Tracheobronchial ruptures (TBR) are life-threatening

Conservative Treatment for Postintubation Tracheobronchial Rupture Jacques Jougon, MD, Michel Ballester, MD, Emmanuel Choukroun, MD, Jean Dubrez, MD, Gilles Reboul, MD, and Jean-François Velly, MD Thoracic Surgery Unit, Centre Médico-Chirurgical, Haut Lévèque Hospital, Pessac, France Background. Postintubation tracheobronchial rupture is usually responsible for unstable intraoperative or postoperative conditions, and its management is discussed. We insist on conservative treatment as a viable alternative after late diagnosis of postintubation tracheobronchial rupture. Methods. We conducted a retrospective study including 14 consecutive patients treated between April 1981 and July 1998. Results. Twelve tracheobronchial ruptures occurred after intubation for general surgery and two after thoracic surgery. In all cases, the tear consisted of a linear laceration of the posterior membranous wall of the tracheobronchial tree ranging from 2 to 6 cm. One death occurred in a very weak patient unfit to undergo a redo operation for surgical repair. Seven patients were treated conservatively and cured without sequelae. Six patients underwent surgical repair, of whom 2 were diagnosed and repaired intraoperatively. Conclusions. Aggressive surgical repair is not always mandatory after delayed diagnosis of iatrogenic tracheobronchial rupture. Conservative treatment must often be considered, except after lung resection. (Ann Thorac Surg 2000;69:216 20) 2000 by The Society of Thoracic Surgeons Tracheobronchial ruptures (TBR) are life-threatening lesions that most commonly occur after blunt trauma to the chest [1] but also may be a complication, hopefully very rare, of l intubation [2]. It is in these situations, where physicians sometimes feel guilty, that the decision of nonsurgical treatment is harder to take. Therefore, the choice between conservative treatment or surgical treatment sometimes implies long debates between physicians [3 5]. The purpose of this study is to examine a series of 14 patients treated in our department for TBR consecutive to l intubation; 6 of these patients having undergone l or bronchial surgical repair and 7 (50%) medical treatment. Retrospective analysis of different cases and review of the literature allows us to propose a decisiontaking algorithm of the best treatment of TBR after l intubation. Patients and Methods All patients treated in our department between April 1981 and July 1998 for TBR consecutive to intubation were reviewed. All data concerning patient history, conditions of intubation, presenting symptoms, endoscopic and radiologic findings, treatment and outcome were carefully reviewed. There were 14 patients (12 women and 2 men) ranging Accepted for publication June 6, 1999. Address reprint requests to Dr Jougon, Thoracic Surgery Unit, Centre Médico-Chirurgical, Haut Lévèque Hospital, 33604 Pessac Cédex, France; e-mail: jacques.jougon@chu-aquitaine.fr. in age from 6 to 72 years (mean, 59 years). In 3 cases, the l rupture was consecutive to l intubation performed in our department. All other patients came from other hospitals and were referred to our center for diagnosis or treatment. Etiology The intubation tube used was a single-lumen tube in 11 cases and a double-lumen endol tube in 3 cases. Causes for intubation are reported in Table 1. Analysis of the conditions of intubation revealed difficulties due to severe facial injury by shotgun in 1 case. In all other cases, there was not any particular difficulty found. Diagnosis In 2 patients, the injury was diagnosed and treated intraoperatively. In one case, the l tear was recognized after exploration of an air infiltration surrounding l tissues during thyroidectomy. In the second case, the tear occurred with a double lumen intubation during an esophageal resection. After removal of the esophagus, the inflated left bronchial cuff appeared in the operative field. In 4 patients, signs of l rupture appeared immediately causing respiratory distress with important desaturation during anesthesia. Bilateral occurred in 2 cases, left tension in 1 case, and tension pneumomediastinum in 1 case. In 1 of these cases, the patient had remained intubated with a very large overinflated l cuff in order to allow the medical transport to our unit (Figs 1 and 2). 2000 by The Society of Thoracic Surgeons 0003-4975/00/$20.00 Published by Elsevier Science Inc PII S0003-4975(99)01129-7

