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Anesth Analg 2005;100:210-214 © 2005 International Anesthesia Research Society doi: 10.1213/01.ANE.0000140780.14175.5A
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Abstract |
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Tracheal injuries, independent of their origin, may be life-threatening. Surgical repair is regarded as the treatment of choice but has not been compared with other approaches. We hypothesized that defects bridgeable by an artificial airway may enable conservative treatment. We report on five patients with tracheal injuries, two in the trachea’s upper third resulting from trauma and intubation and three in its middle third after percutaneous dilational tracheostomy. Tracheal defects were bridged by endotracheal or tracheostomy tubes under bronchoscopic guidance and the cuff was inflated distal to the lesion. Air leakage stopped immediately and all tracheal defects healed without further interventions. No case of stenosis or mediastinitis was observed. These results suggest that treating tracheal injuries conservatively by placing an artificial airway under bronchoscopic guidance may be effective and offers a convenient starting position for secondary surgical repair in selected patients when conservative treatment fails.
IMPLICATIONS: Bronchoscopic-guided bridging of tracheal tears with an artificial airway is a rapid and easy method to stop immediately life-threatening air leakage. Furthermore, with conservative treatment, tracheal injuries can heal without infectious or stenotic complications. Therefore, conservative treatment should be considered an alternative to surgery in selected patients.
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Introduction |
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TopAbstractIntroductionCase StudiesDiscussionReferences |
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Tracheobronchial injuries after penetrating or blunt trauma are rare but life-threatening. Seventy-eight percent of patients die before admission (1) and 21% of those reaching the hospital die within 2 hours (2). Evidence primarily based on small, retrospective case series (3–5) recommends early surgical repair as the treatment of choice for tracheal injuries (6,7).
Recently, tracheal injury in intensive care unit (ICU) patients has been seen in association with percutaneous dilational tracheostomy (PDT), a method that is increasingly popular because of its apparent simplicity and safety even in severe acute respiratory distress syndrome (ARDS) (8–10). Among the few complications, perforation of the posterior tracheal wall is the complication feared most, and its incidence appears to vary widely from nearly zero to 12.5% (10,11). Unfortunately, there are no data as to how these and other tracheal injuries should be treated.
We report on five patients with tracheal injuries treated conservatively by bridging the defect with an endotracheal or tracheostomy tube.
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Case Studies |
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TopAbstractIntroductionCase StudiesDiscussionReferences |
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Case 1
A 19-year-old pregnant woman (18th week of gestation) with severe community acquired pneumonia (CAP) and ARDS was admitted and placed on extracorporeal membrane oxygenation (ECMO). While the patient was on ECMO, in anticipation of prolonged mechanical ventilation, a bronchoscopically guided PDT was performed with a screw-shaped dilator (PercuTwist, Rüsch Kernen, Germany) after 10 days on mechanical ventilation. However, force used during insertion of the tracheostomy tube compressed the tracheal lumen and caused loss of visualization. After placement of the tracheostomy tube a tear of 2 cm length was detected in the posterior wall in the trachea’s middle third (Fig. 1).
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Immediately, the tracheostomy tube was advanced distal to the defect and the cuff was inflated. Esophageal perforation was excluded by esophagoscopy. A chest radiograph revealed no air leakage into mediastinum, subcutaneous tissue, or pleural cavity, and no further procedures were performed. Although it was possible to wean the patient from ECMO, mitral valve replacement became necessary because of severe concomitant mitral valve incompetence. On day 52 (6 weeks after PDT) a fibrin-covered mucosa at the site of the former tear was detected on bronchoscopy without signs of local inflammation or stenosis (Fig. 1). In addition, the patient’s ICU stay was complicated by recurrent pneumonias. Repeated chest computed tomography (CT) scans were performed to exclude mediastinitis as the cause for susceptibility to infectious episodes.
