[Post-intubation rupture of thoracic trachea in a patient with iatrogenic esophageal perforation and mediastinitis]

Iatrogenic injuries of the esophagus and trachea are rare. However, these are life-threatening events due to severe complications. The authors report iatrogenic perforation of cervical esophagus with a long false passage in posterior mediastinum in an 83-year-old patient undergoing endoscopic retrograde cholangiopancreatography for choledocholithiasis. Post-intubation rupture of thoracic trachea was diagnosed early after suturing the defect of esophagus and drainage of mediastinum. Treatment strategy was analyzed and conservative management of tracheal injury was substantiated.

Iatrogenic Tracheal Rupture Related to Prehospital Emergency Intubation in Adults: A 15-Year Single Center Experience

OBJECTIVE

Iatrogenic tracheal rupture is an unusual and severe complication that can be caused by tracheal intubation. The frequency, management, and outcome of iatrogenic tracheal rupture due to prehospital emergency intubation in adults by emergency response physicians has not yet been sufficiently explored.

METHODS

Adult patients with iatrogenic tracheal ruptures due to prehospital emergency intubation admitted to an academic referral center over a 15-year period (2004-2018) with consideration of individual risk factors were analyzed.

RESULTS

Thirteen patients (eight female) with a mean age of 67 years met the inclusion criteria and were analyzed. Of these, eight tracheal ruptures (62%) were caused during the airway management of cardiopulmonary resuscitation (CPR). Stylet use and difficult laryngoscopy requiring multiple attempts were documented in eight cases (62%) and four cases (30%), respectively. Seven patients (54%) underwent surgery, while six patients (46%) were treated conservatively. The overall 30-day mortality was 46%; five patients died due to their underlying emergencies and one patient died of tracheal rupture. Three survivors (23%) recovered with severe neurological sequelae and four (30%) were discharged in good neurological condition. Survivors had significantly smaller mean rupture sizes (2.7cm versus 6.3cm; P <.001) and less cutaneous emphysema (n = 2 versus n = 6; P = .021) than nonsurvivors.

CONCLUSIONS

Iatrogenic tracheal rupture due to prehospital emergency intubation is a rare complication. Published risk factors are not consistently present and may not be applicable to identify patients at high risk, especially not in rescue situations. Treatment options depend on individual patient condition, whereas outcome largely depends on the underlying disease and rupture extension.

[Life-threatening complications following endoscopic recanalization of cicatricial tracheal stenosis]

The authors report an attempt of tracheal stenosis bougienage complicated by tracheal rupture. Particularities of diagnosis and treatment of patients with cicatricial stenoses of breathing pathways are analyzed.

Tracheal rupture after vocal cord polyp resection: A case report

INTRODUCTION

Transoral laser microsurgery (TLM) is one of the most common operations performed for glottic lesions. Several protection measures are taken to prevent tracheal damage. However, some protection measures and common postoperative complications may still cause delayed tracheal rupture in certain situations. Cases of tracheal rupture after surgery are extremely rare, and there are no previous reports of TLM of the glottis causing tracheal rupture.

PATIENT CONCERNS

A middle-aged woman who underwent TLM for bilateral vocal cord polyps developed sudden neck pain, followed by cough and subcutaneous emphysema.

DIAGNOSIS

She underwent head, neck, and chest computed tomography (CT), which revealed a 4-cm membranous tracheal tear located 4.5 cm distal to the glottis, pneumomediastinum, and subcutaneous emphysema extending from the base of skull to the chest.

INTERVENTIONS

The patient underwent an emergency surgical surgical chest exploration and tracheal repair.

OUTCOMES

One month after the surgery, the patient fully recovered with no tracheal stenosis or respiratory dysfunction.

CONCLUSIONS

Conventional protective measures and common postoperative complications of TLM may also cause tracheal rupture.

Traumatic Pediatric Tracheal Rupture After Blunt Force Sporting Injury: Case Report and Review of the Literature

OBJECTIVE

This paper presents the case of a traumatic tracheal rupture in a pediatric patient. The body of literature of the clinical features, evaluation, and management of this uncommon presentation is discussed.

CASE

A 13-year-old boy sustained an intrathoracic tracheal rupture whilst playing Australian Rules football. He developed hallmark clinical features of air extravasation and was intubated prior to transfer to a tertiary pediatric center for further management. After a short trial of conservative management, his respiratory status deteriorated and he was taken to the operating theater for open surgical repair of the defect.

CONCLUSION

Traumatic rupture of the trachea is a rare injury in children. This case demonstrates the dynamic nature of this serious injury and the need for multidisciplinary care in achieving the optimal outcome.

[Assessment of tracheal elasticity and tracheal anastomosis tension in cicatricial stenosis]

OBJECTIVE

To assess the tracheal elasticity and tracheal anastomosis tension for prevention of anastomosis-related complications and estimation of the maximum length of resection.

