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Ann Thorac Surg 1997;63:1209-1210
© 1997 The Society of Thoracic Surgeons

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Correspondence

Iatrogenic Tracheobronchial Lacerations

Thoracic Division, Cliniques Universitaires St Luc, Av Hippocrate 10, 1200 Brussels, Belgium

To the Editor:

We have read with interest the article by Massard and associates entitled "Tracheobronchial Lacerations After Intubation and Tracheostomy" [1]. As a rule, they advocate emergency surgical repair in cases of tracheal laceration.

We have recently published an article not mentioned by Massard and associates about the successful possibilities of conservative treatment [2]. The patient, a 57-year-old woman, presented a large postintubation laceration of the posterior tracheal wall (5 cm in height and 2 cm in width) extending from the middle of the trachea to the level of the carina. She was successfully treated conservatively. Subcutaneous emphysema, which was impressive, was controlled by two subcutaneous tubes. The gap closed spontaneously in just a few days. Our report suggests that under close monitoring with vital functions preserved, membranous laceration of the trachea could benefit from a conservative treatment with no long-term complications (eg, tracheal stenosis). Other authors [3, 4] also have described uneventful recovery under medical supervision in patients suffering from tracheal laceration.

In their article, Massard and associates did not comment much on medical management. In their description of methods, they failed to specify the evolution of vital signs, which are, in our view, one of the key criteria in the management in terms of a conservative (medical) or aggressive (surgical) approach.

We think that in patients with limited tracheobronchial laceration, medical treatment should be attempted. Extension of tracheal laceration, mediastinal symptoms, control of air leak, and cardiovascular stability must always be taken into account before any surgical decision is taken. In this regard, we agree with Massard and associates' views when they state that vital prognosis depends more on the underlying disease than on the injury itself.

References

1. Massard G, Rougé C, Dabbagh A, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483–7.[Abstract/Free Full Text]
2. D'Odemont JP, Pringot J, Goncette L, Goenen M, Rodenstein D. Spontaneous favorable outcome of tracheal laceration. Chest 1991;99:1290–2.[Abstract/Free Full Text]
3. Velly JF, Martigne C, Moreau JM, Dubrez J, Kerdi S, Couraud L. Post-traumatic tracheobronchial lesions. A follow-up study of 47 cases. Eur J Cardiothorac Surg 1991;5:352–5.[Abstract]
4. De La Rocha AG, Kayler D. Traumatic rupture of the tracheobronchial tree. Can J Surg 1985;28:68–71.[Medline]

Reply

Department of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg, F-67091 Strasbourg, France

To the Editor:

We are indebted to Drs d'Odemont and Rodenstein for their interesting contribution to the management of tracheal tears. Conservative management has been advocated by several single case reports in the past 20 years. According to a collective review, the first case managed conservatively to our knowledge was published in 1973 by Larnaudie and colleagues [1, 2]. A recent publication by our group also included a case managed conservatively with uneventful primary healing [3].

However, we would not recommend conservative management as the standard of practice. Although there are several isolated case reports in the literature, successful outcome after nonoperative management has not yet been reported on a large scale. The major threat of conservative management would be the necessity of delayed repair because of a persistent tracheal leak, pneumothorax, or mediastinitis. In this event, the success of repair is likely to be jeopardized by local infection. In 1 of our patients [3], repair was undertaken with a 5-day delay because the diagnosis had been missed initially. When referred to our institution, this patient had bilateral pneumothorax and rapidly spreading subcutaneous emphysema; despite bilateral chest tube drainage, respiratory tolerance was poor, and we decided on operative repair. Postoperatively, the patient was weaned from the respirator and extubated within 12 hours. However, fiberoptic bronchoscopy performed on postoperative day 9 showed a covered dehiscence of the suture line. Second intention healing occurred, fortunately without sequelae.

We may assume that delayed repair is at risk for failure, whereas primary repair leads to straightforward recovery. Based on the currently available experiences, we recommend restriction of conservative management to patients who are breathing spontaneously, who present with small tears and limited respiratory symptoms, and who are clinically stable. Recent work [4] suggests that all other forms of presentation, and in particular patients on a ventilator or who have development of pneumothorax or rapidly spreading surgical emphysema, should undergo operative repair.

References

1. Massard G, Wihlm JM, Roeslin N, et al. Plaies trachéobronchiques iatrogènes au cours de l'intubation. J Chir (Paris) 1992;129:297–302.
2. Larnaudie P, Radoman V, Lipinska V. A propos d'une perforation trachéale par intubation. Ann Fr Anesth 1973;14:389–90.
3. Massard G, Rougé C, Dabbagh A, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483–7.
4. Marty-Ane C, Picard E, Jonquet O, Mary H. Membranous tracheal rupture after endotracheal intubation. Ann Thorac Surg 1995;60:1367–71.[Abstract/Free Full Text]

This article has been cited by other articles:

				L. Spaggiari, M. Rusca, P. Carbognani, and P. Solli Tracheobronchial Laceration After Double-Lumen Intubation for Thoracic Procedures Ann. Thorac. Surg., June 1, 1998; 65(6): 1837 - 1837. [Full Text] [PDF]

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