Ann Thorac Surg 2005;79:1872-1878
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Successful Conservative Management in Iatrogenic Tracheobronchial Injury
Abel Gómez-Caro Andrés, MDa,*,
Francisco Javier Moradiellos Díez, MDa,
Pilar Ausín Herrero, MDb,
Vicente Díaz-Hellín Gude, MDa,
Emilio Larrú Cabrero, MD, PhDa,
Eduardo de Miguel Porch, MDb,
José Luis Martín De Nicolás, MDa
a Department of Thoracic Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain
b Department of Pneumology, Hospital Universitario 12 de Octubre, Madrid, Spain
Accepted for publication October 4, 2004.
* Address reprint requests to Dr Gómez-Caro, Department of Thoracic Surgery, Hospital Universitario 12 de Octubre, Crta. Andalucía KM 5.400, Madrid, Spain (E-mail: abelitov{at}yahoo.es).
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Abstract
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BACKGROUND: The aim of this study was to describe and to assess the effectiveness of conservative treatment as the chosen treatment for managing iatrogenic tracheobronchial injuries (ITBI).
METHODS: Between January 1993 and December 2003, 33 tracheobronchial injuries were treated in our hospital. Eighteen (54.5%) were ITBI and 15 (45.5%) were traumatic noniatrogenic injuries. Of the ITBI patients, sex distribution was 15 (83%) females and 3 (17%) males with a mean age of 57.7 ± 20.7 years (range, 17 to 88 years). Fifteen (83.3%) of the injuries were caused by orotracheal intubation and 3 (15.7%) by tracheotomy. The average diagnostic delay was 25.7 ± 22.9 hours. The mean injury size was 2.83 ± 1.02 cm (range, 1 to 4 cm). Nine (50%) injuries were located in the cervical trachea, 6 (33.3%) in the thoracic trachea, and 3 (16%) involved both trachea and main bronchi. Conservative treatment was chosen for 17 (94.4%) of the 18 cases. We performed surgical repair in only 1 case owing to progressive subcutaneous emphysema and increasing difficulty with mechanical ventilation.
RESULTS: No complications arose from the use of conservative treatment. Four patients (22%) died in our hospital, 3 of these of non-ITBI-related causes. Mortality was not related to four variables: sex, diagnostic delay, location, or size of the ITBI. Fourteen of the 18 patients (77.7%) were discharged uneventfully, and the endoscopic and clinical follow-up examinations were satisfactory in all patients.
CONCLUSIONS: Conservative treatment for ITBI is effective regardless of production, size, or site of the injuries. Surgical treatment is advisable in specific cases: rapid progression of subcutaneous and mediastinal emphysema, mediastinitis, and difficulty with mechanical ventilation.
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Introduction
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Although iatrogenic tracheobronchial injuries (ITBI) are generally rare, such injuries are one of the most common causes of airway injury and are also a feared complication of general anesthesia. The incidence of ITBI is approximately 1 of every 20,000 orotracheal intubations. Postmortem findings have indicated an incidence of 15% after emergency intubations [1]. The incidence of ITBI in double-lumen intubation is less than 1%, significantly higher than that of single-lumen intubation [2]. A surgical approach has traditionally been the most widely accepted treatment [3, 4]. Recently, a few conservative treatment series have been reported [5]. However, the percentage of conservatively treated patients has never exceeded 50% in the reported series [6]. The aim of this study is to assess the results of a conservative approach as the chosen treatment for selected ITBI cases independent of location or size of injury, or diagnostic delay.
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Material and Methods
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Between January 1993 and December 2003, 33 tracheobronchial injuries were diagnosed in our department. A retrospective review of the clinical records was carried out during this period. Eighteen (54.5%) were iatrogenic injuries and 15 (45.5%) were traumatic non-iatrogenic. Among the ITBI cases, 15 (83.3%) were women and 3 (17%) were men, with a mean age of 57.7 ± 20.7 years (range, 17 to 88 years). Diagnostic delay was defined as time between iatrogenic intubation and bronchoscopic confirmation of ITBI. The time of this delay was 25.7 ± 22.9 hours (range, 3 to 72 hours). Diagnosis was carried out by bronchoscopy in all cases. A computed tomographic scan of the chest was taken in all patients to detect mediastinal fluid collections and quick progression of mediastinal emphysema. Blood and serum analyses were performed daily to assess the patients’ clinical situation and progress. The reasons for carrying out intubation and intubation type are listed in Table 1. The mean size of injury measured by bronchoscopic vision was 2.83 ± 1.02 cm (range, 1 to 4 cm). The injury was located in the cervical trachea in 9 (50%) of the cases, the thoracic trachea in 5 (27.7%) of the cases, the trachea and main bronchi in 3 (16.6%) of the cases, and the tracheal carina in 1 (5.5%) of the cases. In all the patients there were one or more of the classic signs and symptoms such as subcutaneous emphysema, mediastinal emphysema, pneumothorax, hemoptysis, dyspnea, or difficulty with mechanical ventilation.
