J.M. Wihlm

J.M. Wihlm

Conservative vs. surgical approach in tracheo-bronchial traumas

Department ofThoracic Surgery,

Strasbourg, FranceLes HôpitauxUniversitairesde STRASBOURG

Classification of tracheo-bronchial traumasClassification of tracheo-bronchial traumas Controversy about conservative managementControversy about conservative management Tracheal laceration after intubationTracheal laceration after intubation Criteria for conservative or surgical treatmentCriteria for conservative or surgical treatment ConclusionConclusion

Tracheo-bronchial traumas

Classification of tracheo-bronchial traumasClassification of tracheo-bronchial traumas

blunt injuryblunt injury 1-2%1-2%

penetrating injurypenetrating injury 2-9%2-9% gunshotgunshot stabstab

iatrogeniciatrogenic endoscopicendoscopic intubationintubation

combined : combined : larynx, esophaguslarynx, esophagus

Incidence

Location

Controversy about conservative managementControversy about conservative management

Surgical treatmentSurgical treatment Grillo, Mathisen, Symbas ...Grillo, Mathisen, Symbas ... Couraud, Marty-Ane, Massard ...Couraud, Marty-Ane, Massard ...

Conservative managementConservative management surgical seriessurgical series

D'Odemont, Amauchi, Jones ...D'Odemont, Amauchi, Jones ... individual publicationsindividual publications

Molins ...Molins ... discussions ...discussions ...

Post-traumatic tracheobronchial lesionsPost-traumatic tracheobronchial lesions

Total cicumferential disruptionsTotal cicumferential disruptions 2424 Laryngo-tracheal junctionLaryngo-tracheal junction 1414 TracheaTrachea 1 1 Main bronchiMain bronchi 7 (1+) 7 (1+) Lobar bronchiLobar bronchi 2 2

Non- cicumferential disruptionsNon- cicumferential disruptions 2323 Laryngo-tracheal junctionLaryngo-tracheal junction 6 6 TracheaTrachea 9 9 Main bronchiMain bronchi 4 (3+) 4 (3+) Lobar bronchiLobar bronchi 4 4

Velly, Couraud : Eur J Cardio-thoracic Surg (1991) 5 : 352-355

47 cases


Associated lesionsAssociated lesions

MusculoskeletalMusculoskeletal 2727 BrainBrain 1919 Pulmonary arteryPulmonary artery 4 (2+) 4 (2+) EsophagusEsophagus 2 (1+) 2 (1+) SpineSpine 4 4 HeartHeart 1 1 AortaAorta 1 1


47 cases


Treatment Treatment (1)(1)

Death before treatmentDeath before treatment 2 2 Medical and endoscopic managementMedical and endoscopic management 77 Surgical procedureSurgical procedure 3838

End-to-end anastomosisEnd-to-end anastomosis 2020 with stentingwith stenting 1313

Suture of lacerationSuture of laceration 14 (1+)14 (1+) Pulmonary resectionPulmonary resection 4 (1+) 4 (1+)


47 cases


Treatment Treatment (2)(2)

Medical and endoscopic managementMedical and endoscopic management : : 77

Laryngotracheal intubation + laserLaryngotracheal intubation + laser 22 partial laryngotracheal disruptionpartial laryngotracheal disruption associated injuries of the larynxassociated injuries of the larynx

Medical + endoscopic follow-upMedical + endoscopic follow-up 55 short tracheal lacerationshort tracheal laceration partial bronchial disruptionpartial bronchial disruption


47 cases

1980 - 19951980 - 1995

14 patients14 patients

1 male : 1 male : 13 females13 females

median age : 54 years (15 - 80)median age : 54 years (15 - 80) mechanismmechanism : :

- single lumen tube :9

- tracheostomy :4

- double lumen tube :1

Tracheobronchial lacerations Tracheobronchial lacerations after intubation and tracheostomyafter intubation and tracheostomy

Massard, Wihlm : Ann Thorac Surg (1996) 61: 1483-87

1- circumstances1- circumstances

females :females : 9 9

surgery : 7surgery : 7 intensive care : 2intensive care : 2

2 : difficult intubation (stylet)2 : difficult intubation (stylet)

4 : selective right main-stem intubation4 : selective right main-stem intubation

experienced physician in all events

Tracheobronchial lacerations after intubationTracheobronchial lacerations after intubation


2- signs and diagnosis

constant signs :pneumomediastinum / cervical emphysema

accessory signs :pneumothorax : 2

moment of diagnosis :induction : 1 recovery room : 2



3- Location of tracheal tears (n=9)3- Location of tracheal tears (n=9)

25 25

1

1

1

1


Endoscopic viewEndoscopic view

4- Interval between injury & repair4- Interval between injury & repair

1 2 3 4 5 6 7 8 90

50

100

150d

éla

is (

he

ure

s)


5- treatment5- treatment

armed expectancy : 3armed expectancy : 3

emergency repair : 6emergency repair : 6

- cervical approach- cervical approach : : 11

- right side thoracotomy : 5- right side thoracotomy : 5

suture-repair of membranosa + pleural flapsuture-repair of membranosa + pleural flap



6- modalities of anaesthesia

proximal tear :selective right or left sided single lumen intubation (endoscopic control)

distal tear :- proximal single lumen intubation- as the tear is exposed :

- 4 x selective intubation of left bronchus

- 1 x Jet



7- results

weaning and extubation :- early < 12 hours : 4

- intermediate = 24 hours : 1- delayed POD+5 : 1

tracheal and bronchial healing- per primam : 8

- covered dehiscence : 1



Discussion : Mechanisms

inexperience or technical difficulties are not the primum movens

cuff inflation +++

selective right side intubation !


Mechanism of intubation-related tracheal tears

Conclusion

Prognosis depends mainly on

precociousness of diagnosis and treatment

underlying health state

Conservative treatment is an option



Criteria for conservative or surgical treatmentCriteria for conservative or surgical treatment

ElectiveElective circumstancescircumstances

causecause delay in diagnosisdelay in diagnosis

clinical and radiological symptomsclinical and radiological symptoms locationlocation

laryngo-tracheal disruption + assoc. lesionslaryngo-tracheal disruption + assoc. lesions membraneous tracheamembraneous trachea distal bronchusdistal bronchus

endoscopic presentation : endoscopic presentation : covering, gap

length of tear : < 3cm, partiallength of tear : < 3cm, partial

A.

Criteria for conservative or surgical treatmentCriteria for conservative or surgical treatment

ImposedImposed general conditiongeneral condition

ageage delay in diagnosisdelay in diagnosis sepsis and inflammationsepsis and inflammation

ventilator dependencyventilator dependency associated lesionsassociated lesions

brain injurybrain injury polytraumapolytrauma

failure of initial treatmentfailure of initial treatment

B.

Surgical approach = gold standardSurgical approach = gold standard

Multiple anatomo-clinical presentationsMultiple anatomo-clinical presentations

Conservative treatment in selected casesConservative treatment in selected cases

Controversy necessary for improving bothControversy necessary for improving both

selection and care of a still severe conditionselection and care of a still severe condition

ConclusionConclusion

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J.M. Wihlm