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Ann Thorac Surg 2007;83:1924
© 2007 The Society of Thoracic Surgeons

Correspondence

Management of Postintubation Tracheobronchial Ruptures

Massimo Conti, MD, Emmanuel Robin, MD, Henri Porte, MD, PhD, Charles-Hugo Marquette, MD, PhD, Alain Wurtz, MD

Clinique de Chirurgie Thoracique, Clinique d’Anesthésie Cardio-Thoracique, Clinique des Maladies Respiratories, Hôpital Calmette-CHU Lille, 1, Bd du Prof Leclercq, Lille, 59037 France

(Email: m-conti{at}chru-lille.fr).

To the Editor:

We read with interest the article by Mercadante and colleagues [1] regarding the conservative management of a major post-intubation tracheobonchial rupture (TBR). A 7-cm tracheal tear due to double lumen intubation was successfully treated by conservative treatment. This favorable outcome is not surprising and is consistent with the burden of evidence that accumulates in the literature. Recently, Gomez-Caro Andres and colleagues [2], in a large series of patients successfully treated by conservative management, considered that outcome was independent of the tracheobronchial length. Between June 1993 and July 2005, 30 patients presenting iatrogenic TBR were treated in our institution [3]. Sixteen were secondary to intubation for elective surgery and 14 to intubation for medical emergencies. Their TBR length measured 4.5 ± 1.5 (range, 1 to 7.5 cm). Fifteen patients not requiring mechanical ventilation underwent simple conservative management. Eight of them showed full thickness rupture with frank anterior intraluminal protrusion of the esophagus. In 3 patients, transient noninvasive ventilatory support (NIV) was necessary. All lesions healed without sequelae. Two patients on mechanical ventilation underwent surgical repair and died. Thirteen patients on mechanical ventilation were considered at high surgical risk and TBR bridging was attempted as salvage therapy. Complete bridging was achieved in 5 patients by simply advancing the endotracheal tube distal to the injury. Separate bilateral mainstem endobronchial intubation was necessary in 6 patients whose TBR was too close to the carina [4]. Nine of 13 (69%) ventilated patients treated conservatively completely recovered. Our findings question the classical criteria for surgical repair. We disagree with the author’s conclusion (ie, "... surgery remains the treatment of choice of these iatrogenic lesions ... Nevertheless, non surgical management should be considered a viable option in high risk patients"). We recommend conservative nonoperative therapy as the best approach to post-intubation TBR in patients who are (1) on spontaneous ventilation, or (2) when extubation is scheduled within 24 hours from the time of diagnosis, or (3) for patients who will require continued ventilation to treat their underlying respiratory status. Surgical repair should be reserved for cases where NIV or bridging the lesion is technically not feasible or for injuries diagnosed during thoracic surgery.


   References
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 References
 

  1. Mercadante E, Giovannini C, Castaldi F, et al. Major iatrogenic tracheal injury during pneumonectomy: conservative treatment Ann Thorac Surg 2006;81:2285-2287.[Abstract/Free Full Text]
  2. Gomez-Caro Andres A, Moradiellos Diez FJ, Ausin Herrero P, et al. Successful conservative management in iatrogenic tracheobronchial injury Ann Thorac Surg 2005;79:1872-1878.[Abstract/Free Full Text]
  3. Conti M, Pougeoise M, Wurtz A, et al. Management of postintubation tracheobronchial ruptures Chest 2006;130:412-418.[Medline]
  4. Marquette CH, Bocquillon N, Roumilhac D, et al. Conservative treatment of tracheal rupture J Thorac Cardiovasc Surg 1999;117:399-401.[Free Full Text]

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Edoardo Mercadante, Cristiano Giovannini, and Massimo Carlini
Ann. Thorac. Surg. 2007 83: 1925. [Extract] [Full Text] [PDF]



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