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Management of postintubation tracheal ruptures

2008; Elsevier BV; Volume: 136; Issue: 1 Linguagem: Inglês

10.1016/j.jtcvs.2008.01.024

1097-685X

Alain Wurtz, Lotfi Benhamed, Massimo Conti, Henri Porte,

Airway Management and Intubation Techniques

To the Editor: We read with interest the article by Park and colleagues,1Park I.K. Lee J.G. Lee C.Y. Kim D.J. Chung K.Y. Transcervical intraluminal repair of posterior membranous tracheal laceration through semi-lateral transverse tracheotomy.J Thorac Cardiovasc Surg. 2007; 134: 1597-1598Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar who described a new approach for the intraluminal repair of membranous tracheal rupture (TR) after emergency intubation. We congratulate them for their result in an elderly patient in poor condition. The authors discussed the value of the different approaches to surgical treatment of TR, mainly transtracheal endoluminal repair through different-shaped anterior tracheotomies. They consider the endoluminal approach “technically complicated owing to limited accessibility and needs a relatively long tracheal injury and complex ventilation management.” We agree with this opinion even though semilateral transverse tracheotomy allows better repair in this field. However, conservative treatment was not discussed, and we consider that the patient could have been managed as follows: prompt placement of a tube in the left side of the chest, microdrainage of subcutaneous emphysema, and advancement of the endotracheal tube distal to the TR to ensure bridging the lesion and mechanical ventilation, which was required to treat the underlying conditions (atelectasis, delirium). According to the evidence accumulated in the recent literature and our own experience,2Beiderlinden M. Adamzik M. Peters J. Conservative treatment of tracheal injuries.Anesth Analg. 2005; 100: 210-214Crossref PubMed Scopus (53) Google Scholar, 3Gómez-Caro Andrés A. Moradiellos Díez F.J. Ausín Herrero P. Díaz-Hellín Gude V. Larrú Cabrero E. de Miguel Porch E. et al.Successful conservative management in iatrogenic tracheobronchial injury.Ann Thorac Surg. 2005; 79: 1872-1878Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 4Meyer M. Iatrogenic tracheobronchial lesions: a report on 13 cases.J Thorac Cardiovasc Surg. 2001; 49: 115-119Crossref Scopus (46) Google Scholar, 5Conti N. Pougeoise M. Wurtz A. Porte H. Fournier F. Ramon Ph et al.Management of postintubation tracheobronchial ruptures.Chest. 2006; 130: 412-418Crossref PubMed Scopus (143) Google Scholar surgical treatment of postintubation TR leads to higher mortality than does conservative management. In patients managed surgically, the initial indication for which the patient was intubated plays a crucial role in postoperative mortality: among patients who underwent emergency intubation for an acute medical event, surgery is usually a high-risk procedure4Meyer M. Iatrogenic tracheobronchial lesions: a report on 13 cases.J Thorac Cardiovasc Surg. 2001; 49: 115-119Crossref Scopus (46) Google Scholar as compared with conservative management (mortality rate 47% vs 29%).5Conti N. Pougeoise M. Wurtz A. Porte H. Fournier F. Ramon Ph et al.Management of postintubation tracheobronchial ruptures.Chest. 2006; 130: 412-418Crossref PubMed Scopus (143) Google Scholar Such a high mortality for the repair of TR demands that alternatives to high-risk surgery be considered and surgical repair be reserved for patients in whom bridging the lesion is technically not feasible or for patients with TR diagnosed during thoracic surgery.