Tracheobronchial lacerations after intubation and tracheostomy

[Tracheobronchial Injuries]

Tracheobronchial injury is a rare, but potentially life-threatening condition. These injuries are associated with high morbidity and mortality, which is ascribed to underlying diseases and additional injuries. Lacerations of the airway are differentiated into iatrogenic and non-iatrogenic injuries, while the group of non-iatrogenic lesions are grouped into blunt and penetrating traumas.The exact incidence of tracheobronchial injury is unknown, because many iatrogenic injuries occur without symptoms and most patients after traumatic laceration die before inpatient treatment. All patients with suspicion of airway injury require fast and accurate management.Common signs and symptoms are dyspnoea, haemoptysis, stridor and subcutaneous emphysema.Bronchoscopy is the most important tool for diagnosis and in several cases also for initial treatment.Further management depends on the patient's clinical condition and findings of bronchoscopy and computed tomography. Surgery has been the cornerstone of therapy, but in selected patients bronchoscopic stent implantation or conservative management must be discussed.

Post-intubation iatrogenic tracheobronchial injuries: The state of art

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

Significance of the evaluation of tracheal length using a three-dimensional imaging workstation

BACKGROUND

Limited information is available on the total tracheal length and its other characteristics for tracheal surgery. This study aimed to investigate the reference value of tracheal length and assess its relationship with physiological variables.

METHODS

We measured the tracheal length of 215 patients (107 men and 108 women) who underwent contrast-enhanced computed tomography before thoracic surgery using a three-dimensional imaging workstation. Pearson correlation analysis and multiple linear regression analysis were performed to investigate the relationship between the total tracheal length (cervical and thoracic) and common physiological parameters.

RESULTS

The mean total tracheal length was 11.5±1 cm (range, 8.8-14.4 cm); 8% of the patients had a total tracheal length <10 cm. The cervical trachea was significantly shorter in men than in women (2.9±1.3 vs. 3.8±1.3 cm, P<0.001), whereas the thoracic trachea was significantly longer in men than in women (8.9±1.1 vs. 7.4±1.1 cm, P<0.001). Correlation analysis showed that the total tracheal length was positively associated with height in both sexes, while the height was positively associated with only cervical tracheal length. In the multiple linear regression analysis, the total tracheal length was influenced most by height, while cervical and thoracic tracheal lengths were influenced most by sex. Older age was also an independent contributor to a shorter cervical trachea and longer thoracic trachea in both sexes.

CONCLUSIONS

The total tracheal length ranged from short to long in individuals, and characteristics of tracheal length varied with height, age, sex, and part of the trachea. We should thus be aware of the tracheal length of each patient for appropriate tracheal management.

Multidisciplinary management of tracheobronchial injury

Tracheobronchial injury is a heterogeneous entity comprising multiple rare and potentially life-threatening scenarios. We performed a systematic literature review focusing on post-intubation tracheal injuries (PiTIs) and post-traumatic tracheobronchial injuries (PTTBIs).PiTIs are often longitudinal lacerations of the middle third of the membranous trachea. Subcutaneous emphysema of the face and trunk following tracheal intubation should immediately trigger the diagnosis. Diagnosis may be suspected on the chest computed tomography (CT) and should be confirmed by bronchoscopic examination. Conservative management is encouraged for a spontaneously breathing or stable patient on noninvasive ventilation. Surgical repair is mandatory when mechanical ventilation is required and if bridging of the injury is impossible.PTTBIs are often associated with other severe injuries. Patients often present with massive subcutaneous emphysema and intractable pneumothorax. Diagnosis may be suspected on the chest CT and should be confirmed by bronchoscopic examination. Early surgical repair is indicated. In selected patients, conservative management can be considered.

Cervical Repair of Iatrogenic Tracheobronchial Injury by Tracheal T-Incision

BACKGROUND

Tracheobronchial injury is a rare but potentially life-threatening condition. Various surgical treatment options have been described for symptomatic patients with full-thickness injury. However, studies comprising a meaningful number of patients are sparse.

METHODS

We retrospectively analyzed all patients who received surgical repair of tracheobronchial injury between January 1999 and May 2021 at the Department of Thoracic Surgery, Medical University of Vienna. Patient characteristics, surgical variables, postoperative morbidity, and mortality were retrieved and analyzed.

RESULTS

Fifty patients with a median age of 68 years (range, 17-88) were included in the analysis. The etiologies of the iatrogenic tracheobronchial injuries were emergency intubation (48%), elective percutaneous dilatation tracheostomy (38%), or elective intubation (14%). The most common location of tracheobronchial injuries was distal third (28%) with a median length of 50 mm (range, 20-100 mm). The surgical approach was cervicotomy in 52%, thoracotomy in 38%, sternotomy in 2%, and combined approaches in 8% of cases. Moreover, intraoperative venovenous (n = 4) or venoarterial (n = 2) extracorporeal membrane oxygenation support was required in 12% of cases. Procedure-related mortality was 0%. However, as patients with tracheobronchial injury usually have severe comorbidities, the rate of patients discharged alive from the intensive care unit was only 66%. The median follow-up period of discharged patients was 5.5 months (range, 0.7-209). Airway stenosis or dehiscence was not observed in any patient.

CONCLUSIONS

Surgical repair of tracheobronchial injuries can be performed safely with a low procedure-related morbidity. If possible, the less-invasive cervical access should be preferred for patients with tracheobronchial injury, even for injuries extending to the main bronchi.

Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication

Background

Lung separation may be achieved through the use of double lumen tubes or endobronchial blockers. The use of lung separation techniques carries the risk of airway injuries which range from minor complications like postoperative hoarseness and sore throat to rare and potentially devastating tracheobronchial mucosal injuries like bronchus perforation or rupture. With few case reports to date, bronchial rupture with the use of endobronchial blockers is indeed an overlooked complication.

