Chest
Volume 130, Issue 2, August 2006, Pages 412-418
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Original Research: CRITICAL CARE MEDICINE
Management of Postintubation Tracheobronchial Ruptures

https://doi.org/10.1378/chest.130.2.412Get rights and content

Study objectives

To determine whether nonoperative management can be applied to iatrogenic postintubation tracheobronchial rupture (TBR).

Patients and interventions

Thirty consecutive patients with TBR complicating intubation between June 1993 and December 2005 entered the study. Patients not receiving mechanical ventilation at time of diagnosis were treated nonsurgically. Patients receiving mechanical ventilation who were judged operable underwent surgical repair, while nonoperable candidates had their TBR bridged by endotracheal tubes.

Results

Fifteen patients not requiring mechanical ventilation underwent simple conservative management. TBR length measured 3.85 ± 1.46 cm (mean ± SD). Eight TBRs showed full-thickness rupture with frank anterior intraluminal protrusion of the esophagus. In three patients, transient noninvasive positive pressure ventilatory support (NIV) was necessary. All lesions healed without sequelae. Two patients receiving mechanical ventilation underwent surgical repair and died. Thirteen patients receiving mechanical ventilation were considered at high surgical risk, and TBR bridging was attempted as salvage therapy. Complete bridging was achieved in five patients by simply advancing the endotracheal tube distal to the injury. Separate bilateral mainstem endobronchial intubation was necessary in six patients whose TBRs were too close to the carina. Nine of 13 patients (69%) treated with nonoperative therapy completely recovered.

Conclusion

We conclude that conservative nonoperative therapy should be considered in patients with postintubation TBR who are breathing spontaneously, or when extubation is scheduled within 24 h from the time of diagnosis, or when continued ventilation is required to treat an underlying respiratory status. Surgical repair should be reserved for cases in which NIV or bridging the lesion is technically not feasible.

Section snippets

Setting

This study took place in the emergency and critical care department and the department of thoracic surgery and respiratory diseases of a university-affiliated hospital that serves as a referral trauma center for a region of 4 million inhabitants.

Study Population and Inclusion Criteria

All patients with TBR complicating endotracheal intubation between June 1993 and July 2005 entered the study. Excluded were tracheobronchial injuries complicating blunt chest trauma, tracheostomy, rigid bronchoscopy, or thoracic surgery.

Procedures and Protocol

All patients

RESULTS

Thirty consecutive patients with TBR entered the study (26 women and 4 men; mean age, 63 ± 13.3 years; range, 31 to 79 years). All had undergone single-lumen tube endotracheal intubation for elective surgical operations (n = 16) or for emergency intubation for respiratory distress or cardiopulmonary resuscitation (n = 14). No patient was receiving long-term ventilation. Intubation was reported to be difficult in nine occasions, and a stylet was used in three occasions.

Subcutaneous emphysema was

DISCUSSION

This study describes our experience in a series of 30 consecutive patients with iatrogenic tracheobronchial injuries. All but two patients were managed without direct repair of the rupture. More than three fourths of the patients, including those with large and full-thickness lacerations, recovered completely. The outcome in this series of patients compares favorably with data reported in the literature.123456789182021

Surgical repair has traditionally been considered as the cornerstone of

ACKNOWLEDGMENT

We are grateful to Alain Tremblay, MDCM, University of Calgary, Canada, for editorial assistance.

REFERENCES (24)

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The authors report that they have no conflicts of interest related to this paper.

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