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Ann Thorac Surg 2000;70:1194-1196
© 2000 The Society of Thoracic Surgeons

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Original article

Extensive posterior-lateral tracheal laceration complicating percutaneous dilational tracheostomy

^a Division of General Thoracic Surgery, Department of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA

Address reprints requests to Dr Landreneau, Division of General Thoracic Surgery, Department of Cardiothoracic Surgery, Allegheny University Hospitals, Allegheny General, 02 Level South Tower, 320 East North Ave, Pittsburgh, PA 15212
e-mail: rlandren{at}pgh.auhs.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. An extensive posterior-lateral longitudinal tracheal laceration is an uncommon but serious complication of percutaneous dilational tracheostomy (PDT). We report the successful management of three ventilator-dependant patients whose percutaneous tracheostomy was complicated by an extensive longitudinal posterior-lateral tracheal laceration requiring operative repair.

Methods. A retrospective review of 134 cases of PDT with concurrent bronchoscopy was performed between April 1997 and July 1999 and compared with a review of 124 cases of open tracheostomy. Tracheal lacerations were primarily repaired and augmented with intercostal muscle pedicle buttress.

Results. Three cases of an extensive posterior-lateral longitudinal tracheal laceration that required operative repair were reported in the PDT group. None were reported in the open tracheostomy group. The 3 patients were managed with an adult high-frequency oscillating ventilator or pressure control ventilation during the postoperative period to limit barotrauma, and all healed without evidence of tracheal leak or stenosis.

Conclusions. The increasing popularity of PDT, particularly among nonsurgical disciplines, may generate an increasing number of complications requiring operative attention. Thoracic surgeons need to be cognizant of the pitfalls of PDT technique and be prepared to manage these difficult clinical scenarios.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Percutaneous dilational tracheostomy (PDT) has become an increasingly common method of performing elective tracheostomy for patients requiring a long-term airway. Multiple publications in recent years have reported the efficacy and relative safety of this approach [3–5,101]. However, with the more widespread use of the percutaneous technique, the uncommon but serious complication of posterior tracheal perforation, or laceration, is more often seen . Because of the increasing use of PDT, thoracic surgeons should become familiar with the technique and strategies to address the complication of posterior tracheal injury.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
A retrospective review of our institutional records from April 1997 through July 1999 revealed that 134 patients underwent PDT and 124 patients underwent open surgical tracheostomy. Only elective indications were included in the review; cases requiring an emergent surgical airway were all performed by the open technique and were excluded. Indications for elective tracheostomy included requirement for prolonged mechanical ventilation, chronic airway protection, pulmonary hygiene, or a combination of those three indications.

All PDT procedures were performed at the intensive care unit beside or at the minor procedures room in the intensive care unit. The insertion of the percutaneous dilational tracheostomy was performed by the trauma surgery intensivists following the technique described by Ciaglia [1]. All PDT insertions were performed with concurrent fiberoptic bronchoscopic guidance by a pulmonologist. The open tracheostomies were performed in the standard fashion described by Jackson [2] by the general surgery and cardiothoracic surgeons in the operating room. Tracheostomies performed as part of an otolaryngology operation were not included.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
We documented 3 patients (3 of 134, or 2.2%) who suffered extensive posterior-lateral tracheal laceration following PDT, compared with none of the patients who had undergone open tracheostomy. All 3 patients with tracheal laceration had suffered a cardiac or respiratory arrest before admission, with the sequelae of irreversible anoxic encephalopathy. All 3 were referred for tracheostomy because of long-term mechanical ventilation requirements and to enhance pulmonary hygiene. Of the 3 patients, 2 were men, both of whom had a tall, frail body habitus. The third patient, a woman, was morbidly obese. In each case, the PDT was performed in the routine fashion under bronchoscopic guidance with no unusual technical difficulty. In all three cases, the tracheal laceration was recognized immediately following insertion of the PDT tube. Clinical signs included evidence of immediate pneumomediastinum, difficulty in ventilation, and minor hemoptysis. The suspicion of tracheal injury was confirmed by fiberoptic bronchoscopy through the tracheostomy. In each case, a single longitudinal laceration along the right posterior lateral aspect of the trachea was noted at the point at which the membranous trachea posteriorly was avulsed from the more rigid cartilaginous trachea. The extent of the injury began just distal to the anterior tracheal puncture site and extended distally to the point from which the right mainstem bronchi branched. The massive airleak resultant from this defect made ventilation difficult; only by intubating the left mainstem with the oral endotracheal tube was it possible to adequately ventilate the patient. Thoracic surgical consultation was then emergently obtained.