Case presentation

A 78-year-old male patient with a left upper lobe lung adenocarcinoma underwent a left upper lobectomy with a Fuji Uniblocker® as the lung separation device. Despite an atraumatic insertion and endobronchial blocker balloon volume within manufacturer specifications, an intraoperative air leak developed, and the patient was found to have sustained a left mainstem bronchus rupture which was successfully repaired and the patient extubated uneventfully. Unfortunately, the patient passed on in-hospital from sepsis and other complications.

Conclusion

Bronchial rupture is a serious complication of endobronchial blocker use that can carry significant morbidity, and due care should be exercised in its use and placement. Bronchoscopy should be used during insertion, and the volume and pressure of the balloon kept to the minimum required to prevent air leak. Bronchial injury should be considered as a differential in the presence of an unexplained air leak.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01430-6.

Balloon tracheoplasty for tracheal stenosis after prolonged intubation: a simple procedure, but is it effective?

Background

Tracheal stenosis following prolonged intubation is a relatively rare but serious problem. This condition is usually managed by surgical or endoscopic interventions. Bronchoscopic balloon dilatation for tracheal stenosis is considered a valuable tool used for the management of tracheal stenosis. In this article, we try to evaluate the role of balloon tracheoplasty in the management of tracheal stenosis and to assess the number of dilatation sessions usually needed as well as the short to midterm outcome.

Results

This study involved 40 patients with tracheal stenosis diagnosed by computed tomography (neck and chest) and bronchoscopy at the Security Force Hospital in Riyadh, KSA, between January 2013 and August 2018. Patients’ data were retrospectively reviewed and analyzed. Patients’ age ranged between 18 and 60 years. Thirty patients were males (75%); those patients underwent balloon tracheoplasty via dilatation of areas of narrowing using catheter balloon insufflation guided by fiber-optic bronchoscope. Ninety-five percent of the patients had initial success with acceptable dilatation of the stenotic area and improvement of the symptoms. There were no technical or major problems which resulted from the procedure, and no patient complained of severe pain or severe discomfort after the procedure. From the total of 81 BBD sessions, no in-hospital mortality is related to the procedure itself, and ICU stay ranged between 1 and 5 days post-procedure. Among those 40 patients, 16 patients (40%) needed one session, 10 patients (25%) needed two sessions, 8 patients (20%) needed three sessions, and 6 patients (15%) needed more than three sessions of balloon dilatation.

Conclusion

Balloon tracheoplasty is a simple, safe method and could be a promising and effective approach that offers immediate symptomatic relief for tracheal stenosis in cases with a history of prolonged intubation. It is worth mentioning that BBD is considered as a temporary measure, and most of the cases will need definitive or additional treatment either resection or stent placement.

[Long-term postoperative outcomes in patients with cicatricial tracheal stenosis depending on surgical approach]

OBJECTIVE

To analyze the long-term postoperative outcomes in patients with cicatricial tracheal stenosis and to determine the indications for various surgical strategies.

MATERIAL AND METHODS

There were 976 patients with benign cicatricial tracheal stenosis for the period 2001-2017. Tracheal stenosis occurred after mechanical ventilation and tracheostomy in 910 (93.2%) patients. Other causes were neck trauma, burns, previous surgery or tuberculosis. Idiopathic stenosis was observed in 41 (4.2%) patients. Multiple-stage reconstructive treatment was possible due to benign nature of disease. There were 2.4 operations per a patient, and 976 patients underwent 2327 procedures. Circular tracheal resection was preferred (n=396).

RESULTS

Surgical complications occurred in 107 (4.6%) cases, mortality rate - 0.3%. In long-term period, 42 patients died for various causes. In most cases (n=34, 80.9%), mortality was associated with concomitant diseases or consequences of trauma rather cicatricial tracheal stenosis or its treatment. Eight patients died from cicatricial tracheal stenosis or its treatment (7 patients after staged repair, 1 after circular tracheal resection). Four patients died due to asphyxia following T-tube obturation with a tracheobronchial secret or unjustified decannulation. For various reasons, 41 (6.2%) patients continued their treatment in other hospitals (4 patients died). Mortality rate in this group was 9.8%. Favorable long-term outcome was observed in 90.1% of patients, good and unsatisfactory results - in 7.2% and 1.8% of patients, respectively. Circular tracheal resection ensured better functional outcome.

CONCLUSION

Surgical treatment of cicatricial tracheal stenosis is associated with low incidence of postoperative complications and mortality. However, further improvement in long-term results is associated with advanced rehabilitation programs for concomitant diseases. Treatment of cicatricial tracheal stenosis should be carried out at specialized hospitals.

Evaluation of transmitted glow point at a priori chosen depth (1 cm below vocal cords) for lightwand intubation: a prospective observational study

Objective

When performing lightwand intubation, an improper transmitted glow position before tube advancement can cause intubation failure or laryngeal injury. This study was performed to explore the transmitted glow point corresponding to a priori chosen depth for lightwand intubation.

Methods

Before lightwand intubation, we marked the transmitted glow point from a bronchoscope on the neck when it reached 1 cm below the vocal cords. Lightwand intubation was then performed using this marking point. The distances from the mark to the upper border of the thyroid cartilage, upper border of the cricoid cartilage, and suprasternal notch were measured.

Results

In total, 107 patients were enrolled. The success rate of lightwand intubation using the mark was 93.5% (95% confidence interval, 88.7%–99.2%) at the first attempt. The marking point was placed 12.0 mm (95% confidence interval, 10.6–13.4 mm) below the upper border of the cricoid cartilage.

Conclusion

Anaesthesiologists should be aware of the appropriate point of the transmitted glow on the patient’s neck when performing lightwand intubation. We suggest that this point is approximately 1 cm below the upper border of the cricoid cartilage.

