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Ann Thorac Surg 2000;69:216-220
© 2000 The Society of Thoracic Surgeons

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Original Articles

Conservative treatment for postintubation tracheobronchial rupture

^a Thoracic Surgery Unit, Centre Médico-Chirurgical MHL, Haut Lévèque Hospital, Pessac, France

Address reprint requests to Dr Jougon, Thoracic Surgery Unit, Centre Médico-Chirurgical MHL, Haut Lévèque Hospital, 33604 Pessac Cédex, France
e-mail: jacques.jougon{at}chu-aquitaine.fr

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Postintubation tracheobronchial rupture is usually responsible for unstable intraoperative or postoperative conditions, and its management is discussed. We insist on conservative treatment as a viable alternative after late diagnosis of postintubation tracheobronchial rupture.

Methods. We conducted a retrospective study including 14 consecutive patients treated between April 1981 and July 1998.

Results. Twelve tracheobronchial ruptures occurred after intubation for general surgery and two after thoracic surgery. In all cases, the tear consisted of a linear laceration of the posterior membranous wall of the tracheobronchial tree ranging from 2 to 6 cm. One death occurred in a very weak patient unfit to undergo a redo operation for surgical repair. Seven patients were treated conservatively and cured without sequelae. Six patients underwent surgical repair, of whom 2 were diagnosed and repaired intraoperatively.

Conclusions. Aggressive surgical repair is not always mandatory after delayed diagnosis of iatrogenic tracheobronchial rupture. Conservative treatment must often be considered, except after lung resection.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Tracheobronchial ruptures (TBR) are life-threatening lesions that most commonly occur after blunt trauma to the chest [1] but also may be a complication, hopefully very rare, of tracheal intubation [2]. It is in these situations, where physicians sometimes feel guilty, that the decision of nonsurgical treatment is harder to take. Therefore, the choice between conservative treatment or surgical treatment sometimes implies long debates between physicians [3–5].

The purpose of this study is to examine a series of 14 patients treated in our department for TBR consecutive to tracheal intubation; 6 of these patients having undergone tracheal or bronchial surgical repair and 7 (50%) medical treatment. Retrospective analysis of different cases and review of the literature allows us to propose a decision-taking algorithm of the best treatment of TBR after tracheal intubation.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
All patients treated in our department between April 1981 and July 1998 for TBR consecutive to intubation were reviewed. All data concerning patient history, conditions of intubation, presenting symptoms, endoscopic and radiologic findings, treatment and outcome were carefully reviewed.

There were 14 patients (12 women and 2 men) ranging in age from 6 to 72 years (mean, 59 years). In 3 cases, the tracheal rupture was consecutive to tracheal intubation performed in our department. All other patients came from other hospitals and were referred to our center for diagnosis or treatment.

Etiology
The intubation tube used was a single-lumen tube in 11 cases and a double-lumen endotracheal tube in 3 cases. Causes for intubation are reported in Table 1. Analysis of the conditions of intubation revealed difficulties due to severe facial injury by shotgun in 1 case. In all other cases, there was not any particular difficulty found.

In 4 patients, signs of tracheal rupture appeared immediately causing respiratory distress with important desaturation during anesthesia. Bilateral pneumothorax occurred in 2 cases, left tension pneumothorax in 1 case, and tension pneumomediastinum in 1 case. In 1 of these cases, the patient had remained intubated with a very large overinflated tracheal cuff in order to allow the medical transport to our unit (Figs 1 and 2).

View larger version (141K): [in this window] [in a new window]   Fig 1. Chest x-ray film of patient 12 showing overinflation of the cuff of the endotracheal tube, pneumomediastinum, and subcutaneous emphysema.

View larger version (129K): [in this window] [in a new window]   Fig 2. Computed tomographic scan of patient 12 showing the endotracheal tube with an overinflated cuff between the sternum and the vertebrae.

In 7 patients, presenting symptoms were more insidious and occurred later on. Clinically, we noted head and neck subcutaneous emphysema, nasal voice, and pneumomediastinum on chest radiograph (see Table 1). Hemoptysis occurred in 1 case only.

Endoscopy
Definite diagnosis was performed bronchoscopically in all cases except those diagnosed intraoperatively (see above). Endoscopic findings are reported in Table 1. The tear was always unifocal and was found at the membranous part or at the junction of the membranous wall and the cartilage. It involved the trachea in 9 patients, the carina in 3, and the left main bronchus in 2. In all cases, tears were linear and parallel to the bronchial tree.

Treatment
Six patients underwent surgery. The tear was always sutured by total layer of interrupted resorbable knots secondarily covered by a muscular or pleural flap.

The patient who suffered from a left stem bronchus rupture after right pulmonary lobectomy was unfit to undergo surgery at time of diagnosis. He was a very weak patient who died a few hours after the endoscopic diagnosis from respiratory distress and cardiac failure.

