal tubes was performed as described previously,
17
with the tubes passed through a large tracheostomy (Fig 1). Pneu-
mothorax, extensive subcutaneous emphysema and mediastinal col-
lections were drained as needed. All the patients underwent bron-
choscopy at 6 months and 1 year.
Statistics
Demographic and descriptive data are given in means 1 SD.
Comparisons between proportions were done using a Pearson
2
test or a Fisher exact test, when appropriate. Significant differ-
ences were considered at p 0.05.
www.chestjournal.org CHEST / 130/2/AUGUST, 2006 413
Page 2
Results
Thirty consecutive patients with TBR entered the
study (26 women and 4 men; mean age, 63 13.3
years; range, 31 to 79 years). All had undergone
single-lumen tube endotracheal intubation for elec-
tive surgical operations (n 16) or for emergency
intubation for respiratory distress or cardiopulmo-
nary resuscitation (n 14). No patient was receiving
long-term ventilation. Intubation was reported to be
difficult in nine occasions, and a stylet was used in
three occasions.
Subcutaneous emphysema was present in all but
four patients, and pneumothorax was present in nine
patients. Hemoptysis was the presenting sign in two
patients. In two patients receiving mechanical venti-
lation, persistent air leak was the only clue suggestive
of TBR.
All TBRs were longitudinal and located at the
posterior membranous part of the trachea. Mean
length was 4.5 1.5 cm (range, 1 to 7.5 cm). Mean
time from intubation to diagnosis was 12.5 24.3 h
(range, 1 to 120) [Table 1].
Fifteen patients were spontaneously breathing at
time of diagnosis and underwent simple conservative
management (patients 1 to 15; Table 1). The TBRs
measured 3.85 1.46 cm (range, 1 to 6 cm). Eight
Figure 1. Selective mainstem bronchus intubation. Small low-pressure cuffed tubes are passed
through a large tracheostomy and placed in each main bronchus. A large orotracheal tube was placed
above the proximal end of the TBR to facilitate bronchoscopic follow-up, to allow ventilation in case
of sudden obstruction of the small tubes and to allow continuous suction of secretions proximal to the
distal cuffs.
414 Original Research
Page 3
TBRs showed full-thickness rupture with frank anterior
intraluminal protrusion of the esophagus (Fig 2). In
three patients, mild respiratory distress led us to pro-
ceed to short-term NIV. In these patients, all TBRs
healed without sequelae, and the patients were dis-
charged after 13 6 days (range, 6 to 30 days). No
mortality was observed in this group (Fig 3).
Thirteen patients receiving mechanical ventilation
were considered at high surgical risk. Underlying
conditions in these patients included severe respira-
tory failure not related to TBR-induced air leaks
(n 9), coma complicating stroke (n 2), and se-
vere myocardial deficiency related to ongoing coro-
nary ischemia (n 2).
Five patients underwent simple bridging. Patients
16, 17, and 18 died. Two deaths, on day 7 and day 11
(hepatic coma and septic shock without mediastini-
tis, respectively), were considered as unrelated to the
TBR. The third death occurred suddenly on day 3
after an acute episode of hypoxemia, so that an acute
complication of the TBR cannot be excluded in this
case. Patients 19 and 20 healed without sequelae and
were discharged after 12 days and 35 days, respec-
tively. The latter patient required transient drainage
of a sterile mediastinal collection via cervical ap-
proach.