Trial registration: ClinicalTrials.gov NCT03480035

Airway Rupture Caused by Double-Lumen Tubes: A Review of 187 Cases

The double-lumen tubes (DLTs) are the most widely used devices to provide perioperative lung isolation. Airway rupture is a rare but life-threatening complication of DLTs. The primary aim of this review was to collect all cases reported in the literature about airway rupture caused by DLTs and to describe the reported possible contributors, diagnosis, treatment, and outcomes of this complication. Another aim of this review was to assess the possible factors associated with mortality after airway rupture by DLTs. A comprehensive literature search for all cases of airway rupture caused by DLTs was performed in the PubMed, EMBASE, Ovid, Wanfang Database, and CNKI. The extracted data included age, sex, height, weight, type of operation, type and size of DLT, site of airway rupture, possible contributors, clinical presentation, diagnosis timing, treatment, and outcome. We included 105 single case reports and 22 case series with a total number of 187 patients. Most of the ruptures were in the trachea (n = 98, 52.4%) and left main bronchus (n = 70, 37.4%). The common possible contributors include use of a stylet, cuff overdistention, multiple attempts to adjust the position of a DLT, difficult intubation, and use of an oversized DLT. Most of the airway ruptures were diagnosed intraoperatively (n = 138, 82.7%). Pneumomediastinum, air leakage, hypoxemia, and subcutaneous emphysema were the common clinical manifestations. Most patients were treated with surgical repair (n = 147, 78.6%). The mortality of the patients with airway rupture by DLTs was 8.8%. Age, sex, site of rupture, diagnosis timing, and method of treatment were not found to be associated with mortality.

Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation

OBJECTIVES

Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes.

DESIGN

Prospective cohort study.

SETTING

Tertiary referral critical care center.

PATIENTS

Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation.

INTERVENTIONS

Laryngoscopy following endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS

One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48-2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0-6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0-0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0-1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury.

CONCLUSIONS

Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.

[Tracheal resection after prolonged stenting in surgery for cicatricial stenosis]

OBJECTIVE

To analyze early and delayed results of various variants of circular tracheal resection (CTR) with anastomosis, to determine the safest approach, dates and conditions of correction, features of postoperative period in patients after previous tracheal surgery.

MATERIAL AND METHODS

There were 831 patients with cicatricial tracheal stenosis. CTR was made in 330 (39.7%) patients. Most patients had previous prolonged ICU-stay. The patients were divided into 4 groups. Group 1 consisted of 61 (18.5%) patients after previous prolonged tracheal stenting. Group 2 included 45 (13.6%) patients who underwent circular tracheal resection with a functioning tracheostomy. Tracheostomy tube served as a stent in these patients. Group 3 enrolled 32 (9.7%) patients with previous staged reconstructive plastic surgeries on cranial segment of the respiratory tract. Tracheostomy or stent were absent in 192 (58.2%) patients who underwent circular tracheal resection at the first hospitalization. These patients were enrolled into the fourth (control) group. Favorable outcomes (without complications and mortality) were achieved in 85.5% (n=282) of patients. Postoperative complications occurred in 48 (14.5%) patients. Mortality rate was 0.6% (n=2). The greatest number of complications including anastomositis and restenosis was noted in patients after CTR and previous tracheoplasty with T-tube (n=8, 25%). The most common complication in patients after tracheal resection and previous stenting was anastomositis (14.7%). Long-term results depended on postoperative complications and methods of their correction. Recurrent stenosis occurred in 5 (1.5%) patients within the period of 3 months - 8 years. CTR after previous tracheoplasty with T-tube was carried out in 4 of these patients.

CONCLUSION

Tracheal resection after preliminary stenting or tracheostomy is quite safe and technically feasible. Stenting allows postponing radical surgery for correction of concomitant diseases and closure of tracheostomy as a focus of infection within the surgical approach and further tracheal anastomosis. Tracheal resection with simultaneous closure of tracheostomy results a higher rate of postoperative complications compared with preliminary stenting.

Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration?

Background

Iatrogenic tracheobronchial injury is a rare, but severe complication of endotracheal intubation. Risk factors are emergency intubation, percutaneous dilatational tracheostomy and intubation with double lumen tube. Regarding these procedures, underlying patients often suffer from severe comorbidities. The aim of this study was to evaluate the results of a standardized treatment algorithm in a referral center with focus on the surgical approach.

Methods

Sixty-four patients with iatrogenic tracheal lesion were treated in our department by standardized management adopted to clinical findings between 2003 and 2019. Patients with superficial laceration were treated conservatively. In the case of transmural injury of the tracheal wall and necessity of mechanical ventilation, patients underwent surgery. We decided on a cervical surgical approach for lesions limited to the trachea. In case of involvement of a main bronchus we performed thoracotomy. Data were evaluated retrospectively.

Results

In 19 patients the tracheal lesion occurred in elective intubation and in 17 patients during emergency intubation. In 23 cases a tracheal tear occurred during percutaneous dilatational tracheostomy and in three patients at replacement of a tracheostomy tube. Two patients received laceration during bronchoscopy. Twenty-nine patients underwent surgery with cervical approach and 14 underwent thoracotomy. There was no difference in the mortality of these groups. Treatment of tracheal tear was successful in 62 individuals. Nine patients died of multi organ dysfunction syndrome (MODS), two of them during surgery.

Conclusions

Iatrogenic tracheal laceration is a life-threatening complication and the mortality after tracheal injury is high, even in a specialized thoracic unit. Conservative management in patients with superficial tracheal lesion is a feasible procedure. In case of complete laceration of tracheal wall, surgical therapy is recommendable, whereby several approaches of surgical management seem to be equivalent.

Automated measurement of tracheal and main bronchial diameters: a feasibility study

BACKGROUND

A thoracic computed tomography scan is rarely used to help choose the appropriate double-lumen tube. Nowadays, bronchial measurements can be automated using dedicated software. The aim of this prospective monocentric study was to compare manual and automated measurements of the diameter of the trachea and both main bronchi in adult patients free from a history of lung surgery or disease.

METHODS

Diameters of the trachea and of the main stem bronchi were measured by trained physicians or automatically using Thoracic Volume Computer Assisted Reading software (GE Healthcare, Chicago, IL, USA). Manual measurements were considered as the goal standard.

