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Eur J Cardiothorac Surg 2001;20:46-52
© 2001 Elsevier Science NL

Acute major airway injuries: clinical features and management

Division of Thoracic Surgery, Cardiac and Thoracic Department, University of Pisa, Pisa, Italy

Received 10 October 2000; received in revised form 17 January 2001; accepted 21 March 2001.

Corresponding author. Tel.: +39-050-995211/995230; fax: +39-050-577239
e-mail: m.ambrogi{at}med.unipi.it

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objective: Patients with an acute major airway injury are coming at our attention with increasing frequency. Despite of its nature, post-traumatic or iatrogenic, these lesions may be life-threatening. An early diagnosis and a prompt treatment reduce morbidity and mortality. Materials and methods: In the last 10 years, on a total of 55 patients treated in our institution for benign lesions of the major airway, 20 were with an acute injury; eleven females and nine males with a mean age of 58 years (range of 24–92). Twelve lesions were iatrogenic (orotracheal intubation) and eight were post-traumatic (three blunt traumas, five penetrating traumas). The cervical trachea was involved in 13 cases (one associated to an incomplete esophageal transection and two associated to laryngeal injuries), the thoracic trachea in six cases (four extended to the right mainstem one and to the left). Sixteen patients underwent immediate surgical repair (13 direct sutures of the tear and three complex restorations of the airway): 11 by cervicotomy and five by thoracotomy. In six cases the suture of a posterior tracheal wall tear was achieved through a new approach which provides for a small collar incision and a longitudinal tracheotomy. Results: All the patients were discharged healed with a normal patency of the airway. At a mean follow up of 49 months (range of 9–122) endoscopy showed a perfect healing process of the lesions. One patient, treated in a conservative fashion, required endoscopic laser Nd-YAG removal of a granuloma. Conclusion: Early diagnosis and surgical repair are the goals to persecute to achieve the best outcomes in this potentially lethal lesions. The surgical approach should be the thoracotomy if the trauma involves the 1/3 inferior trachea and/or a mainstem, the cervicotomy in the case it was injured the 2/3 superior trachea and the larynx. Posterior tracheal wall tears may be repaired via the new transcervical/transtracheal technique. The conservative treatment should be reserved to those patients with minimal signs and symptoms, and with an adequate patency of the airways.

Key Words: Tracheobronchial • Laryngeal • Post-intubation • Trauma • Injury • Treatment

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Acute major airways injuries (AMAI) are still a life-threatening event and a lot of author suggest that an early diagnosis and a prompt treatment are mandatory to improve their outcome [1–3]. Patients with post-traumatic AMAI often had associated injuries that must be recognised in order to plan the right timing of management. However it must be borne in mind that usually the first priority is to secure and airway and to restore airway continuity [1]. In the most of cases, instead, iatrogenic AMAI (post-intubation and post-tracheotomic) are not immediately life-threatening but often are responsible of early and late sequelae, such as mediastinitis and tracheal stenosis [4].

In both cases the surgical repair is the treatment of first choice, and only in selected patients a conservative therapy may be engaged [3,5]. So, when an early diagnosis is made and the right treatment performed, the prognosis for the patient depends more frequently on eventually associated injuries and diseases than on the airway lesion itself.

Actually more patients with a tracheobronchial disruption are arriving still alive at our attention because of improvements in pre-hospital care, early application of the advanced trauma life support (ATLS) and faster transport to hospital emergency ward [2,6].

This increasing frequency, which agrees with our recent experience, led us to retrospectively review our series of AMAI and to compare it with the literature in order to determine how to better recognise such lesions and facilitate their correct management.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
We reviewed our records, over the past 10 years, of patients who went to our attention and were treated for an AMAI. We determined and here reported patients population, aetiology and location of the lesions, clinical features, methods of diagnosis, early airway management and definitive treatment, outcomes.

2.1. Clinical features
Twenty patients were found, 11 (55%) were female and nine (45%) male with a mean age of 58 years (range of 24–92).

Five patients were with a penetrating injury – one stab wound, two gunshot wounds, one metal splinter perforation in a man who was working with a cutter, one metal wire transection in a young man who was riding a scooter when was hit in the anterior neck by an unseen metal wire stretched across the road. Three patients had a blunt trauma by car crash. The other 12 patients were with a post-intubation tear – due to selective double-lumen intubation in three cases.