Six patients underwent double selective intuba-
tion, since the TBR involved the lower third of the
Table 1—Patient Characteristics, Bronchoscopic Findings, and Treatment Outcome*
Patient
No. Sex
Age,
yr
Reason for
Intubations
Body Mass
Index,
kg/m
2
Difficult
Intubation
Presenting
Symptoms‡
Time to
Diagnosis,
h Site§
TBR
Length,
cm
Mechanical
Ventilation Treatment
TBR
Outcome
1 M 59 Mediastinoscopy 28.4 No 2,4,6 5 L 4 No C Success
2 F 79 Orthopedic surgery 21.3 No 2,3,6 7 M 2 No C Success
3 F 74 Colectomy 27.3 No 2,6 3 ML 6 No C Success
4 F 71 Colectomy 29.4 No 2,3 3 M 3 No C Success
5 F 56 Thyroidectomy 17.3 No 2,4 2 LC 5 No C Success
6 F 43 Internal saphenous
stripping
19.8 No 2,4,6 4 ML 4 No C Success
7 F 78 Orthopedic surgery 19.8 Yes 3,6 5 L 3 No C Success
8 F 50 Orthopedic surgery 18.8 No 2,3,4 3 M 4 No C Success
9 F 56 Internal saphenous
stripping
25.3 No 2,4 3 M 5 No C Success
10 F 57 Umbilical hernia 27.2 No 2,9 6 L 3 No C Success
11 F 79 Cardiac arrest 21.5 No† 2,1 2 ML 5 No C Success
12 F 31 Gynecologic surgery NA Yes 2,4 6 M 3 No C Success
13 F 76 Orthopedic surgery 28 No 2 3 M 2.5 No C Success
14 F 72 Mastectomy 28.1 No 2 6 ML 6 No C Success
15 M 61 Mitral valve replacement 34.4 No 12 20 M 1 No C Success
16 F 52 Acute respiratory failure 34.3 Yes† 3 5 L 6 Yes SV Failure
17 F 78 Acute respiratory failure 24.7 No† 4 6 ML 7 Yes SV Failure
18 M 78 Acute respiratory failure 33.5 No† 2,4 2 L 3 Yes SV Failure
19 F 64 Pulmonary edema and
cardiac arrest
24.5 Yes† 2 5 L 5 Yes SV Success
20 F 70 Seizures 17.1 Yes† 1,2 24 M 3 Yes SV Success
21 F 53 Seizures 27.5 No† 1,10,11 72 ML 6 Yes SV Success
22 F 59 Acute respiratory failure,
angina
31.9 Yes† 2,1 6 ML 7.5 Yes SV Success
23 F 48 Acute respiratory failure 58.8 Yes† 2 6 ML 5 Yes SV Success
24 F 67 Acute respiratory failure NA No† 2 4 ML 6 Yes SV Success
25 M 75 Colectomy 25.9 No 2,4,5 120 LC 4 Yes SV Success
26 F 43 Subdural hemorrhage 25.4 Yes† 2,5,7 1 LLMSB 1.5 Yes SV Success
27 F 77 Seizures 29.3 Yes† 1,2,8,11 6 LRMSB 6 Yes SV Success
28 F 79 Orthopedic surgery 21.2 No 2,10,11 26 MLC 7 Yes SV Failure
29 F 47 Acute respiratory failure NA No 2 6 ML 6.5 Yes Surgery Failure
30 F 69 Subdural hemorrhage NA No† 2,1 10 ML 5 Yes Surgery Failure
*F female; M male; NA not available.
†Emergency intubation.
‡1 mediastinal emphysema; 2 subcutaneous emphysema; 3 hemoptysis; 4 pneumothorax; 5 respiratory failure; 6 cervical pain;
7 acute severe asthma; 8 pneumoperitoneum; 9 bronchospasm; 10 uncontrolled air leak (in patient receiving mechanical ventilation);
11 radiologic evidence of balloon overinflation; 12 cough.
§L lower third of trachea; M middle third of trachea; C carina; RMSB right mainstem bronchus; LMSB left mainstem bronchus.
C conservative; SV selective ventilation.
www.chestjournal.org CHEST / 130/2/AUGUST, 2006 415
Page 4
trachea (patients 21 to 24), the carina (patient 25), or
the left mainstem bronchus (patient 26). TBRs mea-
sured 5.25 0.95 (range, 1.5 to 7.5 cm). All six
patients had favorable outcome and were discharged
alive after 45 24 days (range, 20 to 76 days).
Patient 21, however, required transient drainage of a
sterile mediastinal collection via cervical approach on
day 3. On day 38, an esophagotracheal fistula was
found, which was treated sequentially (lower esoph-
ageal exclusion, followed by radical surgical closure
of the fistula, and interposition of an intercostal
muscular flap).