Eventually, the patient recovered and her trachea was decannulated on day 52 after bronchoscopic inspection. Unfortunately, two days later, the patient experienced a cardiac arrest and died. Inspection of the former perforation site on autopsy revealed an intact mucosa without any signs of stenosis, local inflammation, leak, or mediastinitis.
Case 2
A 55-year-old female with aspiration pneumonia resulting from botulism was admitted for severe ARDS and placed on ECMO. PDT was performed under bronchoscopic visualization using the Ciaglia multiple dilator set (Cook, Mönchengladbach, Germany). Loss of visualization during insertion of the tracheostomy tube and poor visibility (blood-covered optics) were responsible for overlooking a tracheal defect. Development of cutaneous emphysema and tension pneumothorax required insertion of bilateral chest tubes, and bronchoscopy performed 12 hours later detected a 3-cm tear in the middle third of the posterior trachea. The tracheostomy tube’s cuff was placed distal to the defect. This resulted in immediate cessation of air leak and resolution of cutaneous emphysema and pneumothorax. Three weeks later, bronchoscopy revealed only a blind ending duct of 5 mm length in the posterior tracheal wall confined to the mucosa (Fig. 2). Throughout her ICU stay the patient received antibiotic treatment, with piperacillin/tazobactam started before the PDT, followed by ciprofloxacin, amikacin, vancomycin, ceftazidime, imipenem, and later amphotericin B and 5-flucytosine for candidemia. Unfortunately, pulmonary disease worsened by progression to pulmonary fibrosis, and 6 weeks later the patient died from candida septicemia. Autopsy revealed the blind ending, 5-mm fistula seen on bronchoscopy. There were no signs of inflammation, stenosis, or mediastinitis.
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Case 3
A 66-year-old female with severe kyphoscoliosis and cor pulmonale underwent endolaryngeal repair of a glottic stenosis. After surgery she developed severe dyspnea, massive air emphysema, and underwent emergency intubation and surgical tracheostomy. Bronchoscopy identified a longitudinal 5-cm laceration of the posterior tracheal wall reaching from the glottis to 5 cm above the carina, presumably as a result of traumatic intubation (Fig. 3). The tracheostomy tube’s cuff was placed just above the carina and antibiotic treatment was started with ampicillin/sulbactam for 6 days, followed by ciprofloxacin and clindamycin after onset of fever and a new infiltrate on chest radiograph. A control CT scan revealed resorption of mediastinal and subcutaneous air. Recurrent infections treated with antibiotics adapted to results of microbiological susceptibility testing, but muscle weakness resulting from prolonged steroid medication and kyphoscoliosis made weaning from mechanical ventilation difficult. Therefore, the patient could not be discharged until 6 weeks of ICU stay, and with the tracheostomy tube in place. Three months later, tracheoscopy during another surgical procedure revealed a normal tracheal wall without any abnormalities or signs of stenosis.
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Case 4
A 9-year-old girl fell on the handle bar of her scooter and presented with severe dyspnea and cutaneous emphysema of the neck. She was tracheally intubated on the scene and admitted to our emergency room. Emphysema extending from the skull along the trachea and mediastinal organs into the abdominal cavity was seen on CT scan. Because of suspicion of a tracheal tear, an emergency right lateral thoracotomy was performed but yielded no tracheal or bronchial injury. However, bronchoscopy detected a 1-cm tear in the membranaceous part of the upper trachea. The endotracheal tube was positioned with its tip just above the carina and its cuff was inflated. Antibiotic treatment was started with ampicillin/sulbactam. With massive emphysema obstructing the larynx, rapid extubation was not possible and early onset ventilator-associated pneumonia delayed extubation. When the girl developed severe septic shock 9 days after trauma, antibiotic medication was changed to imipenem, vancomycin, and gentamicin. Mediastinitis was excluded by chest CT scans that showed complete resolution of the former emphysema. Fifteen days later, the former tear presented on bronchoscopy as a fibrin-coated closed wound. In expectation of the need for prolonged mechanical ventilatory support, a surgical tracheostomy was performed. After 23 days of ICU stay the patient’s trachea was decannulated and she was discharged from the ICU. The further course was uneventful and a year later the girl showed no signs of tracheal stenosis.