The surgical repair was approached through a full right posterior-lateral thoracotomy in the fourth interspace. Preservation and full mobilization of the fourth intercostal muscle pedicle was routinely performed. High-frequency jet ventilation was not required in any of the cases, although the necessary tubing was made ready and available. The tracheal-bronchial defect was easily identified, and primary reapproximation was performed with a 3-0 absorbable monofilament suture ( PDS, Ethicon, Cincinnati, OH), after which the suture line was buttressed with the intercostal muscle pedicle flap. The chest was drained and closed in standard fashion.

Unfortunately, none of these patients could be extubated because of their antecedent respiratory failure. Bronchoscopic evaluation of the tracheal-bronchial repair was thus performed intraoperatively. Blood and airway secretions were removed in order to ensure proper placement of the endotracheal tube, defined as balloon placement in the immediate subglottic region. To prevent any proximal or distal movement or migration of the endotracheal tube, it was secured to an upper canine tooth with dental wire.

Pressure control ventilation was utilized in 1 patient, and a prototype adult high frequency oscillating ventilator was used for the 2 others to maintain the peak airway pressure below 35 cm H₂O in order to minimize barotrauma to the suture line. Postoperative fiberoptic bronchoscopy was performed to promote pulmonary hygiene in all patients. The tracheal-bronchial repairs were found to be intact, with no bronchoscopic evidence of suture line dehiscence, prolonged airleak, or pneumomediastinum. All 3 patients successfully made the transition back to conventional volume-controlled ventilation 7 to 10 days post operatively, and subsequently underwent uneventful open tracheostomy 2 weeks following repair of the tracheal laceration. Two of the 3 patients are alive but in a permanent vegetative state, while the third patient succumbed to pneumonia several weeks following the operation.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The technique of open surgical tracheostomy as described by Jackson [2] is familiar to otolaryngologists, general surgeons, and thoracic surgeons. The introduction of percutaneous dilational tracheostomy in 1985 by Ciaglia [1] has been embraced by many, including anesthesiologists and pulmonologists, who have been assuming an increasing role in critical care medicine. Multiple methods of percutaneous tracheostomy exist, but Ciaglia’s serial percutaneous dilational method with bronchoscopic guidance has been reported as the safest [4]. Despite the variability in the methods employed for percutaneous tracheostomy, the reported incidence of complications following percutaneous approaches are comparable with or below that occurring after open tracheostomies[3–5,7–9]. Minor complications, such as stomal infection, minor bleeding, and accidental decannulation, may in fact occur in PDT less frequently than in open tracheostomy. However, iatrogenic posterior longitudinal tracheal laceration is a complication of PDT not generally associated with open tracheostomy. This serious complication occurs because of technical errors committed during the insertion of PDT, and the use of concurrent endoluminal visualization to confirm proper insertion needle placement, the use of the sequential dilation (Ciaglia) technique, avoidance of excessive force, and proper patient selection have been identified as factors vital to performing PDT in a safe and controlled fashion. Concurrent endoluminal visualization by bronchoscopy is essential in reducing technical complications of PDT insertion. Visual confirmation of needle placement at the proper level and in the midline of the trachea is necessary. Patients with a paramedian insertion are at increased risk for tracheal injury or extraluminal tracheostomy tube placement. However, even with the use of bronchoscopy by a pulmonologist in all 134 PDT cases reported here, there was a 2.2% (3 of 134) incidence of tracheal laceration in our institutional experience. In one case, the patient was morbidly obese, with a short and thick neck; her anatomy made it more likely for the dilators to injure the posterior trachea [5]. The other two patients were thin, but technical errors in needle placement were not adequately conveyed by the endoscopist to the surgeon inserting the PDT. This potential problem maybe eliminated by the use of videobronchoscopy, in which the endoluminal view is projected so that the person actually inserting the PDT can see where the needle and dilators are going.