In the last two cases (patients 27 and 28), bridging
the lesion was not possible due to extension of the
TBR distal to the carina into the right main bron-
chus. Unilateral selective left lung ventilation was
attempted in one patient without success. The other
patient had her tube placed as distally as possible and
received ventilation with low pressures (bilevel pos-
itive airway pressure and pressure support) while
tolerating some air leaks. She was extubated on day
20 and discharged with completely healed TBR on
day 35.
Two patients receiving mechanical ventilation un-
derwent surgical repair by posterolateral thoracot-
omy. TBRs in these patients measured 5 cm and 6.5
cm, respectively. In patient 29, surgical repair was
successful as judged by the absence of air leaks and
by bronchoscopic findings. The patient died from
massive GI hemorrhage on day 15 postoperatively.
The last patient required mechanical ventilation
because of severe aspiration pneumonia. Surgery was
decided since mechanical ventilation was ineffective
because of the importance of air leaks. The patient
died 6 days postoperatively with refractory respira-
tory failure. Bronchoscopy showed partial dehis-
cence of the suture.
Overall mortality in this series was 20% (6 of 30
patients). Half of these deaths were unrelated to the
TBR and were secondary to the underlying illnesses
that lead to the need for endotracheal intubation.
Among the 24 patients who survived, all were treated
conservatively. Complete and spontaneous healing
was usually observed within 1 month, except in three
patients. Two patients receiving high-dose steroids
showed delayed but complete healing (2 months and
4 months, respectively), and esophagotracheal fistula
developed in a third patient, who required secondary
surgical repair.
Discussion
This study describes our experience in a series of 30
consecutive patients with iatrogenic tracheobronchial
injuries. All but two patients were managed without
direct repair of the rupture. More than three fourths of
the patients, including those with large and full-thick-
ness lacerations, recovered completely. The outcome in
this series of patients compares favorably with data
reported in the literature.
1–9,18,20,21
Surgical repair has traditionally been considered
as the cornerstone of therapy of iatrogenic TBR
complicating intubation.
2–8
The stated purpose of
surgical repair of TBR is threefold: First, surgical
Figure 3. Treatment algorithm and outcome. The number of
deaths is given in parentheses.
Figure 2. Shown are images from a 72-year-old woman receiv-
ing high-dose steroids (severe asthma) who underwent elective
surgery (mastectomy). Massive subcutaneous cervical and medi-
astinal emphysema (top left and top right) led to diagnosis of a
large full-thickness TBR of the mid and lower trachea (bottom
left) while the patient was breathing spontaneously. Conservative
management resulted in complete healing of the rupture 4
months later (bottom right).
416 Original Research
Page 5
repair allows closure of the defect in order to allow
effective ventilation. In patients requiring positive-
pressure ventilation, major air leaks directly related
to a TBR may compromise ventilation. In these
patients, repair of the airway injury and pleural
drainage immediately restores effective ventilation.
In contrast, when a patient is extubated and breathes
spontaneously, as it is the case in most patients with
TBR complicating intubation for elective surgery, air
leak is usually absent or is present during the first
few days only when the patients cough. Provided
pneumothorax and subcutaneous emphysema are
properly drained, the consequences of TBR on the
respiratory mechanics are usually minimal.
10,12,14,15
In the present series, three patients with full-thick-
ness ruptures showed frank protrusion of the esoph-
agus in the tracheal lumen that was responsible for
an increase in respiratory workload. Pressure-con-
trolled NIV applied for several days allowed us to
overcome this problem. The situation is completely
different when ongoing mechanical ventilation is
required and the patient is not a candidate for
surgical repair. This is usually the case when TBR
complicates emergency intubation in unstable pa-
tients who require cardiopulmonary resuscitation for
an acute event. In these patients, the only nonopera-
tive means to restore effective ventilation when
TBR-related air leaks are too important are to place
the tip of the artificial positive pressure airway (tip of
the endotracheal tube) distal to the rupture. Such
“bridging of the lesions” was initially proposed as
salvage therapy in patients who had ruptures proxi-
mal to the carina and who could not be operat-
ed.