RESULTS

Two hundred and forty-three patients were assessed for eligibility, 216 were allocated to intervention and 173 analyzed: 102 males and 71 females (61.4±13.9 years, 169.7±9.4 cm, 73.3±16.8 kg). Reliability between the two investigators was poor (20.8±9.0% of measurements with a difference >10%). Intraclass correlation coefficient (ICC) and its confidence interval at 95% (ICC [95% CI]) was 0.97 [0.96; 0.98] for the maximal diameter and 0.94 [0.92; 0.95] for the minimal diameter of the trachea (P<0.01 for both). ICC [95% CI] was 0.97 [0.94; 0.98] for the maximal diameter and 0.93 [0.90; 0.95] for the minimal diameter of the right main bronchus (P<0.01 for both). ICC [95% CI] was 0.96 [0.95; 0.97] for the maximal diameter and 0.93 [0.90; 0.95] for the minimal diameter of the left main bronchus (P<0.01 for both).

CONCLUSIONS

This feasibility study has mixed results since automated measurements were not feasible in around 20% of the cases.

Tracheal Injury Prior to Sternotomy: A Cautionary Tale

Tracheal laceration during cardiac surgery is a rarely reported form of iatrogenic tracheal injury. During dissection prior to sternotomy, the interclavicular ligament must be divided. This structure overlies the proximal trachea, predisposing the trachea to injury at this location. Challenges related to tracheal laceration in cardiac surgery include patients with already tenuous cardiopulmonary status, surgical positioning that increases the risk of injury, obscured traditional clinical findings causing delayed recognition, increased risk of mediastinitis, and a heightened risk of airway fire. The incidence, mechanism, and ideal management of sternotomy-related tracheal injury, though a life-threatening complication, is rarely described in the literature. Consensus is lacking regarding the necessity and timing of tracheal repair versus conservative management, whether to proceed with the initially planned procedure, and the optimal timing of airway exchange in the event of endotracheal tube cuff rupture. In this article, we present the management of a full-thickness thermal tracheal injury due to electrocautery, resulting in a large air leak treated with delayed endotracheal tube exchange and tracheal repair after cardiopulmonary bypass.

Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review

OBJECTIVES

To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the ICU.

DATA SOURCES

PubMed, Embase, CINAHL, and Cochrane Library from database inception to September 2017.

STUDY SELECTION

Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed postextubation laryngeal examinations with either direct or indirect visualization.

DATA EXTRACTION

Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration's criteria.

DATA SYNTHESIS

Nine studies (seven cohorts, two cross-sectional) representing 775 patients met eligibility criteria. The mean (SD; 95% CI) duration of intubation was 8.2 days (6.0 d; 7.7-8.7 d). A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13-31% of patients across studies. The most frequently occurring clinical symptoms reported post extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies.

CONCLUSIONS

Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.

Treatment of Tracheobronchial Injuries: A Contemporary Review

Tracheobronchial injury is a rare but a potentially high-impact event with significant morbidity and mortality. Common etiologies include blunt or penetrating trauma and iatrogenic injury that might occur during surgery, endotracheal intubation, or bronchoscopy. Early recognition of clinical signs and symptoms can help risk-stratify patients and guide management. In recent years, there has been a paradigm shift in the management of tracheal injury towards minimally invasive modalities, such as endobronchial stent placement. Although there are still some definitive indications for surgery, selected patients who meet traditional surgical criteria as well as those patients who were deemed to be poor surgical candidates can now be managed successfully using minimally invasive techniques. This paradigm shift from surgical to nonsurgical management is promising and should be considered prior to making final management decisions.

[Acute and chronic mediastinitis]

BACKGROUND

A systematic approach to the etiology and possible course of acute mediastinitis is a prerequisite for adequate diagnostics and therapy. Chronic mediastinitis represents a rarity in the clinical practice.

MATERIAL AND METHOD

A selective literature search was carried out.

RESULTS

An acute infection of the mediastinum occurs after perforation of mediastinal structures, such as the esophagus and trachea mostly of iatrogenic origin and as descending necrotizing mediastinitis (DNM) from oropharyngeal foci. The mortality rate of esophageal injuries, irrespective of the cause is currently given as 12 %. A DNM results from an unobstructed spread along the cervicothoracic spaces and is a severe infection which manifests as a clinical picture of sepsis. The mortality rate given in the currently available literature is 14 %. Chronic mediastinitis is a very rare condition which is characterized by the proliferation of fibrous and collagenous tissue in the mediastinum. Whereas the pathogenesis remains unclear, there are indications for a Histoplasma capsulatum infection as the causal link. The prognosis is good.

CONCLUSION

After perforation of the esophagus or trachea there is always the risk of an infection of the mediastinum; therefore, the diagnosis is followed by further evaluation and early therapy. The DNM can cause unspecific symptoms of sepsis without an obvious focal point. It is important to be aware of a possible correlation between an oropharyngeal center of infection and mediastinitis in order to initiate appropriate diagnostic imaging in cases with the slightest suspicion. Chronic mediastinitis is a rare condition with varying courses and can be difficult to diagnose. An histological clarification for distinction from malignant diseases appears to be a sensible approach.

Novel Airway and Ventilator Management of Tracheobronchial Disruption After Blunt Trauma

Tracheobronchial injuries can be difficult to diagnose and manage, especially in the presence of polytrauma. A 50-year-old woman presented as a Level I trauma activation after being struck by a motor vehicle. Initial evaluation demonstrated intracranial hemorrhage and multiple chest injuries, including multilevel bilateral rib fractures, pneumomediastinum, and concern for tracheobronchial injury. After initial stabilization, bronchoscopy was performed and demonstrated an injury to the carina. We report a novel airway and ventilation strategy in the setting of concomitant tracheobronchial injury after severe blunt chest trauma in which extracorporeal support is contraindicated.

Iatrogenic rupture of the left main bronchus secondary to repeated surgical lobe torsion during double-lumen tube placement: A case report

RATIONALE

Bronchial rupture is a rare but potentially life-threatening complication during double-lumen endobronchial tube placement. The rupture of the left main bronchus resulting from repeated surgical torsion is uncommon.