Conservative management was the chosen treatment in all cases, independent of the injury size and location, diagnostic delay, or cause. Therefore, with early diagnosis, ITBI that were large in size or found in certain sites, or any other local circumstances, were not considered sufficient grounds for surgical treatment. Mechanical ventilation before diagnosis did not exclude patients from conservative treatment. Most of these injuries occurred during intubation for scheduled surgery, meaning that the extubation happened soon in 11 patients (61%). Only 4 patients were receiving mechanical ventilation when diagnosed with ITBI. Tracheoesophageal injuries were not treated conservatively as they were considered to be a completely different type of injury and were excluded from this study. All patients received broad-spectrum antibiotics and were carefully monitored for signs of air leaks in our unit or in the intensive care unit. Orotracheal intubation was avoided when possible and was never used as a treatment for ITBI in our series. Surgery should be performed in cases with progressive subcutaneous or mediastinal emphysema, severe dyspnea requiring intubation, difficulty with mechanical ventilation, pneumothorax with an air leak through the chest drains, or mediastinitis. Endoscopic examinations were performed between the first and second weeks after diagnosis for visual evaluation of the ITBI healing process. Follow-up was performed in months 1 and 3, and then yearly for the following 5 years after hospital discharge if no other incidences were detected. Statistical analyses were carried out with the computer program package SPSS v.11 (SPSS, Inc, Chicago, IL). Qualitative variables were compared with the 
2 statistical test or Fisher’s exact test where appropriate, with a significance level of p less than 0.05.
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Results
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Conservative management was effective in all 17 of the patients in which this was the chosen approach. Three patients died of non-ITBI-related causes (Table 2). Mortality was not significantly associated with sex, diagnostic delay, or size or site of the injury (p > 0.05). Endoscopic findings were described in Table 1. The ITBI in patient 18 occurred after double-lumen intubation and remained undetected throughout a right upper lobectomy. This injury was later detected during bronchoscopy performed for asymptomatic atelectasis after sputum retention. The patient responded well to conservative treatment. Only one case of ITBI occurred after emergency intubation (Figs 1, 2). Surgery was performed as the initial treatment for patient 6 because of the rapid progression of mediastinal and subcutaneous emphysema, in turn leading to dyspnea and intubation. A cervical approach with plastic tracheal suture and a tracheostomy were performed in a one-stage operation. This particular patient died because of suture dehiscence, mediastinitis, and multiorgan failure. Patient 5 was intubated after a suicide attempt that caused colon perforation and peritonitis followed by multiorgan failure after abdominal surgery. No ventilation problems were reported in this case, but this patient eventually died because of old age and injury-related causes. Patients 9 and 11 died of pneumonia associated with mechanical ventilation and sepsis. These patients needed orotracheal intubation or tracheostomy for sepsis (peritonitis and nosocomial pneumonia), and tracheal injury occurred during this procedure. No radiologic evidence of mediastinitis in thoracic computed tomographic scan or progressive ITBI signs and symptoms were noted in the following days. Bronchoscopic examinations of patients 9 and 11 showed marked improvement or even complete healing of the ITBI days after first exploration. However, these were older patients with many comorbidities and with life-threatening disease. The mean follow-up time for discharged patients was 52.7 ± 36 months (range, 6 to 120 months) with a scheduled follow-up period of 60 months if no pathologic endoscopic findings were observed. Evidence of tracheostomy-related granulomas was found in 2 patients, who were subsequently treated with a laser. Asymptomatic stenosis of the right main bronchus was noted in 1 patient. Follow-up lasted for a longer period, and at 120 months this patient remained asymptomatic.
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Fig 1. Chest roentgenogram of patient with iatrogenic tracheobronchial injury. We observed a large subcutaneous and mediastinal emphysema.
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Comment
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Iatrogenic tracheobronchial injuries are life-threatening complications, and the incidence of such injuries is increasing in hospital and extrahospital environments [7]. Known risk factors for ITBI include female sex and the increasing age of the patients undergoing surgery [8]. The high number of ITBI cases reported in our hospital during such a short time may be related to the fact that ours is a reference center for general thoracic surgery and interventional bronchoscopy where cases from all over the country are treated.
Several other risk factors for iatrogenic airway injuries have been reported in the literature, such as emergency intubation, inadequate orotracheal tube diameter, inappropriate use of stylets, balloon overinflation damaging the tracheal mucosa, and others [3, 8]. We suggest that an injury directly caused by the orotracheal tube usually occurs in the membranous cervicothoracic wall, whereas injuries caused by high pressure or volume ventilation, or sudden movements of the orotracheal tube because of coughing or neck movements, occur in the membranous and cartilaginous portions of tracheal bifurcation and tracheobronchial region [6]. Direct injuries usually consist of small tears and are more frequent after difficult intubation or in older patients (Fig 3) [8]. In our opinion, the appearance of distal injuries in the main bronchi caused by a single-lumen tube could be related to an overinflation of the airway during intubation and is not related to direct injuries as in the case of cervical tears. In our series the minimum delay between diagnosis and procedure means that it is improbable for there to be another mechanism that is not a direct injury in patients with tracheostomy.