Twelve lacerations (60%) were in the cervical trachea, two lesions (10%) were in the thoracic trachea only and five (25%) extended to a main bronchus – the left in one case and the right in four cases – one lesions (5%) involved the laryngotracheal junction.

The most common signs and symptoms are summarised in Table 1. Subcutaneous emphysema has reported to be quite always present, and it was massive in 12 patients. One patient was with a large transverse cervical wound and a complete transection of the cervical trachea. In two patients an intubation related tear has been revealed during the same operation which required general anaesthesia – a pulmonary right upper lobectomy in one case and the removal of a large posterior mediastinal goitre via thoracotomy in the other case. All other patients with a post-intubation related tear had the appearance of subcutaneous emphysema of the upper chest and neck immediately after the extubation or within the following 12 h.

Eighteen patients underwent fiberoptic bronchoscopy that always confirmed the diagnosis and allowed to precisely determine site, extension and depth of the lesion. Three patients with penetrating injuries underwent oesophagoscopy which revealed a subtotal transection of the cervical oesophagus in one case.

Seventy-five percent (6/8) of the patients with post-traumatic lesion were with associated injuries. Three patients had a pneumothorax which required chest tube drainage and was associated to hemothorax in two cases. There were two patients with fractured ribs – in one case associated to pulmonary contusions. In two cases there was an associated laryngeal lesion – one penetrating by small shotgun bullet and one blunt trauma with the simple median fracture of the thyroid cartilage. In one patient the oesophagus was sub-totally transected. We also experienced one laryngeal nerve injury, one bullet lung perforation, one long bone fracture.

2.2. Management
Four patients arrived at the emergency room with severe respiratory distress requiring early control of the airway. The patient with a metal wire complete transection of the trachea was directly intubated through the anterior cervical wound. In one case a tracheotomy was performed due to the laryngeal fracture associated to a partial cricotracheal disruption. Two patients required emergency orotracheal intubation which was carried out under the guide of a fiberoptic bronchoscope in one case.

Treatment of the AMAI was in a conservative fashion in four patients. In all these cases clinical and radiological manifestations were pour and non-progressive. Two patients were with a post-intubation injury of the membranous wall. One patient had the perforation of the anterior wall from a metal splinter that stopped into the trachea without injury of the membranous wall and was coughed out. And another one was struck by two small shotgun bullets that crossed the cervical trachea and the larynx laterally from side to side. In all these cases bronchoscopy showed small tears (less than 3 cm in length) not gaping during respiratory airflow.

All other patients underwent surgical repair of the lesion within 12 h from the diagnosis. In all cases orotracheal intubation was performed under bronchoscopic guide. It was selective in six patients – with a double lumen tube in three cases and with a single lumen tube in the other three patients. Surgical approaches selected are summarised in Table 2 and they were related to the location of the laceration. In five cases the surgical incision was a right posteriorlateral thoracotomy, in 11 a cervical collar incision and in one case the repair was performed through the same post-traumatic cervical wound. Thirteen patients underwent the direct repair of the lesion with interrupted or running absorbable (Maxon or Dexon) suture – in six cases the repair of a membranous tracheal tear (in the last case it was just over the carina) was performed through a small mediastinoscopic-like incision and a longitudinal tracheotomy made on the anterior wall, as reported in detail in a previous paper [7]. The patients with a complete transection of the trachea and a nearly total transection of the esophagus underwent a double layer suture of the esophagus and an end to end anastomosis of the tracheal stumps with separate stitches, interposing a sternohyoid muscle flap between the two suture lines (Fig. 1) . Two patients had the fracture of some tracheal rings that required their resection followed by an end to end anastomosis – in one case it was associated a membranous longitudinal tear starting from the distal stump of the trachea probably a consequence of the emergency intubation carried out without the guide of the bronchoscope (Fig. 2) . In one case a simple fracture of the thyroid cartilage was reduced with interrupted absorbable suture.