PATIENT CONCERNS

A 70-year-old man with a history of chronic obstructive pulmonary disease (COPD), intermediate emphysema, chronic bronchitis, hypertension, type 2 diabetes mellitus, and L3-L4 lumbar intervertebral disc herniation. Chest x-ray and computed tomography revealed a solitary pulmonary nodule in the left lower lobe.

DIAGNOSES

Left lower lobe carcinoma.

INTERVENTIONS

To improve surgical access, forceps were used to oppress and torque the left lung.

OUTCOMES

An irregular, circular, horizontal, full-thickness rupture of 1.2 cm was observed at the tip of the bronchial tube in the left main bronchus upon examination of the bronchial stump.The rupture was repaired via primary suturing with 4-0 prolene thread and secondary reinforcement with a pericardial flap through a left thoracotomy, with no further complications.

LESSONS

Caution should be exercised during compression and torsion of the pulmonary lobe when attempting to improve surgical access, especially in patients with COPD. Conversion to thoracotomy is recommended if other measures have been unsuccessful.

Evolutional trends in the management of tracheal and bronchial injuries

Tracheal and Bronchial injuries are potentially life threatening complications which require urgent diagnosis and therapeutic intervention. They typically occur in association with blunt and penetrating chest trauma although they are increasingly being encountered in patients following endobronchial intervention and percutaneous tracheostomy insertion. Their precise incidence is unknown. Presenting features include dyspnoea, stridor, respiratory and haemodynamic compromise, haemoptysis, surgical emphysema, pneumothorax and persistent significant airleak. There may be other additional injuries to consider in trauma patients with large airway injury. Familiarity with the diagnosis and management of large airway injuries is important for medical teams engaged in emergency medicine, thoracic surgery and medicine, anaesthesia and intensive care. Although early surgical intervention is the mainstay of treatment, endobronchial manoeuvres to seal defects are receiving increasing attention particularly for patients with medical co-morbidities which may contraindicate formal surgery or transfer or where local surgical expertise is not available.

Iatrogenic tracheal laceration in the setting of chronic steroids

We report the case of a 71-year-old woman with end-stage chronic obstructive pulmonary disease who presented with a 10-cm tracheal laceration from a presumed traumatic intubation in the setting of respiratory distress and chronic obstructive pulmonary disease exacerbation and subsequently developed significant subcutaneous emphysema along her neck and mediastinum in addition to her peritoneum and mesentery. We were successfully able to treat this patient conservatively up until the time that tracheostomy was warranted. We discuss and review tracheobronchial injuries with respect to etiology, risk factors, and management and hope to benefit health care providers managing airways in patients at risk for tracheal injury.

Does Surgical Repair Still have a Role for Iatrogenic Tracheobronchial Rupture? Clinical Analysis of a Thoracic Surgeon's Opinion

PURPOSE

The choice of surgical repair or conservative treatment for iatrogenic tracheobronchial rupture (ITBR) remains controversial. However, thoracic surgeons consider that surgical repair is an important treatment modality. The purpose of this study was to evaluate the clinical results from the perspective of the surgery-preferred group.

METHODS

We treated 11 patients (8 women and 3 men; age: 52.6 ± 22.9 years) with ITBR from January 2011 to January 2016. A posterolateral thoracotomy or a trans-tracheal approach was performed according to the mechanism of injury.

RESULTS

Nine patients underwent surgery, and all patients received primary repair. Five patients received a right posterolateral thoracotomy, whereas one patient received a left posterolateral thoracotomy. No mortality or morbidity related to the surgery was observed. The mechanical ventilation time was 65.9 ± 99.2 hours. The intensive care unit duration was 19.7 ± 33.3 days. Two patients received conservative treatment, and all patients died of another disease that was not related to the conservative treatment.

CONCLUSION

Our mortality or morbidity due to surgery was not higher than world literature results of conservative treatment. We thought surgery is the primary treatment choice for ITBR in the absence of a good indication for conservative treatment.

One-Lung Anesthesia Update

One-lung ventilation is used during a variety of cardiac, thoracic, and major vascular procedures. Endobronchial tubes, bronchial blockers, and occasionally, single-lumen tubes are used to isolate the lungs. Patients with difficult airways and pediatric patients provide special challenges for lung isolation. Finally, intraoperative hypoxia and hypercarbia in patients with intrinsic lung disease frequently complicate one-lung anesthesia. The concepts and controversies in lung isolation techniques are discussed.

Successful Conservative Management of Tracheal Injury After Forceful Coughing During Extubation: A Case Report

A-56-year-old woman underwent carpal tunnel release surgery under general anesthesia. Thirty minutes after extubation, the patient complained of chest discomfort with dyspnea. Swelling of the neck and upper anterior chest was observed. Computed tomography of the chest showed tracheal rupture at the brachiocephalic trunk level, and bronchoscopy demonstrated a 5 cm linear tracheal defect in the posterior membranous wall, 6 cm proximal to the carina. Surgical repair of the tracheal injury was impossible due to its location. The patient was managed with intubation, mechanical ventilator care, and antibiotics. She made a full and uncomplicated recovery and was discharged 18 days after the original injury. When suspicious symptoms appear in patients receiving mechanical ventilation support, an immediate and accurate diagnostic process should be undertaken to rule out endotracheal tube-related tracheal injuries and to avoid potentially lethal complications.

Airway stenting in the management of iatrogenic tracheal injuries: 10-Year experience

BACKGROUND AND OBJECTIVE

Iatrogenic tracheal injury (ITI) is a rare yet severe complication of endotracheal tube (ETT) placement or tracheostomy. ITI is suspected in patients with clinical and/or radiographic signs or inefficient mechanical ventilation (MV) following these procedures. Bronchoscopy is used to establish a definitive diagnosis.

