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Departments of *Surgery and Anesthesiology, Stony Brook University Hospital, Stony Brook, New York
Address correspondence to Elliott H. Chen, MD, HSC 19-067, Stony Brook University Hospital Department of Surgery, Stony Brook, NY 11794-8191. Address e-mail to elliottchen{at}hotmail.com Address reprint requests to Thomas Bilfinger, MD, HSC 19-080, Stony Brook University Hospital Department of Surgery, Stony Brook, NY 11794-8191. A list of references containing all 56 case reports mentioned in the Discussion is available upon request.
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Abstract |
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Introduction |
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In the past, operative management of such injuries was the norm; but in the recent literature, nonoperative management in certain cases has been advocated with excellent clinical outcomes (1,3–6). Statistically, women are more predisposed to this than men. Further risk factors include poor medical condition, short stature, and the use of corticosteroids (7). Unfortunately, the presence or absence of these conditions is rarely addressed in the literature.
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Case Report |
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The patient received multiple chest tubes and was taken to the medical intensive care unit. An air leak, however, continued to be present. Widespread subcutaneous emphysema was evident on physical examination. A bronchoscopy was performed, revealing a V-shaped tear of the membranous portion of the trachea at 1.5 cm proximal to the carina. A computed topography scan confirmed this finding and also revealed a moderate amount of mediastinal fluid.
As the patient had unresolving subcutaneous air, an increased white blood cell count creating a possibility of mediastinitis, and continued ventilator dependence, a decision was made with the family to take the patient to the operating room for exploration and repair.
The trachea was approached through a right thoracotomy. No inflammatory tissues or purulence were noted. The injury was closed using interrupted buttressed sutures; a mediastinal pleural flap was raised to cover the suture line. A tracheostomy was performed for anastomotic protection. Postoperatively, the patient’s respiratory status improved. She was weaned off the ventilator over the next 14 days.
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Discussion |
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In our review of 56 previously reported cases, many factors were found on a consistent basis. For one, 85.7% (48 of 56) patients were female. Sixty-six percent (37 of 56) of these patients were also older than 50 years. The location of these injuries has also been consistent. The membranous portion of the trachea was the site of injury in 98.2% (55 of 56) of the cases with involvement of the carina in 78.6% (44 of 56) of the time.
There are multiple factors leading to this injury. Operator errors (multiple attempts, inexperienced physicians), equipment selection (inappropriate use of stylets, cuff overinflation, malposition of the tube, improper tube size), patient actions (abrupt movements, excessive coughing), and anatomic factors (steroid-weakened membranes, chronic obstructive pulmonary disease, tracheomalacia) all contribute to this problem (7,9–13).
What has not been studied, however, is the preponderance of female patients. Perhaps predilection toward female patients is a result of equipment selection. Women tend to be shorter, and improperly large tubes might often be selected for them. Furthermore, female tracheal diameters might be smaller in diameter than men, making them vulnerable to cuff overinflation. Other contributing factors that are not reported are degree of illness, presence of kyphosis, and the use of nitrous oxide.
In our review of the literature, questions that have been addressed lie mainly in the location of the laceration, efficacy of repair techniques, and selection of operative versus nonoperative management. The underlying causes of the process, however, are not routinely reported. Although we were able to pinpoint some definite patterns in this patient population, the lack of uniform reporting makes conclusions difficult (Table 1).
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This article has been cited by other articles:
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  N. Barbetakis, G. Samanidis, D. Paliouras, and C. Tsilikas Tracheal laceration following double-lumen intubation during Ivor Lewis esophagogastrectomy Interactive CardioVascular and Thoracic Surgery, October 1, 2008; 7(5): 866 - 868. [Abstract] [Full Text] [PDF]
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 A. C. Yopp, J. G. Eckstein, R. H. Savel, and S. Abrol Tracheal Stenting of Iatrogenic Tracheal Injury: A Novel Management Approach Ann. Thorac. Surg., May 1, 2007; 83(5): 1897 - 1899. [Abstract] [Full Text] [PDF]
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 P. Saravanan, C. Marnane, and E. A.J. Morris Extubation of the surgically resected airway - a role for remifentanil and propofol infusions: [Extubation de voies aeriennes resequees chirurgicalement - un role pour les perfusions de remifentanil et de propofol]. Can J Anesth, May 1, 2006; 53(5): 507 - 511. [Abstract] [Full Text] [PDF]
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A. D. L. Sihoe, K. M. Ho, T. S. Sze, T. W. Lee, and A. P. C. Yim Selective lobar collapse for video-assisted thoracic surgery Ann. Thorac. Surg., January 1, 2004; 77(1): 278 - 283. [Abstract] [Full Text] [PDF]
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 T. T. V. Pechet, L. Bogar, and Z. Grunwald Anesthetic Considerations for Thoracic Trauma Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2002; 6(2): 95 - 103. [Abstract] [PDF]
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