View larger version (64K): [in this window] [in a new window]   Fig. 1. A total transection of the trachea associated to a subtotal oesophageal cross section was repaired with direct suture (two layers for oesophagus) interposing a sternohyoid muscle flap between the two suture line.

View larger version (125K): [in this window] [in a new window]   Fig. 2. One tracheal ring partially disrupted by the bullet was resected and the iatrogenic longitudinal membranous tear was sutured through the consequent transverse tracheotomy, then airway continuity restored by suturing the anterior tracheal wall.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

All the surgical procedures were effective in restoring an adequate airway continuity. No patient required mechanical ventilation after the operation. Fifteen patients were extubated at the end of the surgical procedure. The patient with the tracheostomy was successfully decannulated 10 days later. We had neither perioperative morbidity nor mortality. All patients were discharged healed with a normal patency of the airway on average 9 days (range of 3–15) after the surgical procedures. A mean endoscopic follow-up of 49 months (range of 9–122) always showed a perfect healing process of the lesions without signs of tracheobronchial stenosis. One granuloma, in a patient treated in the conservative way, was removed by laser Nd-YAG during a fiberoptic Bronchoscopy.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Acute major airway injuries may be related to traumatic events, and generally are reported subdivided in blunt and penetrating injuries, or to medical procedure, usually during general anaesthesia or tracheotomy. If the mechanisms for the penetrating lesions is clear, and gunshot or knife wound are the most responsible, that of the blunt ones have been postulated by Kirsh in 1976 [8]. He described three mechanisms: first, a rapid compression of the thoracic cage widens transverse diameter that produce a quick lateral motion of the two lungs with a traction on the trachea at the carina; second, if the glottis is closed when the impact occurs, the intratracheobronchial pressure may exceed their elastic strength; third, rapid deceleration produce shearing forces where the tracheobronchial tree is more fixed. Moreover, a direct hit on the anterior neck may result in fracture of tracheal rings and laryngeal cartilage. Iatrogenic injuries may be a rare complication of general anesthesia or produced during tracheostomic procedures [4,9]. Similarly to our experience, they have been reported to be associated with both double lumen selective and single lumen intubations. They usually involves the posterior membranous wall and many factors may be responsible for producing the lesion: repeated attempts at a difficult intubation [10], as in one of our cases; the presence of tracheal abnormalities [11] and overdistention or rupture of the tube cuff [4,12]. But many times it occurs after an intubation carried out with no apparent difficulty [13,14] – as in the other cases of this report. Then, the relative high incidence in our series (12 cases in 10 years) may be explained as we are a tertiary referral centre for tracheal surgery in our country.

Despite of their nature, both post-traumatic and iatrogenic injuries of the major airways may be immediately life threatening (above all in the case of bronchial rupture which is often associated to tension pneumothorax and occasionally to a vascular injury that may lead to a massive hemothorax) or responsible of early and belated sequelae, such as a descendent mediastinitis or a tracheal stenosis [1,3,4,15]. Since the report of Kinsella and Johnsrud in 1947 [16], who achieved the first successful repair of a bronchial rupture due to a blunt trauma, several series demonstrated that prompt repair of such lesions produces the best results [2,3,5,15]. More recently, Mathisen and Grillo stressed that successful outcome demands prompt recognition and management of such injuries and failure to accomplish such goals may result in death, multiple reoperations and prolonged tracheostomy [1]. But, as reported by Kelly and Linsey, in the most of trauma centres tracheobronchial injuries are seen only a few times per year and the consequence lack of exposure of individual physicians to such lesions may lead to delay their diagnosis [5]. So, when a physician comes in charge of a patient with a penetrating or blunt injury of the chest and neck he must always keep in mind the possibility of a tracheobronchial lesion. Signs and symptoms that always must give birth to the suspect of a major airway injury are subcutaneous emphysema of the upper chest and neck, hemoptysis and dyspnoea [2,15]. They were quite always present in our series, too (Table 1). Radiology may be helpful to strengthen the suspicious and frequently X-ray chest films reveal subcutaneous air and pneumomediastinum [3,5,17,18], as it happened in 100 and 75%, respectively of our patients (Table 1). Other physical and radiological findings often described in the literature, as well as in our patients, are hemoptysis, shock, cyanosis, pneumothorax, hemothorax, rib fractures and pulmonary contusion.