METHODS

We conducted a retrospective, single-centre chart review of 35 patients between 2004 and 2014. Depending on the nature and location of ITI and need for MV, patients were triaged to surgical repair, endoscopic management with airway stents or conservative treatment consisting of ETT or tracheotomy cannula (TC) placement distal to the wound and bronchoscopic surveillance.

RESULTS

Three of the four patients (11.43%) presenting with tracheoesophageal fistula (TEF) underwent surgery. Seven patients (20%) who did not require MV underwent endoscopic surveillance. Of the 24 ventilated patients (68.57%), 7 with ITI in the lower trachea were treated with silicone Y-stent (ETT or TC was placed inside the stent) and 17 patients with ITI in the upper trachea were managed by placing ETT or TC cuff distal to the injury. Overall management success, defined as complete healing of the ITI, was seen in 88.57% of patients. Four patients (11.43%) died of non-ITI-related comorbidities.

CONCLUSION

Conservative management should be considered in non-ventilated patients with ITI and when ITI is located in the upper trachea of ventilated patients where ETT or TC bypasses the injury. Airway stenting should be considered in ventilated patients with ITI located in the lower trachea. Surgery should be reserved for TEF and conservative and endoscopic management failure.

Acute Airway Distress from Endotracheal Intubation Injury in the Pediatric Aerodigestive Tract

OBJECTIVES: Two unusual cases of pediatric aerodigestive tract trauma postintubation with subsequent complications are described. Pediatric retropharyngeal dissection from trauma has not been reported previously.

METHODS: We conducted a retrospective chart review in a pediatric tertiary care center.

RESULTS: A 6-year-old girl underwent attempted nasotracheal intubation. She sustained retropharyngeal dissection, receiving positive pressure ventilation before this injury was noted. She developed subcutaneous emphysema. The child was managed conservatively and did well. An 8-year-old boy sustained a 4-cm laceration of his posterior trachea, developing pneumomediastinum after intubation. On transfer to our institution, he underwent direct laryngobronchoscopy and was reintubated with the tip of the endotracheal tube distal to the laceration. Postoperatively, the child accidentally pulled his tube and coughed, resulting in severe subcutaneous emphysema with increased pneumomediastinum. An emergent tracheotomy was performed. The patient subsequently did well.

CONCLUSION: A higher index of suspicion with more careful surveillance may prevent further morbidity.

[Surgical approaches in surgery for cicatrical tracheal stenosis]

At present time several surgical approaches are being used for cicatrical tracheal stenosis including cervicotomy, longitudinal- circumferential sternotomy and thoracotomy. Besides location of stenosis an approach is being determined by constitutional and anatomical features of patient, surgeon's and anesthesiologist's experience, well-coordinated work of operating team. If pathological process is placed in cervico-laryngeal, cervical and upper thoracic segment cervicotomy is preferable. Partial longitudinal-circumferential sternotomy is believed to be adequate in case of lesion of thoracic trachea and its bifurcation. This approach provides all types of tracheal reconstructions. Technical difficulties appear if process is localized in membranous wall of suprabifurcational part, bifurcation and primary bronchus. In these cases we recommend thoracotomy through the bed of resected the 3rd or the 4th ribs and patient's position on his front. Interventions including pulmonary tissue resection and tracheal edges convergence are possible through thoracotomy.

Association of Oversized Tracheal Tubes and Cuff Overinsufflation With Postintubation Tracheal Ruptures

Objectives

Postintubation tracheal ruptures (PTR) are rare but cause severe complications. Our objective was to investigate the tracheal pattern of injury resulting from cuff inflation of the tracheal tube, to study the two main factors responsible for PTR (cuff overinsufflation and inapplicable tube sizes), and to explain the context, why small women are particularly susceptible to PTR.

Methods

Experimental study performed on 28 fresh human laryngotracheal specimens (16 males, 12 females) within 24 hours post autopsy. Artificial ventilation was simulated by using an underwater construction and a standard tracheal tube. Tube sizes were selected according to our previously published nomogram. Tracheal lesions were detected visually and tracheal diameters measured. The influence of body size, sex difference and appropriate tube size were investigated according to patient height.

Results

In all 28 cases, the typical tracheal lesion pattern was a longitudinal median rupture of the posterior trachea. Appropriate tube sizes according to body size caused PTR with significantly higher cuff pressure when compared with oversized tubes. An increased risk of PTR was found in shorter patients, when oversized tubes were used. Sex difference did not have any significant influence.

Conclusion

This experimental model provides information about tracheal patterns in PTR for the first time. The model confirms by experiment the observations of case series in PTR patients, and therefore emphasizes the importance of correct tube size selection according to patient height. This minimizes the risk of PTR, especially in shorter patients, who have an increased risk of PTR when oversized tubes are used.

[Simultaneous resection of the two tracheal fragments for cicatrical stenosis]

Treatment of multifocal and extended tracheal stenosis is associated with considerable difficulties in comparison with local lesions. Resection with restoration of respiratory lumen by using of direct intertracheal anastomosis substantially entered into common clinical practice. But these interventions in patients with two-level lesion are performed rarely. Among 900 operated patients with cicatrical tracheal stenosis resection of two tracheal segments with forming of anastomoses was performed only in 5 patients. We presented an experience of single-stage resections of different segments of respiratory tract for nonneoplastic cicatrical stenosis. Indications and contraindications are defined. Technical features of resection are discussed. Our data show that such operations are possible and safe. All patients recovered. Their breath was completely restored. Risk of postoperative complications after similar operations is not higher than after one-level resection. But at present time these techniques may be used by specialists and institutions with serious experience in tracheal surgery.

[Postoperative bleeding in tracheal surgery]

AIM

Tracheal surgery became relatively safe with development of thoracic surgery, endoscopy and anesthesia. However, life-threatening vascular complications especially arrosive bleeding from great vessels play important role in the structure of postoperative complications. It is a major cause of hospital mortality after tracheal surgery.

