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Correspondence

Iatrogenic Tracheobronchial Injury: A Support to Nonsurgical Management

Clinique de Chirurgie Thoracique, Hôpital Calmette, 1, Bd du Prof Leclercq, CHRU Lille 59037, France

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

To the Editor:

We read with great interest the article by Schneider and colleagues [1]. We would like to congratulate the authors for this interesting article. However, a few points should be discussed.

The authors recommended surgery when: (1) mechanical ventilation was not possible, (2) subcutaneous or mediastinal emphysema was progressive, (3) there was an open perforation into the pleural cavity, and (4) an endobronchial tube could not be placed beyond the laceration [1].

We disagree with these recommendations for surgery. Our approach for these patients is based on two key factors: (1) the need for continued mechanical ventilation, and (2) the ability to bridge the tracheobronchial rupture (TBR) if mechanical ventilation is mandatory [2].

First, if pneumothorax and subcutaneous emphysema are properly drained, the consequences of TBR on the respiratory mechanics are usually minimal in patients breathing spontaneously [3–5].

In our experience, and also in a different, recent series, extent of the TBR is not a criterion for surgical treatment, and outcome is independent of the TBR length [2, 6].

Last, transient noninvasive, positive pressure, ventilatory support can be used to treat respiratory failure due to intraluminal esphageal herniation [2].

In ventilated patients, the cuff of a single-lumen tube placed distal to the TBR assures effective ventilation. Consequently, it is unclear why the authors operated on 7 ventilated patients in whom placement of a distal single-lumen tube was feasible.

Moreover, when TBRs are too close to the carina, we were able to achieve separated bilateral endobronchial intubation through tracheostomy [2].

Finally, we believe that the real issue is to avoid unnecessary or harmful surgery. In patients breathing spontaneously, surgery represents an additional trauma, because nonsurgical management is sufficient for healing.

In patients ventilated for medical failure, operation is usually a high-risk procedure due to the underlying disease.

In conclusion, we recommend conservative treatment as the best approach to post-intubation TBR: (1) in patients who have spontaneous ventilation, (2) for patients 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 medical problems. Surgical repair should be reserved for cases in whom bridging the lesion is technically not feasible (Fig 1) or for injuries diagnosed during thoracic surgery.

View larger version (10K): [in this window] [in a new window]   Fig 1. Treatment algorithm for tracheobronchial rupture (TBR).

	References

Top References

 

1. Schneider T, Storz K, Dienemann H, Hoffmann H. Management of iatrogenic tracheobronchial injuries: a retrospective analysis of 29 cases Ann Thorac Surg 2007;83:1960-1964.[Abstract/Free Full Text]
2. Conti M, Pougeoise M, Wurtz A, et al. Management of postintubation tracheobronchial ruptures Chest 2006;130:412-418.[Medline]
3. d'Odemont JP, Pringot J, Goncette L, et al. Spontaneous favorable outcome of tracheal laceration Chest 1991;99:1290-1292.[Medline]
4. Ross HM, Grant FJ, Wilson RS, et al. Non-operative management of tracheal laceration during endotracheal intubation Ann Thorac Surg 1997;63:240-242.[Abstract/Free Full Text]
5. Leo F, Solli P, Veronesi G, Spaggiari L, Pastorino U. Efficacy of microdrainage in severe subcutaneous emphysema Chest 2002;122:1498-1499.
6. Gomez-Caro Andres A, Moradiellos Diez FJ, Ausin HP, et al. Successful conservative management in iatrogenic tracheobronchial injury Ann Thorac Surg 2005;79:1872-1878.[Abstract/Free Full Text]

This article has been cited by other articles:

				H. Hoffmann, T. Schneider, K. Storz, and H. Dienemann Reply. Ann. Thorac. Surg., May 1, 2008; 85(5): 1844 - 1844. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Massimo Conti Henri Porte Alain Wurtz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Conti, M. Articles by Wurtz, A. Search for Related Content PubMed PubMed Citation Articles by Conti, M. Articles by Wurtz, A. Related Collections Trachea and bronchi Related Article