Tracheal Lacerations After Intubation

Abstract

To the Editor: We read with great interest the report by Kaloud and colleagues1Kaloud H Smolle-Juettner FM Prause G et al.Iatrogenic ruptures of the tracheobronchial tree.Chest. 1997; 112: 774-778Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar concerning iatrogenic ruptures of the tracheobronchial tree. We agree that it is an extremely rare condition, much more frequent in middle-age women. We agree about its posterior longitudinal localization on the membranous tracheal wall, and about the need for immediate fibrobronchoseopic evaluation once the clinical diagnosis has been made. We also agree with the cuff-related cause of injury and the an inappropriate use of a stylet during endotracheal intubation as the main cause of tracheal laceration. We would suggest that a little cough in a patient with moderate sedation at the time of the intubation is also an easy way to cause a linear longitudinal tear in the posterior membranous part of the trachea. We cannot support their statement that “an absolute indication for surgical repair is present whenever a transmural tear with a length exceeding 1 cm causes pneumothorax and/or pneumomediastinum.” We have recently published a case report2Buitrago LJ Molins L Boada JE et al.Tratamiento conservador en dos lesiones traqueales secundarias a intubación anestésica.Arch Bronconeumol. 1997; 33: 151-153Crossref PubMed Google Scholar of two female patients and a recent third case who presented with subcutaneous emphysema, pneumomediastinum, and pneumothorax shortly after single-lumen endotracheal intubation; bronchoscopic examination revealed a posterior linear tear of 2.5 cm, 4.5 cm, and 5 cm in each case. After evaluation of a stable patient status, we treated the first two conservatively without intubation and with placement of the tube distal to the lesion in the last ease. There was no progression of the clinical and physical signs in the following days and the outcomes were excellent, without complications. A 2-month fibrobronchoscopic control revealed the lesions to be completely healed with a little granuloma in one patient that disappeared in a subsequent control. Adding the 12 patients reported by Kaloud and colleagues to a review of the literature,3Molins L Buitrago LJ Vidal G Conservative treatment of tracheal lacerations secondary to endotracheal intubation.Ann Thorac Surg. 1997; 64: 1227-1228Abstract Full Text PDF PubMed Google Scholar of 48 eases of tracheal laceration after intubation, 40 were repaired surgically (83.3%) with a 20% mortality (eight patients). The eight patients published as conservatively treated all survived. We assume that this data is not from a homogeneous group, but our and others' experience4Varela G Jimenez M Rotura traqueal secundaria a intubación o traqueostomía.Arch Bronconeumol. 1995; 31: 421-423Crossref PubMed Google Scholar, 5van Klarenbosch J Meyer J de Lange JJ Tracheal rupture after tracheal intubation.Br J Anaesth. 1994; 73: 550-551Crossref PubMed Scopus (38) Google Scholar, 6Regragui IA Fagan AM Natrajan KM Tracheal rupture after tracheal intubation.Br J Anaesth. 1994; 72: 705-706Crossref PubMed Scopus (28) Google Scholar support the criteria to be used as guidelines in deciding on nonoperative management of postintubation tracheal lacerations proposed by Ross and colleagues:7Ross HM Grant FJ Wilson RS et al.Nonoperative management of tracheal laceration during endotracheal intubation.Ann Thorac Surg. 1997; 63: 240-242Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar 1.Stable vital signs.2.No difficulty ventilating the patient while intubated or respiratory distress while extubated.3.No evidence of esophageal injury.4.Minimal mediastinal fluid collection.5.Nonprogressive pneumomediastinum but subcutaneous emphysema.6.No signs of sepsis.