MATERIAL AND METHODS

Since 1963 to 2013 867 patients with cicatrical tracheal stenosis were treated. Their age ranged from 8 to 77 years. Bleeding was the main cause of death after tracheal surgery. It occurs in 31 patients among whom 22 died. 9 patients are alive. There was bleeding from small cervical vessels and carotid artery in 5 and 2 patients respectively. All patients with bleeding from brachiocephalic trunk died except 2 patients who underwent complex vascular reconstructions and recurrent complications were prevented. Vascular complications occurred after both circular tracheal resection with the anastomosis (19 patients) and tracheoplasty followed by airway lumen formation on T-shaped tube (in 11 cases) or endoscopic treatment (in 1 patient). Postoperative complications were predominantly arrosive and accompanied by wound infection or severe purulent tracheobronchitis. Blood loss was relatively small in all patients and asystole was caused by blood asphyxia in died patients. Therefore, firstly respiratory tract lumen should be isolated from source of bleeding. 22 patients were urgently operated. Intraoperative death was observed in 6 cases, 7 patients died within 2-31 days. In 7 other patients cervical soft tissues, thyroid artery collaterals and carotid artery were origin of bleeding.

RESULTS

Final bleeding stop was performed with good immediate and long-term results in all cases. Final bleeding stop usually requires complex vascular reconstructions and it is difficult to predict their outcomes. It is necessary to prevent intraoperative bleeding because of unsatisfactory results of vascular complications management. So careful manipulations with vessels and their isolation from the tracheal anastomosis and tracheostomy channel with patient's own tissues are obligatory.

[Repeated tracheal resection for non-neoplastic restenosis]

Treatment of patients with recurrent cicatrical tracheal stenosis after previous circular tracheal resection is one of the most difficult problems in thoracic surgery at present time. In most cases repeated radical surgery as new resection is declined in favour of palliative treatment. It is often associated with lingering or perpetual preserving of T-shape or tracheostomy tube and respiratory tract stenting. Development of thoracic surgery last years permits to perform repeated tracheal resections with restoration of respiratory tract integrity by using of new tracheal anastomosis. For the last 4 years 6 such operations were performed with satisfactory immediate and remote results. Diagnostic algorithm before repeated surgery is similar to those before primary intervention. Special attention should be attended to state of remained parts of respiratory tract, degree and length of stenosis and tracheomalacia which may be result of divergence of edges of the primary anastomosis. Preserving of not less than 1/4 primary length of intact trachea with its satisfactory mobility is main condition for this surgery because it will permit to perform new anastomosis without high tension. Risk of postoperative complications after repeated operations is not higher than those after primary resection. But at present time these operations are in competence of small number of specialists and medical institutions with serious experience in thoracic surgery.

Conservative management of post-intubation tracheal tears-report of three cases

Iatrogenic tracheal rupture is a rare complication after intubation. We present three patients with tracheal tears. In all of these patients, a common finding was a lesion of the posterior tracheal wall with postoperative subcutaneous and emphysema as the first clinical sign of the rupture. Diagnosis and follow-up were based on clinical and endoscopic findings and chest computed tomography (CT) scans. In our cases with progressive subcutaneous and mediastinal emphysema or dyspnea, we performed a tracheotomy and bypassed the lesion with a tracheostomy tube to avoid an increase in air leakage into the mediastinum. Under broad-spectrum antibiotic therapy, no mediastinitis occurred and all patients survived without sequelae. Closure of tracheostomy was scheduled for 1-2 months after tracheal injury. Analysis of surgical and anesthesiological procedures revealed no abnormalities and the accumulation of tracheal injuries was considered as accidental. We found that in clinically stable patients with spontaneous breathing and with no mediastinitis, a conservative management of tracheal tears is a safe procedure.

Tracheal rupture related to endotracheal intubation after thyroid surgery: a case report and systematic review

Tracheobronchial rupture is an uncommon but potentially serious complication of endotracheal intubation. The most likely cause of tracheal injury is massive overinflation of the endotracheal tube cuff and pre-existing tracheal wall weakness. We review the relevant literature and predisposing factors contributing to this complication. Only articles that reported at least the demographic data (age and sex), the treatment performed and the outcome were included. Papers that did not detail these variables were excluded. We also focus on a case of tracheal laceration after tracheal intubation in a patient with severe thyroid carcinoma. This patient received surgical repair and recovered uneventfully. Two hundred and eight studies that reported cases or case series were selected for analysis. Most of the reported cases (57·2%) showed an uneventful recovery after surgical therapy. The overall mortality was 19·2% (40 patients). Our patient too recovered without any serious complication. Careful prevention, early detection and proper treatment of the problem are necessary when tracheal rupture occurs. The morbidity and mortality associated with tracheal injury mandate a high level of suspicion and expedient management.

Duration of oral endotracheal intubation is associated with dysphagia symptoms in acute lung injury patients

PURPOSE

The purpose of this study is to evaluate demographic and clinical factors associated with self-reported dysphagia after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI).

MATERIALS AND METHODS

This is a prospective cohort study of 132 ALI patients who had received mechanical ventilation via oral endotracheal tube.

RESULTS

The primary outcome was binary, whether clinically important symptoms of dysphagia at hospital discharge were reported by patients, using the Sydney Swallowing Questionnaire score 200 or more. Of 132 patients, 29% reported clinically important symptoms of dysphagia. Of 18 relevant demographic and clinical variables, only 2 were found to be independently associated with clinically important symptoms of dysphagia in a multivariable logistic regression model: upper gastrointestinal comorbidity (odds ratio, 2.82; 95% confidence interval, 1.09-7.26) and duration of oral endotracheal intubation (odds ratio, 1.79; [95% confidence interval, 1.15-2.79] per day for first 6 days, after which additional days of intubation were not associated with a further increase in the odds of dysphagia).

CONCLUSIONS

In ALI survivors, patient-reported, postexubation dysphagia at hospital discharge was significantly associated with upper gastrointestinal comorbidity and a longer duration of oral endotracheal intubation during the first 6 days of intubation.

