Tracheal Trauma: Management and Treatment. Kosmas Iliadis, MD, PhD, FECTS

Transcription

1 Tracheal Trauma: Management and Treatment Kosmas Iliadis, MD, PhD, FECTS Thoracic Surgeon Director of Thoracic Surgery Department Hygeia Hospital, Athens

2 INTRODUCTION Heterogeneous group of injuries mechanism anatomic site of damage severity of respiratory complications Are often life threatening Require early and skillful airway management, careful evaluation, and qualified operative repair

3 Mechanisms of Tracheal trauma Traumatic Iatrogenic Penetrating trauma Gunshot (Transmission of kinetic energy) Stabbing ( Sharp tissue transection) Blunt force trauma Traffic accident (Dashboard injury, deceleration with shoulder belt) Burying (Thoracic compression) Fall (Deceleration, direct cervical injury) Crush injury (Compression, rib fractures, cartilage fractures) Hyperextension of the cervical trachea (Distraction injury, laryngotracheal separation) Endotracheal intubation (Direct longitudinal laceration) Rigid broncoscopy Tracheobronchial stent removal Balloon broncoplasty EBUS-TBNA, EUS-TBNA Surgical procedures: (Thoracic, Head and neck, Thyroid) (Excision of wall structures, devascularization) Tracheostomy: Open, PDT Mediastinoscopy (rarely)

4 Cervical trachea is exposed anteriorly Tracheobronchial injuries (TBI) Bronchial tree and the lower 2/3 of the trachea have good bony protection The anterior trachea, including the cartilage, or the ligamentous portions between the tracheal rings, are most commonly injured during penetrating trauma. Most traumatic TBIs take place within 2.5 cm of the carina and mainstem bronchial injuries comprise 60% of these injuries. Yeh DD, Lee J. Trauma and blast injuries. In: Broaddus VC, Mason RJ, Ernst JD, King TE Jr, Lazarus SC, Murray JF, Nadel JA, Slutsky AS, Gotway MB, eds. Murray and Nadel s Textbook of Respiratory Medicine. 6th ed., Vol. 2. Philadelphia, PA: Elsevier;

5 Diagnosis of TBI Chest radiography: first step in diagnosis. Pneumothorax, pneumomediastinum. Chest CT: useful in detecting unexpected thoracic injuries (present in almost 75% of patients with blunt TBI). Broncoscopy: remains the gold standard.

6 Tracheal Wall Injury: Morphologic Classification Level I Mucosal or submucosal injury without mediastinal emphysema and esophageal injury Level II Lesion extending to the muscular wall with subcutaneous or mediastinal emphysema without esophageal injury or mediastinitis Level IIIA Complete laceration with esophageal or mediastinal soft-tissue herniation without esophageal injury or mediastinitis Level IIIB Any laceration with esophageal injury or mediastinitis Fig 1 Morphologic classification of tracheal injury. (Images designed by illustrator David Schumick. Image created at the Cleveland Clinic, Cleveland, OH.) Cardillo G, Carbone L, Carleo F, et al. Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment. Eur J Cardiothorac Surg. 2010;37(3):

7 Algorithmic approach for contemporary treatment of TBI Suspected airway injury CT image and/or Broncoscopy Level I/II injury Level IIIA and B injury Level IIIA and B injury. Poor surgical candidate Spontaneous respiration stable Intubated Impending respiratory failure Spontaneous respiration stable Intubated Impending respiratory failure Spontaneous respiration, Intubated, Impending respiratory failure Conservative management Broncoscopic evaluation and ET cuff adjustement Broncoscopic intubation Multidisciplinary management Ventilation failure Safe ventilation Multidisciplinary management Multidisciplinary management Broncoscopic evaluation and ET cuff adjustment ECMO Multidisciplinary management Broncoscopic ET cuff adjustment Broncoscopic intubation at bedside or in OR Stent consideration Surgical repair Surgical repair Surgical repair

8 Surgical treatment Emergency surgical treatment is required in patients who have: Worsening subcutaneous emphysema Worsening pneumomediastinum Worsening pneumothorax Development of persistent air leak Failure of lung re-expansion despite chest tube placement,. Other indications for emergency surgical treatment include: Esophageal wall prolapse into the tracheal lumen Ineffective mechanical ventilation in the setting of TBI distal to the placement of the ET tube. Cardillo G, Carbone L, Carleo F, et al. Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide nonsurgical treatment. Eur J Cardiothorac Surg. 2010;37(3):

9 Surgical access to the tracheobronchial tree Operative access to different regions of the trachea and main bronchi. Broncoscopically? Right posterolateral thoracotomy Right bronchial system, carina, and the distal trachea as well as the left central main bronchus are accessible.

10 Treatment of Poor Surgical Candidates Patients at high surgical risk due to comorbidities or the severity of the underlying disease can now be treated by minimally invasive techniques Temporary placement of a covered self-expanding metallic stent (SEMS) or silicon stent could offer advantages. Mechanically obstruct the tracheal defect. Provoces an exuberant inflammatory response with granulation tissue formation that could potentially augment closure of the tracheal defect. Tracheal stent placement can be used successfully even in cases that would have been historically treated via a surgical approach.

11 PATIENTS & METHODS 18 YEARS OLD MAN CAR ACCIDENT INTUBATED IN OTHER HOSPITAL DUE TO LOW GCS INDEX

12

13 Follow up

14 F 48 y SCHEDULED OPERATION PATIENTS & METHODS AFTER THE EXTUBATION SUBCUTANEOUS AND MEDIASTINAL EMPHYSEMA HOARSENESS VOICE SEVERE CHEST PAIN

15 CHEST CT SCAN PNEUMOMEDIASTINUM SUBCUTANEOUS EMPHYSEMA TRACHEAL LACERATION OF THE MEMBRANOUS WALL (4-5 cm LONG)

16

17 TREATMENT ENDOSCOPIC REPAIR 6 HOURS AFTER THE LACERATION RIGID BRONCHOSCOPE 13mm JET VENTILATION POLYDIOXANONE SUTURE 4-0 GRASPER (5mm LARGE-45 mm LONG) KNOT PUSHER TOTAL OPERATIVE TIME 2 H

18

19

20 RESULTS EXTUBATION IN THE OR IMMEDIATE AMBULATION NO POSTOPERATIVE PAIN NO MORBIDITY & MORTALITY HOSPITAL STAY 4 DAYS

21 FOLLOW UP

22 CONCLUSION SCOPE+NEEDLE HOLDER (STORZ) CONTINUOUS 2.0 VICRYL + ABSORBABLE CLIP 5mm 0 o SCOPE FENESTRATED GRASPER 4.0 POLYDIOXANONE SUTURE SEPARATED SUTURES NO CLIPS STAMATIS ET AL. A NEW TECHNIQUE FOR COMPLETE INTRALUMINAL REPAIR OF IATROGENIC POSTERIOR WALL TRACHEAL LACERATIONS 12(2011) 6-9

23 CONCLUSION EMERGENCY PROCEDURE NO NEED FOR SOPHISTICATED INSTRUMENTATION JUST STANDARD EQUIPEMENT AVAILABLE IN A GENERAL HOSPITAL AVOIDING THE PROBLEMS OF THE THORACOTOMY

24 SUMMARY Conservative treatment Level I / II injuries Case-by-case decision in full-thickness mucosal laceration (depending on the severity of accompanying problems and patient condition). Endotracheal reconstruction In experienced centers for all patients who tolerate jet ventilation. Operative reconstruction Mandatory when there is associated esophageal injury or mediastinitis is evident.

25