11,13,15
Sixteen of 23 patients (69.6%) managed in
this way in the literature
2–4,6,7,9,18,20,21
survived.
In the present series, TBR bridging was attempted
as salvage therapy in 13 patients. Complete bridging
was achieved in five patients by simply advancing the
endotracheal tube distally. Separate endobronchial
intubation was necessary in six patients with TBR too
close to the carina. TBR bridging was effective in two
thirds of the patients, which we consider promising,
considering the context of salvage therapy. Not
unexpectedly, among the four deaths, two were
related to the underlying disease.
The second goal of surgical repair is to prevent
mediastinitis secondary to contamination of the medi-
astinal structures from the nonsterile airways.
1–9,18,20
In
contrast to esophageal perforations in which medi-
astinitis is a consistent finding, mediastinitis as a
result of TBR has seldom been reported in the
literature. Only two cases have been reported,
4,21
both in patients managed surgically. In the present
series, only two cases of aseptic mediastinal collec-
tion were found by follow-up chest CT and were
drained by simple cervical approach.
A third reason to consider surgical repair is the
concern regarding healing complications and of po-
tential long-term airway stenosis, especially in case of
lengthy or full-thickness injuries. Delayed healing
and especially secondary bronchial strictures have
been reported in the very context of blunt tracheo-
bronchial injuries.
22
It is noteworthy that tracheal
stenosis resulting from TBR complicating intubation
has been reported only twice. In one case, a patient
initially managed nonoperatively acquired an asymp-
tomatic stenosis
21
; in the other patient, the stenosis
followed a surgically repaired TBR.
1
The mechanism
of blunt tracheobronchial injuries and of iatrogenic
TBR is very different and may explain these discrep-
ancies.
23
None of the patients in the present series
had a secondary stenosis. Healing delays were re-
ported anecdotally in the literature
10,12,14,20
and usu-
ally vary between 2 weeks and 4 weeks. These
findings are consistent with our findings. The length
of the TBR as an indication for surgical management
Table 2—Mortality According to the Indication for Intubation and According to Surgical vs Conservative
Management*
Source
Elective Surgery Emergency Intubation
Surgical Repair Conservative Management Surgical Repair Conservative Management
Marty-Ane et al
2
2 (1) 1 3 (1)
Massard et al
3
612
Kaloud et al
4
6 (1) 3 (1)
Mussi et al
6
711
Meyer
7
1 7 (5)
Carbognani et al
9
73
Jougon et al
18
37(1)11
Beiderlinden et al
20
5 (2)
Gomez-Caro Andres et al
21
1 (1) 11 (1) 6 (2)
Present series 16 (1) 2 (2) 12 (3)
Total 33 (3) 40 (3) 19 (9) 24 (7)
*Data are presented as No. (No. of deaths).
www.chestjournal.org CHEST / 130/2/AUGUST, 2006 417
Page 6
has been debated. Kaloud et al
4
recommended
operating for any TBR lesion 1 cm in length.
Gabor et al,
24
in a case mix of iatrogenic and blunt
tracheobronchial injuries, and Carbognani et al
9
in
iatrogenic TBR recommended that ruptures 2cm
in length be repaired. Jougon et al,
18
in contrast,
proposed nonoperative management if the TBR was
4 cm. Our findings are consistent with the data of
Gomez-Caro et al,
21
who found that outcome was
independent of the TBR length.