Ann Thorac Surg JOUGON ET AL 2000;69:216 20 IATROGENIC TRACHEOBRONCHIAL RUPTURE 217 Table 1. Patient Characteristics Case Sex Age Reason for Intubation Presenting Symptoms Endoscopic Findings (length of the tear/ location) Free Interval Before Diagnosis (h) Treatment Outcome 1 F 6 Appendectomy 2 cm, cervicothoracic 2 F 59 Cholecystectomy Respiratory distress, 4 cm, thoracic bilateral 3 F 70 Coma Respiratory distress 3 cm, thoracic 4 F 80 Hip joint replacement 5 F 40 Face trauma Respiratory distress, (shotgun) bilateral 6 F 72 Internal saphenous, vein stripping hemoptysis 7 F 64 Cholecystectomy 8 F 62 Shoulder wrench 9 F 71 Total hip joint replacement 10 M 61 Esophagectomy Per operative discovery 11 F 69 Hysterectomy 12 F 70 Ankle fracture Respiratory distress, left 13 F 35 Thyroidectomy Per operative discovery 14 M 61 Right lung Excessive air leak lobectomy 3 cm, thoracic 2 cm, thoracic 4 cm, thoracic and recovery 24 Surgical Per primam 3 cm, carena 24 Medical Per primam 3.5 cm, 144 Medical Per primam cervicothoracic 2 cm, on carena 0 Medical Per primam 3 cm, left bronchus stem 2.5 cm, thoracic 24 Medical Per primam 6 cm, thoracic 2 cm, cervical 3 cm, left bronchus stem 24 None Death In 1 patient, excessive air leak and respiratory distress on the 2nd postoperative day after right pulmonary lobectomy led to the diagnosis of a left stem bronchus rupture. In 7 patients, presenting symptoms were more insidious and occurred later on. Clinically, we noted head and neck subcutaneous, nasal voice, and pneumomediastinum on chest radiograph (see Table 1). Hemoptysis occurred in 1 case only. Endoscopy Definite diagnosis was performed bronchoscopically in all cases except those diagnosed intraoperatively (see above). Endoscopic findings are reported in Table 1. The tear was always unifocal and was found at the membranous part or at the junction of the membranous wall and the cartilage. It involved the in 9 patients, the carina in 3, and the left main bronchus in 2. In all cases, tears were linear and parallel to the bronchial tree. Treatment Six patients underwent surgery. The tear was always sutured by total layer of interrupted resorbable knots secondarily covered by a muscular or pleural flap. The patient who suffered from a left stem bronchus rupture after right pulmonary lobectomy was unfit to undergo surgery at time of diagnosis. He was a very weak patient who died a few hours after the endoscopic diagnosis from respiratory distress and cardiac failure. Seven patients underwent medical treatment. All tears occurred after single lumen tube intubations. Presenting symptoms were most often poor and sometimes delayed. Nevertheless, 1 patient presented an acute bilateral which was rapidly exsulfated by bilateral pleural suction. Tracheobronchial lacerations measured 1 to 3.5 cm long. Medical treatment included a broad spectrum antibiotherapy against the tracheobronchial flore, antiseptic antiinflammatory aerosoltherapy, and chest tube in 1 patient. When the subcutaneous was relapsed or important to cause shutting of the