Iatrogenic Left Main Bronchus Injury following Atraumatic Double Lumen Endotracheal Tube Placement

Tracheobronchial disruption is an uncommon but severe complication of double lumen endotracheal tube placement. The physical properties of a double lumen tube (large external diameter and length) make tracheobronchial injury more common than that associated with smaller single lumen endotracheal tubes. Here we present the case of an iatrogenic left main bronchus injury caused by placement of a double lumen tube in an otherwise unremarkable airway.

Management of post-intubation tracheal membrane ruptures: A practical approach

Tracheal rupture is an infrequent, severe complication of endotracheal intubation, which can be difficult to diagnose. Post-intubation tracheal rupture (PiTR) is distinct from non-iatrogenic causes of tracheobronchial trauma and often requires different treatment. The increasing adoption of pre-hospital emergency services increases the likelihood of such complications from emergency intubations. Effective management strategies for PiTR outside specialist cardiothoracic units are possible. Two cases of severe PiTR, successfully managed non-operatively on a general medical-surgical intensive care unit, illustrate a modified approach to current standards. The evidence base for PiTR is reviewed and a pragmatic management algorithm presented.

Tracheal stent to repair tracheal laceration after a double-lumen intubation

A 59-year-old woman was referred for a diagnostic video thoracoscopy under general anesthesia. At the end of the procedure, the patient presented with subcutaneous emphysema and cyanosis, abdominal distension, and bradycardia. A rigid bronchoscopy showed a longitudinal laceration in the pars membranacea of the trachea. A tracheal silicon stent was positioned on an emergency basis. She was intubated, positioning the tracheal tube cuff distal of the stent under bronchoscopic vision. A computed tomographic scan performed immediately after the procedure showed left pneumothorax, pneumoperitoneum, pneumopericardium, and diffuse subcutaneous emphysema. The subsequent course of the patient was uneventful. The patient was discharged home on postoperative day 4. After 1 year, the stent was removed with the evidence of complete trachel healing.

Surgical decision making in tracheobronchial injuries on the basis of clinical evidences and the injury's anatomical setting: a retrospective analysis

BACKGROUND

Airway trauma is a life threatening condition requiring prompt diagnosis and management. We present our experience focusing on the diagnosis, airway management and treatment.

MATERIAL AND METHODS

This is a retrospective analysis of 25 patients treated for tracheal or bronchial injury within a 12 year period. Data collected included: mechanism and sites of injury, associated injuries, clinical presentation, indications for surgical management, treatment and outcome.

RESULTS

There were 15 traumatic injuries (blunt/penetrating, 10/5 patients) and 10 post-intubation perforations. The most common findings included subcutaneous emphysema, pneumomediastinum and pneumothorax. Endotracheal intubation was carried out under bronchoscopic guidance. Tracheostomy was performed in one patient. Most injuries were located at the trachea/carina. Surgical treatment was undertaken in 22 patients. In 13 of them, all with traumatic injuries, the surgical treatment was decided on the basis of the clinical and radiological findings. The decision for surgery in post-intubation injuries was based on the proximity of the injuries to the carina (2 patients), the suspicion of an unsafe airway (1 patient) and the present of posterior tracheal wall perforations>2 cm (2 patients). The surgical approach for the repair was dictated by the location of the injury. There was a single case of perioperative mortality in the subgroup of patients with traumatic injuries.

CONCLUSIONS

Surgical primary repair represents the treatment of choice in airway injuries with the approach depending on the specific site of the lesion. Therefore we consider valuable the division of the tracheobronchial tree in 4 zones.

Conservative and surgical treatment of acute posttraumatic tracheobronchial injuries

BACKGROUND

Acute posttraumatic tracheobronchial lesions are rare events associated with significant morbidity and mortality. They are caused by blunt and penetrating trauma, or they are iatrogenic, appearing after intubation or tracheotomy. Although surgery has traditionally been considered the treatment of choice for these injuries, recent reports show that conservative treatment can be effective in selected patients. The aim of this study was to evaluate the role of surgical and conservative management of these lesions, differentiated on the basis of clinical and endoscopic criteria.

METHODS

From January 1993 to October 2010, a total of 50 patients with acute posttraumatic tracheobronchial lesions were referred for treatment to our department. In all, 36 patients had iatrogenic injuries of the airway, and 14 had lesions resulting from blunt or penetrating trauma.

RESULTS

Of the 30 patients who underwent surgery, the lesion was repaired with interrupted absorbable sutures in 29; the remaining patient, with an associated tracheoesophageal fistula, underwent single-stage tracheal resection and reconstruction and closure of the fistula. In all, 20 patients were treated conservatively: clinical observation in 5 patients, airway decompression with a mini-tracheotomy cannula in 4 spontaneously breathing patients, and tracheotomy with the cuff positioned distal to the lesion in 11 mechanically ventilated patients. One surgical and one conservatively-managed patient died after treatment (4% overall mortality). Complete recovery and healing were achieved in all the remaining patients.

CONCLUSIONS

Surgery remains the treatment of choice for posttraumatic lesions of the airway. However, conservative treatment based on strict clinical and endoscopic criteria-stable vital signs; effective ventilation; no esophageal injuries, signs of sepsis, or evidence of major communication with the mediastinal space-enables favorable results to be achieved in selected patients.

Tracheal laceration during intubation of a double-lumen tube and intraoperative fiberoptic bronchoscopic evaluation through an LMA in the lateral position -A case report-

A 76-year-old, 148-cm woman was scheduled for right upper lobectomy. A 32 Fr left-sided double lumen tube was placed using a conventional technique. Despite several attempts under fiberoptic bronchoscope-guidance, we could not locate the double lumen tube properly. We thus decided to proceed with the bronchial tube in the right mainstem bronchus. During surgery, 8-cm-long laceration was noted on the posterolateral side of the trachea. To check the possibility of laceration of the proximal trachea, the double lumen tube was changed to an LMA for use as a conduit for fiberoptic bronchoscopic evaluation in the lateral position. A plain endotracheal tube with the cuff modified and collapsed was re-intubated after evaluation. And then she was transferred to SICU.