Tracheobronchial laceration after double-lumen intubation for thoracic procedures

Post-intubation tracheal lacerations: Risk-stratification and treatment protocol according to morphological classification

Background

Post-intubation tracheal laceration (PITL) is a rare condition (0.005% of intubations). The treatment of choice has traditionally been surgical repair. Following our first report in 2010 of treatment protocol tailored to a risk-stratified morphological classification there is now clear evidence that conservative therapy represents the gold standard in the majority of patients. In this paper we aim to validate our risk-stratified treatment protocol through the largest ever reported series of patients.

Methods

This retrospective analysis is based on a prospectively collected series (2003-2020) of 62 patients with PITL, staged and treated according to our revised morphological classification.

Results

Fifty-five patients with Level I (#8), II (#36) and IIIA (#11) PITL were successfully treated conservatively. Six patients with Level IIIB injury and 1 patient with Level IV underwent a surgical repair of the trachea. No mortality was reported. Bronchoscopy confirmed complete healing in all patients by day 30. Statistical analysis showed age only to be a risk factor for PITL severity.

Conclusions

Our previously proposed risk-stratified morphological classification has been validated as the major tool for defining the type of treatment in PITL.

A previously published propofol-remifentanil response surface model does not predict patient response well in video-assisted thoracic surgery

Modern anesthesia usually employs a hypnotic and an analgesic to produce synergistic sedation and analgesia. Two remifentanil-propofol interaction response surface models were used to predict sedation using Observer's Assessment of Alertness/Sedation (OAA/S) scores; one predicts an OAA/S <2 and the other <4. We hypothesized that both models would predict regained responsiveness (RR) after video-assisted thoracic surgery (VATS) to reduce total anesthesia time and make early extubation clinically relevant. We included 30 patients undergoing VATS received total intravenous anesthesia (TIVA) combined with thoracic epidural anesthesia (TEA). Pharmacokinetic profiles were calculated using Tivatrainer. Model predictions were compared with observations to evaluate the accuracy and precision of emergence model predictions. The mean (standard deviation) differences between when a patient responded to their name and the time when the model predicted a 50% probability of patient response were 30.80 ± 17.77 and 13.71 ± 11.35 minutes for the OAA/S <2 model and <4 model, respectively. Both models had a limited ability to predict patient response in our patients. Both models identified target concentration pairs predicting time of RR in volunteers and some elective surgeries, but another model of epidural and intravenous anesthetic combinations may be needed to predict time of RR after VATS under TIVA with TEA.

Tracheal Rupture: A Rare Complication of Endotracheal Intubation

There are numerous immediate and delayed complications associated with endotracheal intubation. Tracheal rupture is a rare complication whose diagnosis is often delayed. This can result in significant morbidity and mortality. We present a case of therapeutic misadventure resulting in a significant tracheal rupture in a child intubated by helicopter emergency medical services after a near-drowning. This is followed by a review of endotracheal intubation related tracheal rupture.

Iatrogenic rupture of the trachea caused by double Lumen tube intubation

Acute injuries of the tracheobronchial system are rare and life-threatening situations. Tracheal rupture most commonly occurs after blunt trauma to the chest. It is a rare but most concerning immediate complication of intubation. One-lung ventilation is required in lung surgery. Video assisted thoracoscopic procedures are an absolute indication for one-lung intubation. The double-lumen tube is the mainstay of one lung ventilation. Due to their larger size and rigidity, double lumen tubes are more difficult to insert, and complications are more common than with single lumen tubes. Opinions about the need for checking routinely the position of a double lumen tube by fiber optic bronchoscopy directly after intubation are divided. A 69-year-old woman with epidermoid lung carcinoma was scheduled for video assisted thoracoscopic left upper pulmonary lobectomy under general anaesthesia. The patient was prepared for the operation and itubated with the Carlens double lumen tube as usual. On introducing the camera into the thoracic cavity, the surgeon noted that the lungs were not completely collapsed. During blind adjustment the position of the tube the trachea was ruptured. The right-sided thoracotomy was performed and closed the greater part of the tracheal laceration. Only its upper 1.5-cm segment was surgically inaccessible because of the anatomical situation and thus remained unsutured. The patient received antibiotics, continuous airway humidification, analgesia with piritramide, and chest physiotherapy. She had no complications. In the literature, opinions about checking routinely the position of a double lumen tube by fiber optic bronchoscopy are divided.. Possibly, the very serious complication encountered in our patient could have been avoided, had the tube position been checked by bronchoscopy. The treatment strategy for post-intubation tracheal rupture depends on the size and location of the rupture, its clinical presentation, and the overall condition of the patient). Early surgical repair is the treatment of choice for most patients when a transmural tear with a length exceeding 2 cm. In our the combination of surgical and conservative treatment was performed. The uppermost part of the tear could not be sutured because of the anatomical situation, and so about 1.5 cm of the trachea remained open. The case is interesting from many perspectives. It shows that intubation with a Carlens tube is a potentially hazardous procedure, which should be performed only by experienced anaesthesiologists. Furthermore, our case report underscores the importance of checking routinely the position of a double lumen tube by fiber optic bronchoscopy. It provides evidence that minor tracheal lacerations can be successfully managed by conservative measures.

[Tracheobronchial ruptures: classification and management]

BACKGROUND

Tracheobronchial ruptures are rare surgical emergencies with significant mortality. We present management and outcome of such ruptures treated at the University of Leipzig in Germany and propose a novel therapeutic algorithm-a new classification system for stratifying treatment of patients with tracheobronchial ruptures.

METHODS

We retrospectively studied 24 patients 19 to 88 years old who were treated in our institution for tracheobronchial injury.

RESULTS

Eighty-seven percent of the injuries were caused iatrogenically. Fifty-four percent were type I injuries (isolated tracheal lesions), 38% type II (involvement of carina or main stem bronchi), and 8% type III (distal lesions of lobar or segmental bronchi). Seventy-five percent of the patients were operated via right-sided dorsolateral thoracotomy. In four (22%), insufficiency of the tracheal closure occurred, with mediastinitis possibly being a significant risk factor for this event (P<0.001). In surgically treated patients, rupture-related and overall mortality were 5.5% and 28%, respectively, whereas in medically treated patients, mortality was 33%.

CONCLUSION

The proposed classification of tracheobronchial injuries enables stratifying the treatment of patients with tracheobronchial ruptures. Type I lesions can be surgically closed either by a right-sided thoracotomy or transcervical-transtracheal approach. In contrast, surgical management of type II and III injuries always requires thoracotomy.