218 JOUGON ET AL Ann Thorac Surg IATROGENIC TRACHEOBRONCHIAL RUPTURE 2000;69:216 20 eyelids, we performed two short susclavian incisions and subcutaneous massages in order to evacuate the. Early stabilization of clinical symptoms without progression over a short period of time was the sine qua non condition for conservative treatment. Results The postoperative care of patients who underwent surgery was uneventful. All patients treated by medical means had favorable outcome. A fiberoptic bronchoscopy was systematically performed at day 15 before discharge, and later on the 1st and 3rd months. Follow-up (median 30 months; ranging 3 months to 207 months) sometimes showed at first control small granulomas easily cauterized by laser but never revealed any scar sequellae or stenosis. Comment Fig 1. Chest x-ray film of patient 12 showing overinflation of the cuff of the endol tube, pneumomediastinum, and subcutaneous. Fig 2. Computed tomographic scan of patient 12 showing the endol tube with an overinflated cuff between the sternum and the vertebrae. The incidence of TBR after intubation is rare considering the number of l intubations performed for general anesthesia. However some short tears, spontaneously favorable, are probably misdiagnosed [6, 7]. After double-lumen tube intubations, the frequency of TBR remains low, estimated under 1% (0.12% for Borasio and colleagues [6]; 0.05% for Personne and coworkers [7]; 0.37% for Spaggiari and associates [3]). The most recent series report approximately 10 cases [5, 6, 8, 9] (Table 2). Mechanisms for tracheobronchial ruptures have been largely described [5, 8]. In most cases, they are due to an overinflated cuff, or to sudden moves of the tube. A direct tear caused by the tube itself remains rare. These mechanisms explain the location of the lesions, which are posterior, mainly concerning the membranous wall of the or the junction between the membranous wall and the cartilage. After double lumen intubation, TBR is explained by the same mechanisms: overinflation of the bronchial or the l cuff, respectively, causing bronchial or l rupture. Inadequate intubation tube size is one of the most important risks factors reported in the literature [5]. This explains TBR predominance most particularly in short female patients. We also found this element in our study. Clinical symptoms occur either immediately during mechanical ventilation (compressive, extensive subcutaneous ) or are more insidious, arising in the postoperative period or later. The development of a postoperative subcutaneous must immediately lead to perform a fiberoptic bronchoscopy under sufficient local anesthesia to prevent extension of the by coughing if the patient has already been extubated. Chest radiograph can show a rightside deviation of the intubation tube [10] or an overinflated cuff, as it was once noted in one of our patients (Fig 1). Patients presenting with acute respiratory distress must undergo surgical treatment in the same operative time if it is possible. Outcome is always favorable. Prognosis depends mostly on the patient s general status. TBR occurring after pulmonary or mediastinal surgery, usually requiring double-lumen tubes, implies surgical treatment, even if the symptoms presented by the patient are delayed [3]. Indeed, intrapleural suction converts a tracheobronchial tear in a large bronchopleural fistula. Moreover intrapleural suction for lung reexpansion in a patient who underwent partial pulmonary resection may be inefficient. Nevertheless, 2 patients who underwent left pneumonectomy had favorable outcome after medical treatment of their l rupture [6, 7]. In these 2 cases reported, no surgical treatment was performed considering the important risks implied by a right thoracotomy under single right-lung mechanical ventilation. This is the only circumstance after pulmonary resection where medical treatment can be considered [3]. Surgical approach, as well as techniques of suture, have been already described elsewhere [5, 6, 8]. If pulmonary or mediastinal surgery has not been performed, conservative treatment in a thoracic surgery department under continuous care can be considered

