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J Thorac Cardiovasc Surg 2007;134:821-822
© 2007 The American Association for Thoracic Surgery
Letter to the Editor |
Chirurgie Thoracique–Hôpital Calmette, CHU Lille, Lille, France
To the Editor:
We read with interest the article by Griffo and colleagues1
regarding the conservative management of a postintubation tracheobronchial rupture (TBR), and we congratulate the authors for their results. This favorable outcome is not surprising and is in agreement with the evidence accumulated in recent literature.2 Between June 1993 and July 2005, 30 patients presenting iatrogenic TBR, 16 secondary to intubations for elective surgery and 14 secondary to intubations for medical emergencies, were treated at our institution.3 The mean TBR length was 4.5 ± 1.5 cm (range, 1–7.5 cm). Fifteen patients, not requiring mechanical ventilation, underwent simple conservative management. In 3 cases, transient noninvasive ventilatory support was used to treat a mild respiratory distress correlated to a frank anterior intraluminal protrusion of the esophagus trough full-thickness rupture. All of these lesions healed without sequelae. Thirteen patients on mechanical ventilation were considered at high surgical risk. To ensure ventilation, tracheal tears were bridged as salvage therapy. In 5 patients, TBR bridging was attempted by simply advancing the endotracheal tube distal to the injury; in 6 other patients, presenting a TBR too close to the carina, TBR bridging was attempted by separating bilateral mainstem endobronchial intubation. Two cases of aseptic mediastinal collection were found by follow-up chest computed tomography and were drained by simple cervical approach. Nine of 13 ventilated patients (69%) who were treated conservatively completely recovered. Two patients on mechanical ventilation, in whom the bridging was technically not feasible, underwent surgical repair and died. Our results confirm the effectiveness of conservative management in iatrogenic TBR. In patients not requiring mechanical ventilation, conservative management includes noninvasive ventilatory support. The outcome was independent of the tracheobronchial length2,3; pneumothorax, extensive subcutaneous emphysema, and mediastinal collections were drained as needed. So, we disagree with the author’s conclusions: "Treatment can be conservative or aggressive depending on the extension of the lesion... . Usually, conservative treatment is preferred for stable patients with small uncomplicated tracheobronchial lesions... . Surgical treatment (through a standard thoracotomy or transcervical approach) is reserved for patients requiring mechanical ventilatory support... ." Surgery in critically patients involves a high risk, with a reported mortality as high as 71.4%.4 Such a high mortality for the repair of TBR in critically ill patients receiving mechanical ventilation demands that alternatives to high-risk surgery be considered.
We recommend conservative nonoperative therapy as the best approach to post-intubation TBR (1) in patients who are on spontaneous ventilation, (2) when extubation is scheduled within 24 hours from the time of diagnosis, or (3) for patients who will require continued ventilation to treat their underlying respiratory status. Surgical repair should be reserved for patients in whom bridging the lesion is technically not feasible or for patients with injuries diagnosed during thoracic surgery.
References
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