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Ann Thorac Surg 1999;68:1124-1125
© 1999 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
To the Editor
I must congratulate Nazari and associates for this technical and therapeutic proposal concerning the treatment of tracheobronchial postintubation laceration. I think highly of their efforts regarding news surgical proposals. Tracheabronchial intubation-related lacerations are infrequent events but probably underestimated.
The debate concerning the "ideal" treatment of postintubation tracheabronchial lacerations has been ongoing for a long time, especially in this journal; several papers have discussed both pathophysiology and therapy.
Concerning the conservative treatment, to the best of my knowledge, only few case reports and no consecutive series have been published until now. This may reflect a selection of the cases medically treated with positive outcome; in other words, patients with fatal outcome have not been reported. Therefore, no conclusions can be made regarding this kind of treatment. By contrast, in the last 10 years, four surgical series with more than 5 consecutive patients each have been published with an overall population of 42 patients (Table 1) [1–4].
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Undoubtedly, double-lumen tubes are associated with more serious and complex tracheabronchial rupture, often diagnosed peroperatively (88% of cases) [5] or during the extubation, requiring immediate surgical repair. In the majority of cases, these lacerations are treated through a right side thoracotomy [5].
Concerning the discussion about Nazari and colleagues’ paper, to my knowledge, this technique is not usually considered as an alternative therapy for tracheobronchial laceration and I do not find any patients cured by mean of the so-called "decompressing tracheostomy."
However, I would like to make some comments concerning this therapeutic option. It is my feeling that patients with large tracheobronchial laceration should be treated by primary surgical repair whereas a stable patient with only a small tear, according to Ross and associates’ criteria [6], might undergo conservative treatment.
The cure of a tracheabronchial laceration with another "opening" in the trachea (ie, tracheostomy) is a difficult concept to accept, except in patients requiring tracheostomy for acute respiratory failure. Even though Nazari proposes to remove the cuff of the tracheostomy tube to prevent it inflating, which may cause worsening of the laceration, the tracheostomy tube might, per se, be dangerous. It may move in the trachea during respiration and cough; besides, if the diameter of the tracheostomy tube is too small, it may not decompress the airways; by contrast, if too big, it might affect tracheabronchial laceration recovery.
In this series, there is no mention of the general conditions after tracheal rupture of the 2 patients who were treated with decompressant tracheostomy after 4 and 6 days. Possibly, these 2 patients could have healed with conservative treatment alone. In conclusion, postintubation iatrogenic tracheabronchial lacerations are potentially life-threatening conditions requiring an aggressive treatment. To date, the efficacy of conservative treatment has not been demonstrated. It is my belief that postintubation double-lumen laceration and large rupture by single lumen should be treated by primary surgical repair, whereas a small rupture in an uncompromised patient might be considered for conservative treatment.
References
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