MATERIAL AND METHODS

At the first stage, 20 patients with cicatricial tracheal stenosis underwent tracheoscopy in usual position, under maximum flexion and extension of the head for the period from September 2017 to December 2019. We measured the total length of trachea and length of stenotic segment. Tracheal extensibility was assessed considering the difference in measurements. At the second stage, anastomosis tension was intraoperatively measured using a dynamometer in normal head position, as well as at maximum flexion in 22 patients who underwent tracheal resection. Unlike multiple other studies, we studied tissue tension intraoperatively.

RESULTS

Mean length of trachea was 12.8 cm, extensibility - 1.3 cm. Tracheal elasticity was greater in patients with a longer trachea and in patients under 40 years old. Mean length of resection was 3.9 cm (30% of mean length of trachea), anastomosis tension - 2.7 H or 270 g. Head flexion was followed by tension decrease by 0.7 H (26.9%), i.e. 70 g. This approach is less effective in case of resection of more than 30% of trachea length in a particular patient.

CONCLUSION

Further experience in measurement of tracheal extensibility and anastomosis tension will make it possible to establish clinical significance of these indicators for prevention of complications.

Prognostic Factors for Iatrogenic Tracheal Rupture: A Single-Center Retrospective Cohort Study

Iatrogenic tracheal ruptures are rare but severe complications of medical interventions. The main goal of this study was to explore prognostic factors for all-cause mortality and rupture-related (adjusted) mortality. We retrospectively analyzed patients admitted to an academic referral center over a 15-year period (2004-2018). Fifty-four patients met the inclusion criteria, of whom 36 patients underwent surgical repair and 18 patients were treated conservatively. In a 90-day follow-up, the all-cause mortality was 50%, while the adjusted mortality was 13%. Rupture length was identified as a predictor for all-cause mortality (area under the curve, 0.84; 95% confidence interval (CI) 0.74-0.94) with a cutoff rupture length of 4.5 cm (sensitivity, 0.70; specificity, 0.81). Multivariate analysis confirmed rupture length as a prognostic factor for all-cause mortality (adjusted hazard ratio (HR) 1.5; 95% CI 1.2-1.9; p = 0.001), but not for adjusted mortality (HR 1.5; 95% CI 0.97-2.3; p = 0.068), while mediastinitis predicted adjusted mortality (HR 5.8; 95% CI 1.1-31.7; p = 0.042), but not all-cause mortality (HR 1.6; 95% CI 0.7-3.5; p = 0.243). The extent of iatrogenic tracheal rupture and mediastinitis might be relevant prognostic factors for all-cause mortality and adjusted mortality, respectively.

Transmural rupture and cartilage ring fracture in a tracheobronchial tuberculosis patient

Tuberculosis (TB) tracheobronchial stenosis is considered as the worst complication of tracheobronchial TB (TBTB). Endobronchial balloon dilation (EBD) is a promising treatment for adult tracheal stenosis; however, it may be complicated by transmural rupture and cartilage ring fracture. We present a 29-year-old female with a six-month history of cough and chest pain, and three weeks of dyspnoea. She was diagnosed with TBTB with active caseous lesions and had an effective response to anti-TB treatment. Nevertheless, she suffered recurrent tracheobronchial stenosis requiring several bronchoscopic treatments, including EBD. Her eight-month follow-up bronchoscopy showed transmural rupture and cartilage ring fracture of the anterior trachea. The patient finally recovered after 18 months of conservative management. Transmural rupture and cartilage ring fracture on the anterior trachea wall without pneumomediastinum or subcutaneous emphysema in TBTB patients may be best treated with a conservative approach.

Tracheal Rupture: A Rare Complication of Endotracheal Intubation

Clinicians can encounter various complications after endotracheal intubation as a result of patient anatomy, difficult intubation, and time and number of interventions performed. A life-threatening complication of intubation is iatrogenic tracheal rupture that leads to pulmonary air leak syndromes. In this case report, we present a 10-month-old patient who presented to the healthcare center with cyanosis and cough after foreign body aspiration and underwent endotracheal intubation for hypoxia. In our report, we aim to draw attention to tracheal rupture, a complication that was identified in bronchoscopy and found to be associated with repeated interventions and stylet use.

Conservative management of pediatric tracheal rupture

Traumatic injuries to the pediatric trachea are uncommon events that require prompt diagnosis and management. When they do occur, tracheal injuries often arise in the setting of high impact trauma and are accompanied by major injuries to other organ systems. In this report, we present the diagnosis and conservative management of tracheal rupture at the carina in an 11-year-old female with severe intracranial injuries. Pediatr Pulmonol. 2017;52:E1-E3. © 2016 Wiley Periodicals, Inc.