The liberal use of early fiberoptic bronchoscopy must be encouraged thus it is the only way to confirm the diagnosis [2]. Except for the patient with the large cervical wound, we always performed such examination before to decide a therapeutic strategy. In fact, moreover, it allows to determine location, extension and depth of the lesion in order to choice the correct treatment and, in case of a surgical decision, the right approach. Oesophagoscopy is often required in patients with penetrating and post-tracheotomy injuries due to the possibility of an associated oesophageal perforation, and in this cases a barium swallow may be helpful too [15]. Blunt and post-intubation trauma, instead, are rarely associated to oesophageal injuries as it is evident due to the mechanism that produces them [4].

Only smaller tears, not gaping during respiratory air flow, in patients with minimal and non-progressive clinical manifestations, justify their treatment in a conservative fashion [4,5,17]. In all other cases an aggressive approach is widely accepted and the primary surgical repair preferred [2,3,5,17]. First of all in some patients with large defects of the tracheobronchial tree an urgent control of the airway is often required. Orotracheal intubation is the method of choice and, if possible, it should be performed always under bronchoscopic guide, in order to avoid extensions of the injury [1,3], as it probably happened in one of our cases (Fig. 2). In some cases, above all if a larynx lesion is associated, a tracheostomy could be necessary [1,2]. This was our strategy in the patient with associated thyroid cartilage fracture. In the case of penetrating injury with large cervical wound, instead, intubation may be carried out through the same wound in the distal trachea [2,15], as we did in another case (Fig. 1).

Also patients undergoing surgical treatment must be intubated under bronchoscopic guide, for the same reasons of those intubated in emergency, but in this case such procedure is mandatory. In the most of cases, then, the surgical management consists of debridement and direct repair of the lesion to re-establish airway continuity [1,2,3,15]. We utilised such procedure in 81% of our surgically treated patients. In other cases may be necessary the resection of irreparable segment of the tracheobronchial tree, followed by end to end anastomosis, as well as a resection of lung parenchima [17,19,20]. Two patients of our series underwent resection/anastomosis of the cervical trachea for irreparable fractures of the cartilaginous rings. In one of this cases (Fig. 2), through the transverse tracheotomy which followed the removal of the fractured tracheal ring, we performed the repair of the associated longitudinal membranous tear with a running suture, as recently described by Lanceline and colleagues [21]. Then, a few complex tracheobronchial injuries require skilful surgical management with a good deal of improvisation and fantasy to restore a satisfactory airway continuity [22,23]. The choice of the surgical incision depends from the location of the injury itself. Traditional techniques provide for a right thoracotomy in the case of a juxtacarinal lesion, especially if it involves a main bronchus, and for a cervicotomy if the tear involves the proximal 2/3rd of the trachea, sometimes extended to a sternal split [1,4,24]. In the case of a membranous tear, a left cervicotomy along the sternocleidomastoid muscle or a generous collar incision is usually performed, followed by a lateral and then posterior tracheal dissection in order to isolate the trachea and to reach the membranous wall for suturing. Recently we developed a new approach, suggested by Angelillo Mackinlay in 1995 [14], which provide for a small collar incision, 2 cm above the sternum, followed by a longitudinal tracheotomy that allows to suture the membranous tear, avoiding posterolateral dissection and the risks to injury the recurrent laryngeal nerve and oesophagus. Our preliminary results with this technique were reported in a previous paper [7], and authorises to strongly suggest this technique in the case of membranous tracheal tears.

In conclusion we would like to underline a few points that both for the literature and for our own experience may significantly improve outcomes in patients with AMAI. First of all, an early diagnosis is necessary, and it is not a difficult one if the physician keeps in mind such a possibility in all traumatised patients with subcutaneous emphysema, hemoptysis and dispnoea, or on those who recently underwent tracheal intubation and tracheotomy. And to achieve such goal an aggressive use of bronchoscopy is required, useful to plan the correct management too. Second, all patients must be intubated, either to secure an airway or to start the surgical treatment, under bronchoscopic guide reducing the risks to enlarge the tracheobronchial lesion. Third, primary surgical repair is the treatment of choice and must be performed as soon as possible to avoid infections. In these cases, in addition to the traditional techniques it is to recommend the transcervical transtracheal approach in the case of membranous tears. The tecnique suggested by Angelillo Mackinlay is to prefer in case of membranous tear only, while the transverse tracheotomy approach described by Lanceline must be reserved to the membranous lacerations associated to cartilaginous rings disruption. In fact, we do not think that a circular anastomosis is easier than a linear one and, moreover, the possibility of an anastomotic stenosis is higher in the first case. The conservative management must be reserved to those smaller tears in patients with minimal and non-progressive clinical manifestations.