Ann Thorac Surg JOUGON ET AL 2000;69:216 20 IATROGENIC TRACHEOBRONCHIAL RUPTURE 219 Table 2. Review of the Main Recent Series Location of Tear Conservative Treatment Death Surgical Treatment Free Interval Before Diagnosis Length of Tear (cm) Main Bronchus Middle and Lower Third Upper Third of Trachea Double Tube Tracheostomy Single Tube No. of Patients References 14 9 1 4 1 12 1 3 7 0 124 h 13 1 2 Massard et al [5] 3 0 10 8 2 0 6 4 0 1 5 0 5 days 6 1 tracheostomy Borasio et al [6] 6 6 0 0 1 5 0 2 6 6 12 h 5 1 2 Marty-Ane et al [8] 12 7 4 1 7 3 2 2 13 0 5 days 12 0 3 Kaloud et al [9] Present series 14 12 2 0 3 9 2 2 6 0 6 days 6 7 1 [11, 12]. In our series, in the patients who were treated conservatively, presenting symptoms were immediate in 1 patient only, and delays of 1, 2, and 6 days in, respectively, 2, 3, and 1 patients. The tear must be shorter than one third of the (4 cm), which is the mean length of the endol cuff. These tears caused by the overinflated cuff are not deep in the mediastinum or associated with esophageal lesion. A tear more than 4 cm is generally deeper and produced by withdrawing of the tube without deflation of the cuff. Clinical signs must been stable without progression over a short period of time. Temporary tracheostomy has been proposed in such circumstances [6], as well as l intubation [9], their aim being to prevent the patient from sudden intrabronchial hyperpressures caused by coughing, which may worsen subcutaneous and widen the tear. In our series, we always tried to avoid tracheostomy, performing short subclavian skin incisions associated to cutaneous massages in order to evacuate. We consider that surgical treatment is the appropriate treatment when a tracheostomy is indicated. A broad-spectrum antibiotherapy against common tracheobronchial flore associated to antiinflammatory aerosoltherapy were prescribed. A bronchoscopy was performed at day 15 after the l rupture and always showed perfect scarring. We never found stenosis, thus confirming findings of international literature reports. According to our experience and after having reviewed the literature, we propose an algorithm for the treatment of postintubation TBR on Figure 3. Fig 3. Algorithm for assessment of postintubation tracheobronchial ruptures.

220 JOUGON ET AL Ann Thorac Surg IATROGENIC TRACHEOBRONCHIAL RUPTURE 2000;69:216 20 We conclude that surgical repair must be performed for postintubation l ruptures occurring after thoracic surgery. Nevertheless, conservative treatment has to be discussed when the tear involved in TBR is short, revealed by poor symptoms, and occurs after general anesthesia for nonthoracic surgical procedures. Care must be taken to choose a small-size tube during intubation of short female patients. References 1. Velly JF, Martigne C, Moreau JM, Dubrez J, Kerdi S, Couraud L. Post traumatic tracheobronchial lesions. Eur J Cardiothorac Surg 1991;5:352 5. 2. Kumar SM, Pandit SK, Cohen PJ. Tracheal laceration associated with endol anesthesia. Anesthesiology 1977;47: 298 9. 3. Spaggiari L, Rusca M, Carbognani P, Solli P. Tracheobronchial laceration after double-lumen intubation for thoracic procedures. Ann Thorac Surg 1998;65:1837 8. 4. D Odemont JP, Rodeinstein DOA. Iatrogenic tracheobronchial lacerations [Letter]. Ann Thorac Surg 1997;63: 1209 10. 5. Massard G, Rougé C, Dabbag A, et al. Tracheobronchial laceration after intubation and tracheostomy. Ann Thorac Surg 1996;61:1483 7. 6. Borasio P, Ardissone F, Chiampo G. Post-intubation l rupture. A report on ten cases. Eur J Cardiothorac Surg 1997;12:98 100. 7. Personne C, Kleinmann P, Bisson A, Toty L. Les déchirures trachéo-bronchiques par tube de Carlens. Ann Chir 1987;41: 494 7. 8. Marty-Ane CH, Picard E, Jonquet O, Mary H. Membranous l rupture after endol intubation. Ann Thorac Surg 1995;60:1367 71. 9. Kaloud H, Smolle-Juettner FM, Prause G, List WF. Iatrogenic ruptures of the tracheobronchial tree. Chest 1997;112:774 8. 10. Rollins RJ, Tocino I. Early radiographic signs of l rupture. Am J Radiol 1987;148:695 8. 11. Ross HM, Grant F, Wilson RS, Burt M. Non operative management of l laceration during endol intubation. Ann Thorac Surg 1997;63:240 2. 12. D Odemont JP, Pringot J, Goncette L, Goenen M, Rodenstein D. Spontaneous favorable outcome of l laceration. Chest 1991;99:1290 2.