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Fig 3. Thoracic computed tomographic scan of a 19-year-old woman with postintubation tracheal injury that was medically treated. Deep cervical emphysema can be observed.
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Iatrogenic tracheobronchial injuries as a result of double-lumen intubation could be more related to excessive tube size [8, 9]. In our series, intubation or airway procedures were performed in all but one case and were not rated as difficult by the anesthesiologist in any case.
Iatrogenic airway injuries are more common in women [2, 3, 6], probably because of oversizing of the tracheal tube and of the shorter average tracheal length in women.
The most common sign observed in our series was subcutaneous emphysema. However, this symptom was only detected intraoperatively in 2 (11.1%) patients. Initial signs that were less frequently noted were radiologic mediastinal emphysema and hemoptysis. The diagnostic delay in our series is related to the fact that many patients (n = 6) were transferred to our center from other hospitals with diagnoses yet unconfirmed. Nevertheless, this delay period was similar to those of other published series [6, 8, 9].
Surgical management has been accepted as the classic therapeutic approach for ITBI [3, 4, 9, 10]. However, published cases [11, 12] and series [5, 6, 13] have also described the conservative management of such injuries (Table 3). Nevertheless, conservative management has usually been limited to small tears, less than 2 cm in length, in the membranous trachea [5] or in patients with a delayed diagnosis or unstable clinical situation. Jougon and colleagues [6] reported a series in which conservative treatment was the chosen treatment in 50% of the cases. The decision to use conservative management has been based on the following criteria: injuries with a length equal to or less than 4 cm, significant diagnostic delay, and integrity of the tracheobronchial junction [14].
In our series we propose the following criteria to be used as guidelines for nonoperative management of intubation-related injuries: vital sign stability, no evidence of esophageal injury, no evidence of difficulty with mechanical ventilation if intubation is needed, no development of subcutaneous or mediastinal emphysema, and no signs of sepsis related to ITBI [11].
The diagnosis should be made as early as possible [15], preferably in the first 12 hours. In our series, only 36% of patients were diagnosed within this time. Even in these cases initial surgical treatment was not advised, and no increase in mortality or morbidity was observed.
Injury size was not a determining factor when choosing the optimal treatment for our patients, although no injury longer than 4 cm was observed in our series. Contrary to other authors, we do not believe that injury size alone provides sufficient grounds for surgery as the immediate treatment. However, in injuries larger than 4 cm, we think that conservative treatment is risky for the patient [3, 6, 8, 10, 14, 16]. The decision to operate was made if massive subcutaneous emphysema, progressive mediastinal emphysema, tension pneumothorax, an air leak through the chest drain, or mediastinitis developed in the patient. Direct visualization of the intact esophageal wall through the tracheal injury does not warrant surgical repair in itself. Intubation, as well as tracheostomy, should be avoided if possible for patients recommended for conservative management [6]. On the other hand, we know of other opinions that propose distal intubation beneath the injury as a conservative treatment in seriously compromised patients [17]; however, we prefer early extubation if this is possible.
Posttracheostomy iatrogenic injuries are detected later, usually after encountering problems with mechanical ventilation, with aspiration of secretions, and with frequently associated tracheoesophageal fistulas. Posterior tracheal wall injuries are much more likely to occur among those injuries caused by percutaneous procedures [3, 18].
Broad-spectrum antibiotics covering the mixed bacterial populations of the tracheobronchial tree should be applied for at least 1 week [6, 11].
Long-term complications are rarely detected in endoscopic follow-up of medically [2, 6, 13] and surgically [19, 20] treated patients.
In conclusion, treatment of ITBI should be carefully assessed, but we believe conservative management is recommended, particularly for ITBI patients with no associated esophageal injuries, no rapidly progressive subcutaneous or mediastinal emphysema, and no mediastinitis. If these guidelines are carefully followed, the conservative approach will have a good outcome, regardless of size, location, or diagnostic delay of the injury.
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Fig 2. Thoracic computed tomographic scan from patient with iatrogenic tracheobronchial injury in a emergency intubation in a suicide attempt. A large mediastinal emphysema without intrathoracic collection was detected. The iatrogenic tracheobronchial injury was medically treated.
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Acknowledgments
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We are indebted to Pedro A. Anton, MD, of Sant Creu and Sant Pau Pneumology Department for his help in the preparation and correction of this original article.
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Abstract
Introduction
