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Ann Thorac Surg 2004;77:406-409
© 2004 The Society of Thoracic Surgeons

Original article: general thoracic

Management of postintubation membranous tracheal rupture

Paolo Carbognani, MD, PhDa*, Antonio Bobbio, MDa, Leonardo Cattelani, MDa, Eveline Internullo, MDa, Domenico Caporale, MDa, Michele Rusca, MDa

a Department of Thoracic Surgery, University of Parma, Parma, Italy

Accepted for publication April 28, 2003.

* Address reprint requests to Dr Carbognani, Department of Thoracic Surgery, via Gramsci 14, 43100 Parma, Italy.
e-mail: paolo.carbognani{at}unipr.it


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: Postintubation tracheobronchial laceration is a rare complication of general anesthesia. A renewed interest in this disorder induced us to review our experience on its treatment, focusing on the evolution of the surgical approach, and describing a technical variation of the transcervical approach.

METHODS: From January 1994 to December 2002 we treated 13 patients with diagnosis of postintubation tracheobronchial laceration. The treatment was nonsurgical in 3 patients (1-cm-long tear) and surgical in the other cases. Two lesions extending to the main bronchi were repaired through a right thoracotomy as well as four lesions limited to the trachea observed before January 2001. After this date we used the transcervical approach for entirely intratracheal lesions: in three cases we performed an anterior transverse tracheotomy and in one case a transverse and midline vertical incision (T tracheotomy).

RESULTS: Both conservative and surgical therapy were successful in all the cases. Two patients in the thoracotomy group had a transient right vocal cord palsy. No morbidity was observed with the cervical approach. Normal healing of the sutures was evidenced by an endoscopic follow-up 30 days later.

CONCLUSIONS: In our experience nonsurgical treatment is advisable in small (length < 2 cm) uncomplicated tears. Concerning surgery, thoracotomy is indicated in tracheal lacerations extending to the main bronchi, whereas the transcervical approach is preferred for intratracheal tears because of its efficacy in reaching and suturing the lesions extending to the carina and for its limited invasiveness.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Postintubation tracheobronchial laceration is a rare but feared complication of general anesthesia. It would appear to be caused by an interlacing of mechanical, anatomic, and undefined individual factors [1]. Recent reports have shown a renewed interest in this disorder, with proposals of less invasive surgical treatment [2, 3] and criteria for conservative management [4, 5]. We have examined our experience in treating these lesions, focusing on the evolution of the surgical approach and describing a technical variation of the transcervical approach.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
From January 1994 to December 2002 we treated 13 patients, all women, with a mean age of 58 years (range, 52 to 69 years), with a diagnosis of postintubation tracheobronchial laceration. Of these, 7 were referred to us by other hospitals. All the patients had undergone elective surgery for various indications, which are reported in Table 1 together with all the data concerning intubation, anatomy of the lesions, and clinical features of the patients. Diagnosis delay, management, and morbidity are summarized in Table 2.


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  		Table 1. Anatomy and Clinical Features of Tracheal Tears

 

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  		Table 2. Management and Morbidity

 
In all the patients intubated with a single-lumen tube, the diagnosis was suggested by the appearance of symptoms such as dyspnea, subcutaneous emphysema, and hemoptysis. Chest roentgenogram and computed tomographic scan were performed, and revealed a pneumomediastinum in seven cases. In all the patients the tracheal tear was confirmed by bronchoscopy no later than 6 hours after the injury (Table 2). In the 3 patients intubated with a double-lumen tube, the tracheal laceration showed up during resective right lung surgery. The membranous part was the site of all the tears, the location and extension of which are shown in Table 1. In 3 patients the treatment was nonsurgical because they presented with small uncomplicated tears of 1 cm, together with stable vital signs without any progression of clinical symptoms during the hospital stay. The medical treatment was essentially based on a broad-spectrum antibiotic therapy. Ten patients underwent surgical treatment. The three lesions revealed during right lung resection were repaired through the thoracotomy: two of these extended to the main bronchi and one required an additional left lateral cervicotomy because of the involvement of the cervical trachea. Three lesions limited to the trachea but observed before January 2001 were approached through a right thoracotomy. After this date, the subsequent four tracheal lacerations were repaired through a transcervical transtracheal approach. In three cases an anterior transversal tracheal incision was performed to reach the membranous part. In one case, to suture a 5-cm-long tear extending to 1 cm above the carina, a transversal and a midline vertical incision (T tracheal incision) were made (Fig 1). In the cervical approach, the bronchoscope guided the site of tracheal incision; ventilation was secured by an endotracheal tube (5.5 mm inner diameter) inserted through the surgical field. To better expose the tracheal tear and to facilitate suturing, the endotracheal tube was withdrawn several times under the control of the anesthesiologist, who monitored the vital signs during the apneic state. The membranous lacerations were repaired with 4-0 polydioxanone running suture using a thoracoscopic needle-holder, and the anterior tracheotomies, transversal and vertical, with 3-0 polydioxanone interrupted sutures. All the patients treated surgically underwent the procedure no later than 6 hours after the injury and were extubated in the operating room.



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  		Fig 1. Intraoperative view of the T-tracheal incision: vertical tracheotomy (a), transversal tracheotomy (b), and sutured tear of the membranous part (c).