Seven patients underwent medical treatment. All tears occurred after single lumen tube intubations. Presenting symptoms were most often poor and sometimes delayed. Nevertheless, 1 patient presented an acute bilateral pneumothorax which was rapidly exsulfated by bilateral pleural suction. Tracheobronchial lacerations measured 1 to 3.5 cm long. Medical treatment included a broad spectrum antibiotherapy against the tracheobronchial flore, antiseptic antiinflammatory aerosoltherapy, and chest tube in 1 patient. When the subcutaneous emphysema was relapsed or important to cause shutting of the eyelids, we performed two short susclavian incisions and subcutaneous massages in order to evacuate the emphysema. Early stabilization of clinical symptoms without progression over a short period of time was the sine qua non condition for conservative treatment.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The postoperative care of patients who underwent surgery was uneventful. All patients treated by medical means had favorable outcome. A fiberoptic bronchoscopy was systematically performed at day 15 before discharge, and later on the 1st and 3rd months. Follow-up (median 30 months; ranging 3 months to 207 months) sometimes showed at first control small granulomas easily cauterized by laser but never revealed any scar sequellae or stenosis.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The incidence of TBR after intubation is rare considering the number of tracheal intubations performed for general anesthesia. However some short tears, spontaneously favorable, are probably misdiagnosed [6, 7]. After double-lumen tube intubations, the frequency of TBR remains low, estimated under 1% (0.12% for Borasio and colleagues [6]; 0.05% for Personne and coworkers [7]; 0.37% for Spaggiari and associates [3]). The most recent series report approximately 10 cases [5, 6, 8, 9] (Table 2).

Clinical symptoms occur either immediately during mechanical ventilation (compressive pneumothorax, extensive subcutaneous emphysema) or are more insidious, arising in the postoperative period or later. The development of a postoperative subcutaneous emphysema must immediately lead to perform a fiberoptic bronchoscopy under sufficient local anesthesia to prevent extension of the emphysema by coughing if the patient has already been extubated. Chest radiograph can show a rightside deviation of the intubation tube [10] or an overinflated cuff, as it was once noted in one of our patients (Fig 1).

Patients presenting with acute respiratory distress must undergo surgical treatment in the same operative time if it is possible. Outcome is always favorable. Prognosis depends mostly on the patient’s general status.

TBR occurring after pulmonary or mediastinal surgery, usually requiring double-lumen tubes, implies surgical treatment, even if the symptoms presented by the patient are delayed [3]. Indeed, intrapleural suction converts a tracheobronchial tear in a large bronchopleural fistula. Moreover intrapleural suction for lung reexpansion in a patient who underwent partial pulmonary resection may be inefficient. Nevertheless, 2 patients who underwent left pneumonectomy had favorable outcome after medical treatment of their tracheal rupture [6, 7]. In these 2 cases reported, no surgical treatment was performed considering the important risks implied by a right thoracotomy under single right-lung mechanical ventilation. This is the only circumstance after pulmonary resection where medical treatment can be considered [3]. Surgical approach, as well as techniques of suture, have been already described elsewhere [5, 6, 8].

If pulmonary or mediastinal surgery has not been performed, conservative treatment in a thoracic surgery department under continuous care can be considered [11, 12]. In our series, in the patients who were treated conservatively, presenting symptoms were immediate in 1 patient only, and delays of 1, 2, and 6 days in, respectively, 2, 3, and 1 patients. The tear must be shorter than one third of the trachea (4 cm), which is the mean length of the endotracheal cuff. These tears caused by the overinflated cuff are not deep in the mediastinum or associated with esophageal lesion. A tear more than 4 cm is generally deeper and produced by withdrawing of the tube without deflation of the cuff. Clinical signs must been stable without progression over a short period of time.

Temporary tracheostomy has been proposed in such circumstances [6], as well as tracheal intubation [9], their aim being to prevent the patient from sudden intrabronchial hyperpressures caused by coughing, which may worsen subcutaneous emphysema and widen the tear. In our series, we always tried to avoid tracheostomy, performing short subclavian skin incisions associated to cutaneous massages in order to evacuate emphysema. We consider that surgical treatment is the appropriate treatment when a tracheostomy is indicated. A broad-spectrum antibiotherapy against common tracheobronchial flore associated to antiinflammatory aerosoltherapy were prescribed. A bronchoscopy was performed at day 15 after the tracheal rupture and always showed perfect scarring. We never found stenosis, thus confirming findings of international literature reports. According to our experience and after having reviewed the literature, we propose an algorithm for the treatment of postintubation TBR on Figure 3.

View larger version (15K): [in this window] [in a new window]   Fig 3. Algorithm for assessment of postintubation tracheobronchial ruptures.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques Jougon Emmanuel Choukroun Jean Dubrez Jean-François Velly Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jougon, J. Articles by Velly, J.-F. Search for Related Content PubMed PubMed Citation Articles by Jougon, J. Articles by Velly, J.-F.