Management of esophageal stenting-associated esophagotracheal fistula, tracheal stenosis and tracheal rupture: a case report and review of the literature

OBJECTIVE

Although the placement of esophageal self-expandable stents (SES) can effectively relieve dysphagia after radiotherapy in patients with esophageal cancer (EC), it may induce severe esophageal complications. This article reports a case of emergency endotracheal intubation in an EC patient who suddenly developed severe dyspnea two months after SES placement.

METHODS

Electronic bronchoscopy of the patient's airway confirmed the diagnosis of esophagotracheal fistula, tracheal stenosis and tracheal rupture. Endotracheal intubation was successfully performed under the guidance of electronic bronchoscopy.

RESULTS

Dyspnea due to tracheal stenosis was relieved effectively by inserting the tracheal catheter to a proper place under the guidance of electronic bronchoscopy.

CONCLUSION

Bronchoscopic examination is strongly recommended in EC patients who are highly suspected as having airway stenosis associated with esophageal stenting, for which endotracheal intubation under the guidance of bronchoscopy is suggested.

Tracheal ring fracture secondary to percutaneous tracheostomy: is tracheal flaccidity a risk factor?

OBJECTIVE

To evaluate the risk factors of tracheal ring fracture and whether previous tracheal ring flaccidity predisposes to it in consecutive, mechanically ventilated, intensive care unit patients undergoing different percutaneous dilatational tracheostomy procedures (Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin).

DESIGN

Single-center retrospective study performed between November 2006 and July 2013.

SETTING

Single-center university hospital.

PARTICIPANTS

Two hundred nineteen consecutive intensive care unit patients.

INTERVENTIONS

Video bronchoscopic percutaneous dilatational tracheostomies using different techniques, including Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin, were performed consecutively. During the procedure, the tracheal wall response to the routine external palpation was evaluated endoscopically to find the interanular space. An abnormal change in the tracheal ring shape (fingerprint) with anterior airway wall collapse was diagnosed as tracheal flaccidity.

MEASUREMENTS AND MAIN RESULTS

Tracheal ring fracture occurred in 21 patients (9.6%). The proportion of tracheal ruptures was 16 (76.2%) after PercuTwist, 3 (14.3%) after Ciaglia Blue Dolphin, and 2 (9.5%) after the Blue Rhino technique. Significant risk factors for tracheal rupture were PercuTwist procedure (p = 0.02), tracheal flaccidity (p = 0.0001), and a period of intubation before a percutaneous dilatational tracheostomy procedure>14 days (p = 0.01).

CONCLUSIONS

In addition to the PercuTwist technique and intubation>14 days before tracheostomy, tracheal flaccidity was a significant risk factor for tracheal ring fracture. In the presence of this finding, a less traumatic tracheostomy procedure should be applied.

It could suddenly happen: delayed rupture of the trachea after total thyroidectomy. A case report

INTRODUCTION

We report the case of a patient who presented with subcutaneous emphysema, dyspnea and cough 7 days after total thyroidectomy for cancer. In addition we review the Literature and discuss the therapeutic challenges as well as management options.

CASE REPORT

A 17-year old female patient underwent a total thyroidectomy with right cervical lymph adenectomy for papillar cancer. Lung metastases are present. On postoperative day 7 she presented with face and neck swelling due to subcutaneous emphysema, dyspnea and persistent cough. The radiological evaluation revealed a tear on the right antero-lateral wall of the trachea. The patient underwent surgical exploration of the neck which confirmed the tracheal rupture and showed an important tracheal necrosis all around the tear. Due to the impossibility to make primary closure of the trachea or a tracheal resection, the tear was repaired with muscular flap interposition, (around the trachea as a scarf ), using the contralateral clavicular part of sternocleidomastoid muscle and prethyroid muscles bilaterally. The postoperative course was uneventful and the patient is alive 20 months after surgery and iodine induced adjuvant therapy.

CONCLUSION

Delayed tracheal rupture should be suspected in all patients who present subcutaneous emphysema after thyroid surgery. The lesion should be promptly treated with primary closure or tracheal resection when possible. Muscular flap interposition could be a safe alternative option when the other procedures are contraindicated.

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.

Tracheotomy-related posterior tracheal wall rupture, trans-tracheal repair

Laceration of the membranous part of the tracheo-bronchial tree is a rare complication that can occur after single lumen intubation, double-lumen intubation, percutaneous and surgical tracheotomy. The case of a 76-year-old male is presented in whom a posterior tracheal wall laceration, related to tracheotomy, was diagnosed and immediately treated at the end of a head and neck operation. A 6 cm long laceration started 1.5 cm below the tracheotomy level and ended 2 cm above the carina. The tear was closed from distal to proximal area via the tracheotomy opening with PDS 4/0 interrupted sutures using a thoracoscopic needle-holder. This original surgical technique is described in detail. In tracheotomy related tears, the fact that an opening in the trachea already exists and that the lesion rarely extends beyond the carina, should guide the surgeon to make every effort to repair the laceration through this already existing access.