Tracheal lacerations after endotracheal intubation: a proposed morphological classification to guide non-surgical treatment☆☆☆

Abstract

Level I or II PITL should be managed non-surgically. When adequate respiratory status is present, Level IIIA PITL can be managed conservatively in selected institutions only, because these injuries are high-risk injuries. Any PITL associated with injury involving the oesophagus or with mediastinitis (Level IIIB) must be treated as soon as possible by surgery.

Does Surgical Repair Still have a Role for Iatrogenic Tracheobronchial Rupture? Clinical Analysis of a Thoracic Surgeon’s Opinion

“…Cardillo et al 6) reported that lesions are classified into four types depending on the depth of the tracheal injury: Level I includes injuries with mucosal or submucosal tracheal involvement without mediastinal emphysema and without esophageal injury; level II includes tracheal lesions up to the muscular wall with subcutaneous or mediastinal emphysema but without esophageal injury or mediastinitis; level IIIA is a complete laceration of the tracheal wall with an esophageal or mediastinal soft-tissue hernia but without esophageal injury or mediastinitis; and level IIIB is any laceration of the tracheal wall with an esophageal injury or mediastinitis. 6) The authors reported no mortalities and postulated that conservative treatment was possible even with a complete laceration of the tracheal wall if no esophageal injury or mediastinitis was present (level IIIA). We disagree with his opinion.…”

“…Generally, the indications for conservative treatment are as follows: 1) stable vital signs, 2) spontaneous ventilation, 3) absence of esophageal injury, 4) non-progressive pneumomediastinum with/without subcutaneous emphysema, and 5) no signs of sepsis. [1][2][3][4][5][6] Surgical repair is highly recommended under some clinical situations. First, a tracheal injury of >2 cm should be treated surgically.…”

“…Recently, conservative treatment has been preferred to primary treatment because mortality and morbidity due to conservative treatment are significantly lower than that following surgery. [1][2][3][4][5][6] However, the question of surgical or conservative treatment for ITBR has not been determined until now. It is difficult to conclude that conservative treatment is superior to surgery despite the fact that the reported absolute mortality due to surgery is higher than that of conservative treatment.…”

Post-Intubation Tracheal Tearing in a Young Woman with Rheumatoid Arthritis

“…First, technical errors, including intubation by force, inexperienced hands, inappropriate tube size, over distended cuff. Second, factors related to the patient condition, consist of tracheal anomalies, old age patients, chronic corticosteroid therapy, short stature, female sex and COPD [5][6][7].…”

Endoscopic treatment with fibrin glue of post-intubation tracheal laceration

“…Some authors recommend surgery while others do not definitely exclude endoscopic treatment giving a greater attention to the depth of the tracheal injury than to its length (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Recently, Cardillo et al (12) classified PITL into four levels according to the depth of the tracheal fear and proposed a protocol for its management. Level I: laceration of mucosa and submucosa with subcutaneous or mediastinal emphysema; Level II: tracheal lesion up to the muscularis wall without mediastinal emphysema and without oesophageal injury; Level III-A: complete laceration of the tracheal wall with oesophageal or mediastinal soft-tissue hernia without oesophageal injury or mediastinitis; and Level IIIB: any laceration of tracheal wall with oesophageal injury or mediastinitis.…”