Post-intubation iatrogenic tracheobronchial injuries: The state of art

Abstract

Iatrogenic tracheobronchial injury (ITI) is an infrequent but potentially life-threatening disease, with significant morbidity and mortality rates. Its incidence is presumably underestimated since several cases are underrecognized and underreported. Causes of ITI include endotracheal intubation (EI) or percutaneous tracheostomy (PT). Most frequent clinical manifestations are subcutaneous emphysema, pneumomediastinum and unilateral or bilateral pneumothorax, even if occasionally ITI can occur without significant symptoms. Diagnosis mainly relies on clinical suspicion and CT scan, although flexible bronchoscopy remains the gold standard, allowing to identify location and size of the injury. EI and PT related ITIs more commonly consist of longitudinal tear involving the pars membranacea. Based on the depth of tracheal wall injury, Cardillo and colleagues proposed a morphologic classification of ITIs, attempting to standardize their management. Nevertheless, in literature there are no unambiguous guidelines on the best therapeutic modality: management and its timing remain controversial. Historically, surgical repair was considered the gold standard, mainly in high-grade lesions (IIIa-IIIb), carrying high morbi-mortality rates, but currently the development of promising endoscopic techniques through rigid bronchoscopy and stenting could allow for bridge treatment, delaying surgical approach after improving general conditions of the patient, or even for definitive repair, ensuring lower morbi-mortality rates especially in high-risk surgical candidates. Our perspective review will cover all the above issues, aiming at providing an updated and clear diagnostic-therapeutic pathway protocol, which could be applied in case of unexpected ITI.

Neck and breast swelling after tracheal intubation

“…1 The usual clinical presentations are neck and upper-trunk emphysema and respiratory symptoms. 1 Despite its rarity, the recent COVID-19 pandemic has raised issues regarding severe tracheal complications associated with invasive mechanical ventilation. 2 The risk factors are older age, female sex, corticosteroid use, COVID-19, multiple attempts at tracheal intubation, and inappropriate cuff pressure and cuff size.…”

“…1,3 Endoscopy remains the gold standard for diagnosing tracheal tears and assessing their severity. 1 Surgical or endoscopic approaches are often needed if the patient's clinical status deteriorates, especially in patients complicated with compartment syndrome, but a conservative approach can be adopted for asymptomatic or stable patients. 1,4…”

“…Tracheobronchial injury is a rare complication of tracheal intubation due to advancements in medical devices and the development of less invasive procedures 1 . The usual clinical presentations are neck and upper‐trunk emphysema and respiratory symptoms 1 .…”

“…Despite its rarity, the recent COVID‐19 pandemic has raised issues regarding severe tracheal complications associated with invasive mechanical ventilation 2 . The risk factors are older age, female sex, corticosteroid use, COVID‐19, multiple attempts at tracheal intubation, and inappropriate cuff pressure and cuff size 1,3 . Endoscopy remains the gold standard for diagnosing tracheal tears and assessing their severity 1 .…”

Tracheobronchiale Verletzungen

“…Auch hier wird im Stadium PITL IIIA nur bei einem spontan atmenden Patienten ein konservatives Management empfohlen und auf das Stadium PITL IIIB ausgeweitet. Ein erfolgreiches Management von Patienten im Stadium IIIB über den Einsatz von Nitinol-Stents wird von Passera et al beschrieben[4,26].Die Behandlung sollte somit über ein multidisziplinäres Management durch Chirurgen, Intensivmediziner, Pneumologen und Infektiologen erfolgen[4]. Die Therapie in einem interdisziplinären Setting ist bei den betroffenen Patienten mit den grundlegenden Begleiterkrankungen absolut obligat.Sowohl instabile Patienten mit einer ITV im PITL-Stadium IIIA und IIIB als auch Patienten mit einem PITL-Stadium IV sollten einer sofortigen operativen Therapie zugeführt werden, um die klaffenden Wundränder zu adaptieren und so einen kontinuierlichen Atemweg sicherzustellen[18,26] und die Mediastinitis zu behandeln.Ein vereinfachtes Schema der therapeutischen Optionen ist in ▶ Abb.3 wiedergegeben.…”