Modern Management of Penetrating Tracheal Injuries

Abstract

Complications after tracheal repair in the past have included wound infections, tracheal stenosis, “spitting” of sutures, and tracheoesophageal fistulas. Modern operative approaches have significantly decreased the incidence of these complications. We conducted retrospective data collection using the TRACS database. Changes that preceded the time interval of the study included the following: 1) an emphasis on clinical (rather than endoscopic) recognition of injury; 2) minimal peritracheal dissection and repair with absorbable sutures; 3) limited use of “protective” tracheostomies; and 4) use of muscle buttresses to cover tracheal repairs, especially in patients with combined injuries. From 1997 to 2010, 22 patients were treated for wounds to the trachea (cervical 20, thoracic 2). The mechanism of injury was a gunshot wound in 15 patients and a stab wound in seven. A clinical diagnosis of the need for cervical operation or of a tracheal injury was made in 19 patients (86%), whereas three patients had positive diagnostic studies. Direct tracheal repair (No. 19) or evaluation of a superficial injury (No. 1) was performed in 20 patients, and three (15%) had a tracheostomy performed. Combined injuries were present in 12 patients (55%), most commonly to the esophagus (10 of 12 [83%]), and 10 of these 12 patients had vascularized buttresses applied to the tracheal repair. There were seven significant complications in patients with combined injuries to the esophagus or carotid artery. One patient (4.5%) died. Patients with penetrating tracheal injuries most commonly present with overt findings. Modern techniques of repair have eliminated many of the complications noted in the past.

Treatment of Tracheobronchial Injuries

“…Risk factors for tracheobronchial injury can be categorized as mechanical and anatomic (Table 2). [1][2][3][4][5][6][7]11,12,[27][28][29][30][31] Of these, the most important modifiable risk factors are procedural or instrumentation related. These risk factors can be addressed by appropriate education about airway treatment.…”

“…Penetrating airway injury can occur from sharp objects, such as knives and ice picks, or from gunshot wounds. [2][3][4][5] Iatrogenic airway injury can occur during surgery, endotracheal (ET) intubations, or bronchoscopy. [6][7][8][9][10] The incidence of airway injury is likely to be underestimated as these injuries are often underrecognized and underreported.…”

Diagnostic and therapeutic approach to post-traumatic tracheobronchial injuries

“…They also therefore must be carefully assessed during the diagnostic and intraoperative evaluation. Penetrating airway trauma, mostly due to knives or gunshot wounds, may involve any part of the tracheobronchial tree [15]. However, penetrating injuries of the intrathoracic trachea and main bronchi are seldom recognized, since they are usually associated with lesions of the heart and major vessels that lead to death before a diagnosis is obtained.…”

Use of Platelet Rich Plasma (PRP) in the Treatment of Acute Post Intubation Tracheal Rupture: Report of Two Cases

“…In medium or distal third lesions a right posterolateralthoracotomy using intercostal muscle flap to buttress the tracheal suture is the most performed technique. However, with surgical approach there is always the risk of wound infection, leaking of sutures, post operative tracheal stenosis and fistulas [19]. Alternatives to this surgery are the realization of a decompression tracheostomy in order to wait for the spontaneous healing of the defect, the use of fixed or removable stents and lately the intraluminal suture using an optical needle holder with telescope which avoids surgical access but needs high frequency jet ventilation, not available everywhere, to obtain good ventilation and less movement of the site of operation [19]- [22].…”