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Ann Thorac Surg 1998;65:1838
© 1998 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg, F-67091 Strasbourg, France
e-mail: gilbert.massard{at}chru-strasbourg.fr
To the Editor
Doctor Spaggiari and his colleagues address the specific, and fortunately rare, setting of tracheobronchial lesions consecutive to insertion of a double-lumen catheter. Their report of 3 cases is laudable in that such lesions are usually reported in single case reports; to our knowledge, the only series dealing with 5 consecutive cases cared for at a single center was published by Guernelli and colleagues in 1979 [1].
We wish to start our reply with a kind opposition to the statement that we "did not record any tracheobronchial lesions caused by double-lumen intubation." Actually, the referenced article included a single case of left bronchial laceration by a double-lumen tube, in a series of 14 consecutive patients with intubation-related tracheobronchial lesions [2]. Since the publication of the latter article, we have observed a second case with an almost identical presentation. Both lesions were discovered during right thoracotomy, at the conclusion of an esophageal resection: removal of the specimen exposed a tear of the membranosa of the left main bronchus, which was tightened by the inflated bronchial cuff. Immediate repair was made with interrupted absorbable sutures. During the repair, the bronchial cuff was deflated, but the tube was left in place. Routine bronchoscopy on postoperative day 10 showed primary healing.
We would like to comment separately on the issue of lacerations with double-lumen catheters, before going into the debate concerning conservative management reactivated by Dr Spaggiari and colleagues. In a previously published article, we have analyzed 26 case reports dealing with airway trauma consecutive to double-lumen intubation, collected from the available literature [3]. The prevalence was estimated close to 0.05%, a single author reporting a rate of 0.19%; the consequently higher incidence of 0.37% reported by Dr Spaggiari and colleagues is unexpected and therefore surprising. The mechanisms of such injuries may be summarized as either "popping injuries" consecutive to undue inflation of any cuff, or extensive lacerations after "ploughing injuries" caused by a stylet, the tip of the catheter, or a carinal spur. The location of the tear was left bronchial in 62.5% of collected cases and tracheal in 40%; a single patient had a combined laceration. Most often, the length of the lesion was correlated to the corresponding cuff: 4 cm for tracheal lesions and 2 cm for bronchial lesions. We therefore speculate that most lesions were actually caused by a popping injury. Diagnosis of the airway laceration was made during thoracotomy in 88% of cases; 73% of the latter cases were right-sided thoracotomies. Half of the lesions were directly found at mediastinal dissection, either during esophagectomy or during clearance of mediastinal lymph nodes; the remaining were discovered because of ventilation problems such as loss of tidal volume or desaturation. Disruptions discovered intraoperatively were immediately repaired in all cases but 1. This particular patient had been operated on for lobectomy through a left thoracotomy. Intubation was complicated with a huge laceration of the trachea extending from the cricoid to the carina. Obviously, this lesion was out of reach through the left thoracotomy approach. Conservative management was decided on, and the patient was extubated as soon as the chest wound was closed. Primary healing was obtained, and no long-term sequelae were reported [4].
This leads us to the debate opposing conservatism to liberal surgical repair. There is increasing evidence from various case reports that spontaneous healing of tracheal tears without long-term sequelae can reasonably be expected in selected cases. Conversely, we totally agree with Dr Spaggiari and colleagues that delayed repair in infected tissues is likely to fail. We have reported a single event of breakdown of the suture line, which occurred after repair 5 days after the initial injury [2]. Therefore, when deciding on a conservative treatment, one should be aware that there is no alternative pathway with second-intention operation. However, the fear of tracheal or bronchial stenosis after healing of an untreated laceration is unfounded. A recent update from Dr Couraud’s group [5] confirmed Dr Grillo’s and Dr Pearson’s previous demonstration that the main mechanism leading to postintubation or posttracheostomy tracheal stenoses results from circumferential ischemic necrosis of airway cartilage and subsequent retraction during the scarring process. Besides, untreated circumferential ruptures of the airway occasionally show stenotic spontaneous healing. As opposed to this mechanism, a longitudinal tear cannot achieve a circumferential retraction; fear of stenosis should not be the motivation for surgical repair. The threats that should make us consider emergency repair are cardiorespiratory distress through compressive mediastinal emphysema or tension pneumothorax, and mediastinitis owing to a combined esophageal wound. Doctor Ross and colleagues [6] have adequately defined criteria for conservative management: (1) stable vital signs, (2) no difficulty in ventilation of the patient while intubated or respiratory distress while extubated, (3) no evidence of esophageal injury, (4) minimal mediastinal fluid, (5) nonprogressive pneumomediastinum or subcutaneous emphysema, and (6) no signs of sepsis. To this list we should add the endoscopic appearance: the tear should be less than 5 cm, no major gaping of the wound should be observed during spontaneous breathing, and no major retrotracheal mediastinal space should be accessible with the scope.
Our colleagues from the anesthesiology staff stress some important measures to prevent airway trauma during double-lumen intubation as follows: (1) Read carefully the bronchoscopy report to be aware of any abnormality of airway caliber, length, or anatomy. (2) Use double-lumen catheters without carinal spur. (3) Inflate the cuffs with the least volume providing air-tightness. (4) Use fiberoptic bronchoscopy liberally during placement of tubes, and for check up of their final placement in the thoracotomy position.
We thank Dr Spaggiari and colleagues for placing the focus of discussion on the stimulating problems of airway trauma with double-lumen intubation.
References
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