Case 5
A 57-year-old male was admitted with CAP-evoked ARDS. After an apparently uneventful PDT with the Blue Rhino Set (Cook) on day 2 of mechanical ventilation he developed massive cutaneous emphysema. A translaryngeal fiberoptic tracheoscopy 2 hours later revealed a 2-cm tear ending 3 cm above the carina. The tracheostomy tube was placed directly below the defect and its cuff was inflated. This stopped air leakage immediately and the emphysema resolved gradually. Subsequently, the defect healed without further intervention. During healing the defect was coated with fibrin, which dissolved completely on day 28 after injury (Fig. 4). A small, inconspicuous scar could be identified. One day later the patient was discharged with the tracheal cannula in place.
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Discussion |
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TopAbstractIntroductionCase StudiesDiscussionReferences |
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Tracheal injuries, independent of their origin, are life-threatening incidents, and surgical repair has been recommended as the treatment of choice. However, there are no randomized trials to support this recommendation (6,7). Recommendation for surgical repair is based on the assumption that tracheal perforation otherwise results in mediastinitis or subsequent tracheal stenosis (6). Our case series contradicts this assumption, as our conservatively treated tracheal injuries all healed without these feared complications. Thus, our cases encourage consideration of conservative treatment in all tracheal injuries that can be bridged by an artificial airway. This is usually possible when the injury is localized in the upper or middle third of the trachea as a consequence of PDT, postintubation injury, or trauma.
Case 3 illustrates successful conservative management of postintubational tracheal injury using a tracheostomy tube advanced beyond the defect in a patient requiring long-term ventilatory support. Only a few case reports have described conservative treatment as an alternative to primary surgical repair (12,13), but many of those patients did not depend on mechanical ventilation (13). In a series of patients with postintubation tracheal trauma, 3 patients with smaller tears of approximately 1-cm length were treated conservatively, but the authors recommended surgical repair as the preferred treatment (14). In another series, only 5 of 13 patients survived surgery of iatrogenic tracheobronchial lesions despite apparently sufficient reconstruction (15). Against this background, a conservative trial for treatment of postintubation tracheal injuries seems to be justified.
Whereas traumatic and postintubational tracheal injuries are rare events, the popularity of PDT increases, and with it the number of tracheal wall perforations. With approximately 30,000 PDT procedures performed annually in Germany (16), posterior tracheal wall perforations are a typical complication (11), with an incidence varying from zero (10) to 12.5% (11). In a retrospective analysis, three of 134 patients (2.2%) with PDT had a tracheal perforation (17). Therefore, more than 600 patients experience this complication annually in Germany alone. However, there is uncertainty regarding appropriate treatment of these injuries because few reports describe their management and most recommend surgical repair (17,18).
Our cases show that conservative treatment of PDT-evoked tracheal lesions appeared to be safe and was not associated with mediastinitis or tracheal lumen obstruction. Furthermore, the cases provide additional insight into the mechanism of tracheal perforation during bronchoscopic-guided PDT. All cases occurred during loss of visualization during cannula placement. In case 1, a firm pretracheal fascia in combination with elastic tracheal and paratracheal tissues, as often observed in younger humans, required strong force causing compression of the trachea during the most important phase of PDT, i.e., tracheostomy tube insertion. In case 2, blood-covered optics precluded detection of the perforation, and in case 5 tracheal compression also resulted in transient loss of vision of the posterior tracheal wall. Thus, although bronchoscopic guidance increases safety in PDT (19), tracheal perforation may still occur with impaired visualization.