Although extensive posterior tracheal lacerations have been mentioned as a potential complication in several reviews of PDT [3–5], the mechanism of injury has not been detailed, except in Trottier’s recent publication [6]. In a clinical and laboratory study, Trottier identified the increased risk for posterior tracheal perforation when the plastic dilator guide is not maintained securely and the dilator is thus advanced beyond the guide at a right angle to the posterior tracheal wall. Trottier also found that perforation did not occur when the guide was carefully maintained in proper position. This pattern of an extensive longitudinal laceration of the posterior membranous trachea, essentially separating it from the more rigid cartilaginous airway, was consistent in our 3 patients and has been noted by others as well (personal communication with D. Sugarbaker). Strict adherence to maintaining control of the guide wire and the plastic dilator guide and advancing the dilators without undue force is therefore essential to minimize the risk of the dilator advancing over the guide catheter and causing posterior longitudinal laceration of the trachea [6].

Despite taking the appropriate precautions, the complication of a posterior longitudinal tracheal laceration may still occur, however. Prompt recognition of this problem is paramount before the ability to ventilate the patient is lost. The strategy for repair begins with a generous posterior-lateral thoracotomy to provide optimal exposure of the posterior mediastinum while preserving the intercostal muscle pedicle. Provisions should be made for jet ventilation through the operative field in case the ability to ventilate by way of the oral endotracheal tube is lost. The repair should include the use of a long-lasting, absorbable monofilament suture and the use of available pleura, pericardial fat, and the intercostal muscle pedicle to buttress the repair line. The patient should be extubated, if at all possible, to minimize barotrauma to the suture line. Pulmonary hygiene must be maintained, in most cases by fiberoptic bronchoscopy, to avoid the blind insertion of the tracheal suction tube in the immediate postoperative period. When patients cannot be extubated because of their underlying respiratory failure, secure fixation of the oral endotracheal tube must then be performed to avoid distal migration of the balloon to the suture line or proximal migration leading to accidental extubation. Pressure control ventilation was successful in limiting peak airway pressures to below 35 cm H₂O for 1 of our patients, and a prototype adult high frequency oscillating ventilator was used to successfully ventilate 2 others, including one who had an aspiration pneumonia complicated by the adult respiratory distress syndrome. Conventional volume-controlled ventilation may produce excessive peak airway pressures, which are detrimental to maintaining the integrity of the suture line and should be avoided in the initial perioperative period. Creative manipulation of the mechanical ventilator maybe necessary to minimize the peak and mean airway pressures to minimize the barotrauma to the tracheal repair.

The technique of percutaneous dilational tracheostomy is attractive and has been adopted by many physicians who care for critically ill patients who require a long-term airway. The routine use of videobronchoscopic guidance and proper insertion techniques should be followed to minimize complications. Although thoracic surgeons are unlikely to be performing any significant numbers of percutaneous tracheostomies, we have to be cognizant of the developing pitfalls of this approach The thoracic surgeon should also be aware of the unique anatomic nature of this injury and the necessary strategies for successful repair.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Ciaglia P., Firsching R., Syniec C. Elective percutaneous dilational tracheostomy. Chest 1985;87:715-719.[Abstract/Free Full Text]
2. Jackson C. Tracheostomy. Laryngoscope 1909;19:285-290.
3. Walz M.K., Peitgen K., Thurauf N., et al. Percutaneous dilational tracheostomy-early results and long-term outcome of 326 critically ill patients. Intensive Care Med 1998;24:685-690.[Medline]
4. Moe K.S., Schmid S., Stoeckli S.J., et al. Percutaneous tracheostomy. Ann Otol Rhinol Laryngol 1999;108:384-391.[Medline]
5. Hill B.B., Zweng T.N., Maley R.H., et al. Percutaneous dilational tracheostomy. J Trauma 1996;40:238-244.
6. Trottier SJ, Hazard PB, Sakabu SA, et al. Posterior tracheal wall perforation during percutaneous dilational tracheostomy. Chest I 999;1 15:1383–9.
7. Porter J.M., Ivatury R.R. Preferred route of tracheostomy-percutaneous versus open at the bedside. Am Surgeon 1999;65:142-146.[Medline]
8. Graham J.S., Mulloy R.H., Sutherland F.R., et al. Percutaneous versus open tracheostomy. J Trauma 1996;42:245-250.
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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): Jeffrey C. Lin Richard H. Maley, Jr Rodney J. Landreneau Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lin, J. C. Articles by Landreneau, R. J. Search for Related Content PubMed PubMed Citation Articles by Lin, J. C. Articles by Landreneau, R. J.