	Acknowledgments

 
We would like to thank Mr. Paolo Cavallo for the great patience and ability to traduce our requests in excellent line drawings.

	Footnotes

 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Dr A. Wahba (Trondheim, Norway): That seems to be a very interesting technique to repair these ruptures. Can you tell us how far down on the trachea you can repair the tear with this transcervical technique?

Dr Ambrogi: In the first 5 cases the tear was almost 3 cm above the carina. In the last patient the tear was 5 cm in length and 5 mm above the carina, so just over the carina.

Dr Wahba: Do you have any special techniques to move the trachea upwards?

Dr Ambrogi: Yes. In the last patient we put two lateral stitches with which we made traction and we could extend the anterior tracheotomy further down.

Dr A. Tcherveniakov (Sofia, Bulgaria): Do you have experience with partial, for example, sternotomy for this operation with the cervical approach?

Dr Ambrogi: No. We never had the necessity to do a sternal split. We were successful in reaching the carina without a sternal split by the transtracheal approach. Moreover, we have had the feeling that probably, with thoracoscopic devices, it is possible to reach also lacerations extended below the carina in a main bronchus.

Dr G. Massard (Strasbourg, France): I would like to add one short comment and ask you one question.

My comment is as follows. Most of the patients in whom we have had to deal with intubation lacerations of the membranous trachea had extensive lacerations which extended beyond the tracheal end up to the origin of the right stem bronchus. So I'm not very convinced that you are as good with the transcervical approach as with a short muscle-sparing thoracotomy in the fourth interspace, which is not real harmful for patients who have no major risk, and it avoids doing a second hole into the trachea to repair the first one. Sorry, but I disagree a little bit on that.

My question is, in the standard patient you see with a tracheal tear following intubation, would you recommend routine operation in every case or would you accept for small lacerations in stable patients to observe and to wait for spontaneous healing?

Dr Ambrogi: About your first consideration, we always perform the bronchoscopy before choosing the correct treatment. Obviously when the laceration extended to a main bronchus, we decided to perform a thoracotomy. So we also do the same approach you suggested.

Regarding your question, no. We also had two patients with a post-intubation tracheal tear who were managed conservatively, because at bronchoscopy they had a small tear not gaping during respiratory air flow and they were with minimal manifestations, as a poor subcutaneous emphysema. In these cases we decided to observe the patient, and if clinical and radiological manifestations didn't evolve, we continued with the treatment in a conservative fashion.

Dr L. Voltolini (Siena, Italy): I'm a bit concerned about the possibility of the development of tracheal stenosis. How long is your follow-up, and have you observed any tracheal stenosis?

Dr Ambrogi: The mean follow-up was 47 months, so I think it's quite a long follow-up. And we never observed tracheal stenosis. In all patients treated via the trans-tracheal approach, we never observed signs of a tracheal stenosis.

Dr I. Poliakov (Krasnodar, Russia): Your method is very interesting. I have never seen your technique before. Is it possible to see your technique on the film? Is it possible to see your technique when you stitch a very low laceration?

Dr Ambrogi: It isn't possible because we did only one patient this way and, in that case, it wasn't technically possible to do the video.

Dr K. Jeyasingham (Winterbourne Down, UK): In your transtracheal repair of a membranous tracheal rupture, what precautions do you take to ensure that the esophagus adjacent to it is not damaged?

Dr Ambrogi: We performed esophagoscopy only in two cases with a postintubation tracheal laceration. We believe that due to the mechanism of these injuries, it is difficult to think that the esophagus can be injured too. They are longitudinal tears probably caused by the same tube at its insertion.

	References

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