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


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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    • "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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