Unfortunately, there are no data to identify patients at increased risk of perforation during PDT. However, our impression is that in younger patients even low pressure can evoke complete compression of the tracheal lumen during PDT. Trottier et al. (11) identified an improperly stabilized guidewire and guiding catheter as a technical cause of perforation. Therefore, to detect PDT-evoked tracheal lesions immediately, routine direct visualization of the posterior tracheal wall should become mandatory once the tracheostomy tube is in place. For this purpose, the bronchoscope should be advanced translaryngeally to the carina next to the deflated cuff of the tracheostomy tube and retracted to the vocal cords while the mucosa is inspected for potential injuries. Postprocedural chest radiographs may help to detect air leakage into surrounding tissues after PDT but are regarded unnecessary in the absence of clinical deterioration or anticipation of complications (20).
With tracheal perforation, persistent air leakage from the trachea can cause pneumothorax, pneumomediastinum, and pneumopericardium, and hence the leakage must be stopped immediately. Therefore, management of suspected tracheal injury must include a procedure to localize the defect precisely and to plan further measures. The value of bronchoscopy in trauma patients is documented in case 3, where an unnecessary thoracotomy had been performed before a tracheobronchoscopy.
For lesions below or close to the tracheal carina and hemodynamic instability, emergency thoracotomy with surgical repair may be the treatment of choice. Persistent air leak despite positioning of the artificial airway just above the tracheal carina also limits a conservative approach, indicating a defect too close to the bifurcation for bridging. However, as long as the defect is localized in the trachea’s upper or middle third, conservative treatment by bridging the defect by the artificial airway can be performed quickly and conveys no additional surgical risk. This measure stops air leakage immediately and is a convenient starting point for further diagnostic and therapeutic interventions.
Every tracheal perforation should require an esophagoscopy (to exclude perforation) and, in doubtful situations, a chest CT scan. Perforations of the esophagus or other mediastinal organs should not be treated conservatively, and surgical repair, potentially combined with tracheal stenting, may offer an alternative (21). Once these complications are excluded, conservative treatment should be encouraged as long as air leakage is stopped and normal healing is documented by regular tracheobronchoscopy.
In tracheal injuries in the upper and middle third after trauma or traumatic intubation, bridging the defect with an endotracheal tube can easily be performed by advancing it just above the tracheal carina. This might not be as simple in tracheal injuries after PDT when fixed-length tracheal cannulae have been used. Fixed-length tracheostomy tubes are inappropriate under these circumstances because they may be too short for bridging the defect. Accordingly, tracheostomy tubes with an adjustable flange should always be preferred. Translaryngeal bronchoscopy with inspection of the defect should also be performed regularly to follow healing or, if necessary, to identify the need for surgical repair.
Surgical repair of tracheal injuries has a mortality as frequent as 42% in ventilator-dependent patients (22); this rate alone provides a rationale for considering alternative approaches to the management tracheal injuries.
The most interesting result in our study was that none of our patients acquired a mediastinitis and that all tracheal defects healed without stenosis. Although all injuries became fibrin-covered during the healing process, this was not accompanied by obstruction of the tracheal lumen in our cases and seems to reflect normal healing, as the formerly fibrin-covered defect disappeared in case 5 (Fig. 4). These results are encouraging because a nonsurgical approach has previously been suggested to evoke mediastinitis and tracheal stenosis (6). Although we cannot exclude that tracheal perforations prolonged the ICU stay of our patients, the absence of inflammation around the injury site makes this unlikely. Nevertheless, antibiotic therapy should always be considered in cases of tracheal perforation. A possible algorithm for dealing with injuries is presented in Figure 5.
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In conclusion, conservative treatment of tracheal injuries by bridging the defect with an artificial airway is a feasible treatment and an alternative to surgery in selected patients. All lesions in our case study healed without stenosis, signs of local inflammation, or mediastinitis. Regular bronchoscopy is important to assess localization and extent of the lesion and to monitor the progress of healing.
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References |
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