 

   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
In our series all the patients were short women, and this is a recognized risk factor for tracheobronchial laceration. A difficult intubation was scheduled by the anesthesiologists for 6 patients. No particular difficulties were reported in any of the other cases. All the nonsurgically treated patients had an uneventful hospital course with no need for intubation, and were discharged after 5 days. Eight of the 10 patients treated surgically had an uneventful postoperative course. The remaining 2 patients, treated during a right lung resection through a thoracotomy, with the addition of a left cervicotomy in one case, had a transient right vocal cord palsy. This complication could have been caused by the effect of the heat spread by a monopolar electrocautery and by inappropriate traction during the dissection of the upper membranous part of the intrathoracic trachea. Concerning postoperative management, no intubation or bronchoscopy was necessary. The mean postoperative hospital stay was 7.1 days (range, 6 to 10 days) for thoracotomies and 4.7 days (range, 4 to 6 days) for cervicotomies. The intraoperative airway control was more easily achieved in the cervical approach, by a small single-lumen tube inserted through the surgical field, as opposed to the thoracotomy approach, in which the tracheal cuff of the double-lumen tube can hamper the suturing of the tear. Endoscopic follow-up after 30 days showed a normal healing of the lacerations in all cases, with no evidence of tracheal or bronchial stenosis.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Tracheobronchial lacerations rarely complicate the surgical procedures in general anesthesia. Our experience is similar to those reported by other centers concerning the patients (short women), the type of intubation (with single-lumen or double-lumen tube), and the site of the tear (the pars membranacea) [1, 2, 5, 6]. Mechanical factors, such as repeated attempts at intubation [4] or the overdistention or rupture of the cuff [1], and anatomic abnormalities of the trachea [7], are considered as being the main causes of this complication, although it can be difficult to make out a laceration that happens after an intubation without difficulties. Except for the case of intraoperative evidence, the appearance of symptoms such as head and neck emphysema, hemoptysis, and dyspnea should raise the suspicion of tracheobronchial laceration.

Tracheobronchoscopy is the mandatory investigation to establish the diagnosis and to identify the anatomy to choose the appropriate treatment and approach. Our experience confirms this statement, as no discrepancies were observed between the length of tracheal tear measured by the preoperative bronchoscopy and the intraoperative findings. Nonsurgical therapy must be considered in small (length < 2 cm) uncomplicated tears in stable patients, because under these conditions healing can be achieved with minimal risks and discomfort for the patient [4, 5]. Surgery is nevertheless the treatment of choice for the great majority of patients, although it should be performed promptly to guarantee success, and to avoid a feared complication, that of descendent mediastinitis [1, 2]. We can distinguish between a traditional surgical approach performed through a right thoracotomy and a more recent transcervical approach proposed in 1995 by Angelillo-Mackinlay [8]. Each approach has its own indication. The so-called traditional approach is suggested when the tracheal laceration is extended to the membranous part of the main bronchi. The cervical approach is used for postintubation lesions limited to the trachea. Mussi and associates [2] and Lancelin and colleagues [3] have popularized and modified this procedure, which we have recently adopted. In three cases we used the transverse anterior tracheotomy and in one case, in which the laceration reached the carina, we proved that the suture can be made easily if the anterior transverse tracheotomy is completed with a longitudinal one to make a T tracheal incision. The use of a thoracoscopic needle-holder can be helpful in performing the distal part of the suture in the narrow endotracheal space.

In this approach, we suggest that the trachea should be entered first through the anterior transverse tracheotomy, which enables direct evaluation of the tear; the longitudinal tracheotomy should be added only in selected cases, if the lesion reaches the carina. Considering the vascular support of the trachea, we do not think that the T-shaped tracheotomy adds further risks to the normal healing of the sutured incisions.

We can conclude that, except for selected cases in which nonsurgical therapy is indicated, surgery is the treatment of choice in the vast majority of postintubation tracheal injuries. Although thoracotomy still has its own indications, the transcervical approach should be the procedure of choice in postintubation lesions limited to the trachea because of its low invasiveness, which avoids the morbidity caused by thoracotomy, and to the lateral dissection of the trachea.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Massard G., Rougé C., Dabbagh A., et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483-1487.[Abstract/Free Full Text]
  2. Mussi A., Ambrogi M.C., Menconi G., Ribechini A., Angeletti C.A. Surgical approaches to membranous tracheal wall lacerations. J Thorac Cardiovasc Surg 2000;120:115-118.[Abstract/Free Full Text]
  3. Lancelin C., Chapelier A.R., Fadel E., Macchiarini P., Dartevelle P.G. Transcervical-transtracheal endoluminal repair of membranous tracheal disruption. Ann Thorac Surg 2000;70:984-986.[Abstract/Free Full Text]
  4. Ross H.M., Grant F.J., Wilson R.S., Burt M.E. Nonoperative management of tracheal laceration during endotracheal intubation. Ann Thorac Surg 1997;63:240-242.[Abstract/Free Full Text]
  5. Jougon J., Ballester M., Choukroun E., Dubrez J., Reboul G., Velly J.F. Conservative treatment for postintubation tracheobronchial rupture. Ann Thorac Surg 2000;69:216-220.[Abstract/Free Full Text]
  6. Borasio P., Ardissone F., Chiampo G. Postintubation tracheal rupture. A report on ten cases. Eur J Cardiothorac Surg 1997;12:98-100.[Abstract]
  7. Thompson D.S., Read R.C. Rupture of the trachea following endotracheal intubation. JAMA 1968;204:995-997.[Medline]
  8. Angelillo-Mackinley T. Transcervical repair of distal membranous tracheal lacerations. Ann Thorac Surg 1995;59:531-532.[Abstract/Free Full Text]



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