Does less surgical trauma result in better outcome in management of iatrogenic tracheobronchial laceration?

Abstract

Background: Iatrogenic tracheobronchial injury is a rare, but severe complication of endotracheal intubation. Risk factors are emergency intubation, percutaneous dilatational tracheostomy and intubation with double lumen tube. Regarding these procedures, underlying patients often suffer from severe comorbidities. The aim of this study was to evaluate the results of a standardized treatment algorithm in a referral center with focus on the surgical approach. Methods: Sixty-four patients with iatrogenic tracheal lesion were treated in our department by standardized management adopted to clinical findings between 2003 and 2019. Patients with superficial laceration were treated conservatively. In the case of transmural injury of the tracheal wall and necessity of mechanical ventilation, patients underwent surgery. We decided on a cervical surgical approach for lesions limited to the trachea. In case of involvement of a main bronchus we performed thoracotomy. Data were evaluated retrospectively. Results: In 19 patients the tracheal lesion occurred in elective intubation and in 17 patients during emergency intubation. In 23 cases a tracheal tear occurred during percutaneous dilatational tracheostomy and in three patients at replacement of a tracheostomy tube. Two patients received laceration during bronchoscopy. Twenty-nine patients underwent surgery with cervical approach and 14 underwent thoracotomy. There was no difference in the mortality of these groups. Treatment of tracheal tear was successful in 62 individuals. Nine patients died of multi organ dysfunction syndrome (MODS), two of them during surgery. Conclusions: Iatrogenic tracheal laceration is a life-threatening complication and the mortality after tracheal injury is high, even in a specialized thoracic unit. Conservative management in patients with superficial tracheal lesion is a feasible procedure. In case of complete laceration of tracheal wall, surgical therapy is recommendable, whereby several approaches of surgical management seem to be equivalent.

Prognostic Factors for Iatrogenic Tracheal Rupture: A Single-Center Retrospective Cohort Study

“…These high rates reflect that most of our patients were critically ill or had undergone airway management measures due to acute emergency conditions. Our results are in line with other studies and our own previous results that preinjury morbidity and underlying disease play key roles in outcome and that adjusted mortality numbers are considerably lower compared with those of all-cause mortality [2][3][4][5][8][9][10]13,14].…”

“…Studies involving higher patient numbers or prospective randomized controlled trials of iatrogenic tracheal rupture are not available. Only a few studies have included cohorts with only one causative procedure (e.g., single-and/or double-lumen tracheal intubation-related, tracheotomy-related, or surgery-related procedures) [2,9,16], and most studies included different proportions of these iatrogenic causes [5,6,8,[10][11][12][13][14]. Furthermore, some studies also present a variety of other, noniatrogenic causes, leading to tracheobronchial injuries [11,17].…”

“…Rupture length was significantly associated with all-cause mortality, although it has previously not been identified for the prediction of any outcome [2]. Recently, Herrmann et al published a large series of 64 patients with a hospital mortality of 15.6% (n = 10); of these, 30 patients with a rupture length of up to 4 cm and 24 patients with a rupture length exceeding 4 cm survived (p = 0.498) [14]. They concluded that there was no association between rupture length and mortality.…”

“…Iatrogenic tracheal ruptures are rare but severe complications of medical interventions. Their incidence is reported to be approximately 0.005% in single-lumen intubations, 0.05-0.19% in double-lumen intubations, and up to 1% in percutaneous dilation tracheotomies [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. The risk factors are unspecific and not applicable for identifying high-risk patients, given the high numbers of procedures that are performed daily.…”

“…Due to different causative events, which are each associated with various risk factors (i.e., skills and training of the operator, anatomy and morbidity of the patient), clear prognostic determinants are difficult to identify. There is a common agreement that prognosis is widely dependent on the severity of underlying diseases, but studies focusing on outcome prediction are scarce [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. In the literature, predictive power related to outcomes has been observed for delayed diagnosis and therapy in general, surgical or conservative treatment in particular, and occurrence of mediastinitis, sepsis, and suture insufficiency [1][2][3][4][5][6][7][8][9][10][11][12][13][14].…”