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Reviews

Tracheal rupture after endotracheal intubation: a literature systematic review

^a Service of Intensive Care, Marqués de Valdecilla University Hospital, Santander, Spain
^b Division of Epidemiology and Computational Biology, University of Cantabria, Santander, Spain
^c CIBER Epidemiología y Salud Pública (CIBERESP), Spain
^d Public Health Technic, Servicio Cantabro de Salud, Santander, Spain

Received 24 July 2008; received in revised form 15 January 2009; accepted 22 January 2009.

^_* Corresponding author. Address: Service of Intensive Care Medicine, Hospital Universitario Marqués de Valdecilla, Avenida Marqués de Valdecilla s/n, E-39008 Santander, Spain. Tel.: +34 942 203304; fax: +34 942 203543. (Email: jandro120475{at}hotmail.com).

We aim to perform a systematic review and meta-analysis of the cases of postintubation tracheal rupture (PiTR) published in the literature, with the aim of determining the risk factors that contribute to tracheal rupture during endotracheal intubation. A further objective has been to determine the ideal treatment for this condition (surgical repair or conservative management). A MEDLINE review of cases of tracheal rupture after intubation published in the English language and a review of the references in the articles found. The articles included were those that reported at least the demographic data (age and sex), the treatment performed, and the outcome. Those papers that did not detail the above variables were excluded. The search found 50 studies that satisfied the inclusion criteria. These studies included 182 cases of postintubation tracheal rupture. The overall mortality was 22% (40 patients). A statistical analysis was performed determining the relative risk (RR), 95% confidence intervals (95% CI) and/or statistical significance. The analysis was performed on the overall group and after dividing into 2 subgroups: patients in whom the lesion was detected intraoperatively, and other patients. Patient age (p = 0.015) and emergency intubation (RR = 3.11; 95% CI, 1.81–5.33; p = 0.001) were variables associated with an increased mortality. In those patients in whom the PiTR was detected outside the operating theatre (delayed diagnosis), emergency intubation (RR = 3.05; 95% CI, 1.69–5.51; p < 0.0001), the absence of subcutaneous emphysema (RR = 2.17; 95% CI, 1.25–4; p = 0.001), and surgical treatment (RR = 2.09; 95% CI, 1.08–4.07; p = 0.02) were associated with an increased mortality. In addition, age (p = 0.1) and male gender (RR = 1.89; 95% CI, 0.98–3.63; p = 0.13) showed a clear trend towards an increased mortality. PiTR is an uncommon condition but carries a high morbidity and mortality. Emergency intubation is the principal risk factor, increasing the risk of death threefold compared to elective intubation. Conservative treatment is associated with a better outcome. However, the group of patients who would benefit from surgical treatment has not been fully defined. Further studies are required to evaluate the best treatment options.

Key Words: Meta-analysis • Tracheal rupture • Intubation