J Thorac Cardiovasc Surg 2008;136:232
© 2008 The American Association for Thoracic Surgery
Reply to the Editor:
In Kyu Park, MD
Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
We thank Dr. Conti and associates for their comments on our report.1
We agree that conservative management could be the best method for the treatment of postintubation tracheal rupture (TR), especially in stable and spontaneously ventilating patients. However, we disagree with their remark that surgical treatment results in a higher mortality rate than conservative or mechanical ventilation in TR. According to reports about experience with surgical treatment based on relatively large series of patients,2-4 there were no operation-related deaths or complications after surgical treatment for TR. The cause of death in TR was not the surgical treatment but the underlying condition that necessitated intubation. Surgical treatment was also safe for patients in stable condition.
In general, conservative treatment is selected for first-line treatment. However, we cannot conclude that conservative treatment can succeed in all patients on the basis of experience from this small series of patients.5 If conservative management fails, subsequent surgical treatment would be more complicated and the chance of mortality would increase. Mechanical ventilation (MV) with bridging or selective ventilation also could be applied in patients unfit for conservative care. However, MV needs complicated management and intensive care, which could induce unforeseen complications. MV requires more medical facilities, cost, and time. Treatment failure with MV is also fatal. Of 14 patients treated by MV in the report by Conti and associates,5 1 patient died suddenly on day 3 after an episode of acute hypoxemia, which might be a complication of TR, and 2 patients could not survive despite delayed surgical treatment. Surgical treatment has some advantages over conservative treatment or MV. It is definitive and safe treatment. The success rate is also high. The duration of treatment is relatively short. A weak point is the invasiveness. However, this could be minimized with various less invasive approach methods such as our method. It is apparent that conservative treatment can be the first choice in patients who are in stable condition and breathing spontaneously after TR according to the experience of recent literature and Conti's work. However, physicians should be able to select the best method and offer tailored treatment for each patient on the basis of clear knowledge about advantages and disadvantages of each treatment modality because TR mostly develops in complicated situation and the failure of the treatment might be fatal. The patient in our report1 was not suitable for conservative treatment because she was not in stable condition and spontaneous ventilation seemed impossible. We thought that more definitive treatment and a shorter duration of treatment would be better for this elderly patient in poor condition. We already had enough experience with tracheal surgery and confidence about surgical outcome. We selected to use surgical treatment as the treatment of choice.
References
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