Recommendations regarding management of TBR
complicating intubation have historically been based
on experience with blunt tracheobronchial ruptures
in which surgical repair is usually mandatory. Over
the past 20 years, nonoperative management of TBR
has been proposed for select patients in the following
circumstances: stable vital signs, easy achievement of
an adequate functional respiratory status under me-
chanical ventilation or in spontaneous ventilation,
absence of esophageal injury, minimal mediastinal
fluid collection, nonprogressive pneumomediasti-
num or subcutaneous emphysema, absence of sepsis,
short ruptures, delayed diagnosis. In patients man-
aged surgically, the initial indication for which the
patient was intubated appears to play a crucial role in
postoperative mortality. Including present data,
three deaths were reported among the 33 patients
(9%) with iatrogenic TBR who were intubated for
elective surgery (Table 2). In contrast, the mortality
is much higher (9 of 19 patients, 47%) among
patients who underwent emergency intubation for an
acute medicosurgical event (p 0.004). This also
holds true for conservatively managed patients in
whom mortality was only 7.5% (3 of 40 patients) in
case of scheduled surgery and 29% (7 of 23 patients)
in case of emergency intubation (p 0.003). Lastly,
independent of the reason for intubation, there was
a trend toward a higher mortality in surgically man-
aged (12 of 52 patients) as compared with conserva-
tively managed (10 of 64 patients) [23% and 16%,
respectively; p 0.475; Table 2].
These findings question the classical criteria for
surgical repair. We recommend conservative nonop-
erative therapy as the best approach to postintuba-
tion TBR in patients who are breathing spontane-
ously, or when extubation is scheduled within 24 h
from the time of diagnosis, or for patients who will
require prolonged mechanical ventilation to treat
their underlying respiratory status. Surgical repair
should be reserved for patients in whom NIV or
bridging the lesion is technically not feasible.
ACKNOWLEDGMENT: We are grateful to Alain Tremblay,
MDCM, University of Calgary, Canada, for editorial assis-
tance.
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418 Original Research
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  • Source
    • "On the other hand, the authors mention two known methods to calculate the capillary pressure of the trachea with approximate pressure of 25 mmHg and indirect functional measurement of the capillary pressure of approximately 17 mmHg [25,26] . An injury caused by the pressure of the inflated cuff under the lining of the tracheal mucosa leads (in less than 48 hours) to varying degrees of inflammation and edema of the epiglottis and vocal cords [23,24] . Experimental studies demonstrate ulceration, even necrosis, of the larynx in the cases of use greater than 48 hours [21] . "
    [Show abstract] [Hide abstract] ABSTRACT: The inflation pressure of the endotracheal tube cuff can cause ischemia of the tracheal mucosa at high pressures; thus, it can cause important tracheal morbidity and tracheal microaspiration of the oropharyngeal secretion, or it can even cause pneumonia associated with mechanical ventilation if the pressure of the cuff is insufficient. In order to investigate the effectiveness of the RUSCH® 7.5 mm endotracheal tube cuff, this study was designed to investigate the physical and mechanical aspects of the cuff in contact with the trachea. For this end, we developed an in vitro experimental model to assess the flow of dye (methylene blue) by the inflated cuff on the wall of the artificial material. We also designed an in vivo study with 12 Large White pigs under endotracheal intubation. We instilled the same dye in the oral cavity of the animals, and we analyzed the presence or not of leakage in the trachea after the region of the cuff after their deaths (animal sacrifice). All cuffs were inflated at the pressure of 30 cmH2O. We observed the passage of fluids through the cuff in all in vitro and in vivo experimental models. We conclude that, as well as several other cuff models in the literature, the RUSCH® 7.5 mm tube cuffs are also not able to completely seal the trachea and thus prevent aspiration of oropharyngeal secretions. Other prevention measures should be taken.
    Full-text · Article · Oct 2014 · Revista Brasileira de Cirurgia Cardiovascular
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    • "A challenging scenario is that of an injury fulfilling the criteria for conservative treatment located to the distal intrathoracic trachea and carina. If selective bilateral intubation of the bronchi, as the one proposed by Conti et al. [43], cannot be performed the patient should be treated with surgery. Despite the favorable outcome reported so far, the patients should be under strict follow up and they should be referred to surgery if airway loss, inadequate ventilation or signs of infection and sepsis arise. "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Jun 2014 · Journal of Cardiothoracic Surgery
  • Source
    • "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. "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Feb 2014 · Annals of Intensive Care
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