Original article
General thoracic
Management of Iatrogenic Tracheobronchial Injuries: A Retrospective Analysis of 29 Cases

https://doi.org/10.1016/j.athoracsur.2007.01.042Get rights and content

Background

Tracheobronchial injuries are rare but potentially life-threatening complications of endotracheal intubations or endobronchial interventions. This retrospective analysis discusses the criteria for the operative and nonoperative management of tracheal lacerations.

Methods

From July 1996 to June 2006, 29 patients with iatrogenic tracheobronchial injuries were diagnosed at our institution. The injury occurred during single-lumen tube intubation in 14 patients and during double-lumen tube intubation in 2 patients. Two ruptures were diagnosed after surgical tracheostomy, eight after dilational percutaneous tracheostomy, and three after interventional bronchoscopy.

Results

The lacerations in 11 patients were superficial or were sufficiently covered by the esophagus, and they underwent conservative management. Bronchoscopy revealed healing per primam in every case. Surgical repair was done in 18 patients (62%). The transtracheal approach was used for repair in 7 patients; a right-sided posterolateral thoracotomy was performed in 11 patients with lacerations affecting the lower third of the trachea. Three surgical patients died from causes unrelated to the tracheal injury. No clinically evident mediastinitis or postoperative tracheobronchial stenosis was observed.

Conclusions

The decision for operative or nonoperative treatment of iatrogenic tracheobronchial lacerations is determined by the ventilating situation and the local extent of the injury. Nonoperative management of iatrogenic tracheobronchial injuries may be a save option in patients with uncomplicated ventilation, superficial or sufficiently covered tears, and moderate and nonprogressive emphysema. Immediate surgical repair remains warranted in those patients who require mechanical ventilation that cannot be delivered past the laceration.

Section snippets

Patients and Methods

From July 1996 to June 2006, 29 patients with iatrogenic tracheobronchial injuries were diagnosed at our institution, and their records were analyzed for patient profile, cause, and extent of tracheobronchial injury, clinical symptoms, chosen treatment option, treatment success or failure, and patient outcome. There were 20 women (69%) and 9 men (31%), with a mean age of 65 years (range, 17 to 89 years). The ethics committee of the University of Heidelberg approved this retrospective study

Treatment Success and Failure

Eleven patients underwent conservative management. These patients presented with the following symptoms: cutaneous emphysema in 2, mediastinal emphysema in 6, pneumothorax in 1, and no symptoms in 4 (Table 3). In all cases, the lacerations were either superficial or sufficiently covered by the esophagus. Two of these lacerations occurred at our institution: one happened when a tracheal canula was changed through a tracheostoma and the other was associated with the bronchoscopic dilation of a

Comment

Tracheobronchial injuries are rare but potentially life-threatening complications of endotracheal intubations or endobronchial interventions. Our data in essence reconfirm the reported experiences of other authors, that the cause of the iatrogenic injury in most cases was single lumen intubation under emergency conditions or dilational tracheostomies [2, 13, 15]. The risk for tracheal lacerations seems to increase with difficult or emergency intubations, multiple vigorous attempts of an

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